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Original Report |
1 All authors: Department of Diagnostic Imaging and Nuclear Medicine, Kyoto University Graduate School of Medicine, 54 Kawaharacho, Shogoin, Sakyoku, Kyoto, 606-8507, Japan.
Received May 27, 1999;
accepted after revision July 13, 1999.
Address correspondence to T. Shibata.
Abstract
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CONCLUSION. Percutaneous ethanol injection was successfully performed in nine nodules in seven patients. During follow-up, six nodules in five patients showed no increase in size. Four patients were alive 6-28 months after injection, one patient died of hepatic failure, one of brain metastasis, and one of multiple metastases. Percutaneous ethanol injection can be an alternative treatment for adrenal metastasis of hepatocellular carcinoma.
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We used the following parameters during percutaneous ethanol injection.
Intramuscular injection of 0.5 mg of atropine sulfate and 25 mg of hydroxyzine
hydrochloride was administered for sedation before percutaneous ethanol
injection. Local anesthesia was induced with 8-10 ml of 1% lidocaine. Before
the first session, core needle biopsy was performed with a 21-gauge biopsy
needle (Biopty; Bard, Covington, GA). Metastasis from HCC was pathologically
confirmed in all nine nodules. Then, a 21-gauge needle with three side holes
and no end hole (PEIT; Hakko, Tokyo, Japan) was introduced into the tumor. IV
injection of 15 mg of pentazocine and 10 mg of diazepam was given immediately
before the introduction of ethanol for patients who complained of severe pain
in the first session. In two patients, two or three needles were
simultaneously introduced into two large nodules, 5.8 and 6.0 cm in diameter.
Sonographically guided percutaneous ethanol injection was performed for three
nodules on the patient's right side using a transhepatic approach. CT-guided
percutaneous ethanol injection was performed for six nodules; four on the
patients' right and two on the patients' left with a direct posterior
approach. Five to 30 ml of absolute (99.5%) ethanol was slowly injected at
each session. Ethanol injections were performed once or twice a week. The
volume of injected ethanol in each nodule was calculated according to the
equation; V = 4 / 3
r3, where V is the volume of
ethanol and r is the radius of the lesion. We did not use the
standard equation of V = 4 / 3(r + 0.5)3 for
intrahepatic nodules [6]
because adrenal metastasis was not thought to be circumscribed by the normal
adrenal tissue.
After a series of sessions, dynamic CT was performed to evaluate the therapeutic effects of injection therapies. Early- and late-phase CT scans were obtained after bolus injection of 100 ml of 65% iopamidol (Iopamiron 300; Nihon Schering, Osaka, Japan) at a rate of 3 ml/sec. When enhancing lesions were not seen in the nodules, we stopped the percutaneous ethanol injection. Follow-up CT or sonography was performed at 3-month intervals.
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Two patients (29%) experienced abdominal pain in five sessions (22%), fever developed in two patients (29%) in three sessions (13%), and one patient (14%) experienced adrenal insufficiency in one session (4.3%). Two patients (62 and 72 years old) with large nodules had abdominal pain and fever; all sessions in these patients were per- formed using a posterior direct approach. A 72-year-old man showed general fatigue after a session involving insertion of 20 ml of ethanol simultaneously into bilateral adrenal metastases (Fig. 2). The adrenal insufficiency was diagnosed by a low serum cortisol level and a high plasma adrenocorticotropic hormone level. The patient required hormonal supplementation for 2 months. None of our patients developed retroperitoneal hematoma, intrahepatic hematoma, or pneumothorax. Dynamic CT after a series of sessions showed no enhancing lesions in seven of nine nodules, but enhancing lesions remained in two nodules of a 72-year-old man.
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Six to 36 months after percutaneous injection therapy, six nodules in five patients had not increased in size. Increased size was seen in three nodules of two patients (58 and 72 years old). However, the 58-year-old man could not continue injection therapy because of worsening liver function. The 72-year-old man refused further injection therapy after he experienced adrenal insufficiency. Four patients were alive 6-28 months after percutaneous injection therapy, one patient died of hepatic failure, another of brain metastasis, and another of multiple metastases.
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Surgical resection may be an effective treatment for adrenal metastasis from HCC [2, 3, 4, 5]. However, most patients with adrenal metastasis from HCC have poor hepatic reserve because of associated liver cirrhosis, and they often have intrahepatic HCC nodules. Treatment of HCC involves various options. Percutaneous ethanol injection is an effective, nonoperative treatment.
Imaging-guided biopsy for adrenal masses is an established diagnostic method [12]. The technique is safe and available for diagnosis of benign and malignant adrenal masses. Percutaneous ethanol injection is technically performed as easily as adrenal biopsy. Pain and fever are more commonly seen in percutaneous ethanol injection than during adrenal biopsy. In this study, pain occurred in five sessions for two nodules using a posterior direct approach, which was more severe than that in standard percutaneous ethanol injection for intrahepatic nodules. Adrenal insufficiency was seen in a session of simultaneous ethanol injection for bilateral adrenal metastases, but it was temporary. Morimoto et al. [5] described a patient with bilateral adrenalectomy who was treated successfully by supplemental administration of corticosteroids. However, simultaneous ethanol injection into both adrenals should be avoided; treating one adrenal metastasis at a time did not induce adrenal insufficiency.
In two patients with bilateral adrenal metastases, increase in tumor size was seen during follow-up. Percutaneous ethanol injection has limited value for large or bilateral metastases. However, no increase in size was seen in five patients with unilateral metastasis. Percutaneous ethanol injection is effective for smaller, unilateral metastatic nodules. In conclusion, percutaneous ethanol injection is a viable alternative method of treatment for adrenal metastasis in patients with controlled intrahepatic HCC nodules and with no other distant metastasis.
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