Percutaneous Ethanol Injection Group Research Articles

Percutaneous ethanol injection is an acceptable bridging therapy to hepatocellular carcinoma prior to liver transplantation.

Locoregional therapies (LRT) are employed for bridging patients with hepatocellular carcinoma (HCC) awaiting orthotopic liver transplantation (OLT). Although the main LRT options include transarterial chemoembolization (TACE) and radiofrequency ablation (RFA), percutaneous ethanol injection (PEI) is an alternative with considerably lower costs. This study is a pioneering evaluation of the natural history of PEI bridging to OLT as compared to TACE. All consecutive cirrhotic patients with HCC enlisted for OLT (2011-2020) at a single center were analyzed. Patients were divided into three LRT modality groups: PEI, TACE, and PEI+TACE. The primary study outcome was waitlist dropout due to tumor progression beyond Milan criteria. A comparison of post-transplant outcomes of patients as stratified by LRT modality also was performed. One hundred twenty-nine patients were included (PEI=56, TACE=43, PEI+TACE=30). The dropout rate due to tumor progression was not different among the three groups: PEI=8.9%, TACE=14%, PEI+TACE=16.7% (p=0.54). Thirteen (76.4%) patients underwent OLT after successful downstaging (3 [75%] in the PEI group, 5 [83.3%] in the TACE group, and 5 [71.4%] in the PEI+TACE group). For the 96 patients undergoing OLT, 5-year post-transplant recurrence-free survival was PEI=55.6% vs. TACE=55.1% vs. PEI+TACE=71.4% (p=0.42). Complete/near-complete pathological response rate was similar among groups (p=0.82). Dropout rates and post-transplant recurrence-free survivals related to PEI were comparable to those of TACE. This study supports the use of PEI alone or in combination with TACE for HCC patients awaiting OLT whenever RFA is not an option.

Suppression of Local Tumor Progression in Perivascular Hepatocellular Carcinoma by Combination Therapy with Radiofrequency Ablation and Percutaneous Ethanol Injection: A Propensity Score Matching Analysis

Background and Aims: Radiofrequency ablation (RFA) has replaced percutaneous ethanol injection (PEI) as the treatment of choice for hepatocellular carcinoma (HCC); however, control of local tumor progression (LTP) remains a challenge in perivascular HCC. The aim of this study was to determine whether PEI added to RFA can reduce the LTP rate in perivascular HCC patients. Methods: We retrospectively analyzed 167 patients, with 197 newly diagnosed HCC nodules with peritumoral vessels, who underwent either RFA plus PEI or RFA monotherapy as the first-line treatment between June 2001 and April 2015. Ethanol was injected inside the tumor close to the peritumoral vessels in the combination therapy group. Patients were matched 1:1 according to their propensity scores to reduce selection bias; cumulative LTP was then analyzed using log-rank tests and Cox proportional hazard regression analyses. Results: The two matched groups comprised 62 tumors each. The overall median follow-up period was 34 months (range, 1–140 months). In the RFA plus PEI group, the cumulative LTP rates were 5.7%, 15.5%, and 20.4% at 1, 3, and 5 years, respectively; in the RFA monotherapy group, the rates were 13.2%, 32.0%, and 40.2%, respectively. The rates were significantly lower in the RFA plus PEI group (p = 0.032). Cox proportional hazard regression analysis showed that PEI combination treatment was significantly associated with a reduced risk of local HCC recurrence (hazard ratio, 0.44; 95% confidence interval, 0.19–0.93; p = 0.031). Discussion/Conclusion: The risk of LTP after RFA for perivascular HCC can be significantly reduced by injecting ethanol close to the peritumoral vessels.

The safety and efficacy of percutaneous ethanol injection in the treatment of tumor thrombus in advanced hepatocellular carcinoma with portal vein tumor thrombus.

To compare the efficacy and safety of percutaneous ethanol injection (PEI) combined with transarterial chemoembolization (TACE + PEI) vs. TACE alone for the treatment of patients with advanced hepatocellular carcinoma (HCC) and portal vein tumor thrombus (PVTT). A total of 130 HCC patients with PVTT treated from May 2014 to August 2018 were retrospectively evaluated. Among them, 33 patients received TACE + PEI and 97 patients received TACE alone. PVTT was classified according to the Japanese Society of Hepatology; 97 patients had VP3 PVTT. Propensity score matching (PSM) was used to reduce selection bias. Before PSM, the median overall survival (mOS) was 11months (95% CI: 7.8-14.2) in the TACE + PEI group and 6months (95% CI: 5.1-6.9) in the TACE group (p < 0.001), and the median progression-free survival (mPFS) was 5months (95% CI: 3.7-6.3) in the TACE + PEI group and 2.5months (95% CI: 2.1-2.9) in the TACE group (p < 0.001). Similar results were seen after PSM. Subgroup analysis showed that in patients with tumors > 5cm in diameter and the VP3 subgroup, TACE + PEI brought a significant survival advantage over TACE alone before and after PSM. In the adverse event analysis, severe abdominal pain and bleeding after operation were seen in more patients in the TACE + PEI group than in the TACE group before PSM (P < 0.05). For HCC patients with PVTT (especially those with tumor diameters > 5cm and grade VP3), TACE combined with PEI for HCC patients with PVTT is safe and may provide better survival outcomes.

Comparison of percutaneous ethanol injection and radiofrequency ablation for the treatment of hepatocellular carcinoma

Objectives: The objectives of the study were to compare overall survival (OS) and disease-free survival (DFS) following percutaneous ethanol injection (PEI) and radiofrequency ablation (RFA) for the treatment of hepatocellular carcinoma (HCC). Material and Methods: This is a single-institution retrospective cohort study. Patients who underwent PEI or RFA between January 1, 2008, and December 31, 2009, for HCC were included in this study. Patient data were collected from the time of their procedure to October 31, 2017. One hundred and twenty-five patients received RFA or PEI during the study period. Twenty-one patients were excluded from the study because they received RFA or PEI for non-HCC cancers, leaving 47 patients in the PEI group and 57 patients in the RFA group. Primary endpoints were OS and DFS following PEI or RFA. Secondary endpoints included rates of secondary intervention and liver transplant. Statistical analysis was performed using SAS Enterprise Guide 7.13 (Cary, NC). Results: One-hundred and four patients are included in this study: 47 in the PEI group and 57 in the RFA group. At 9-year follow-up, the OS rates were not statistically significant between the RFA and PEI groups, 23.9% and 22.8%, respectively (P = 0.25). However, at earlier time points, there was a statistically significant difference between the two groups with higher rates of OS in the RFA group (Wilcoxon, P = 0.04). Patients in the RFA group had OS rates of 56.1%, 43.9%, and 35.1% at 3, 5, and 7 years, respectively, compared to the PEI rates of 36.4%, 27.3%, and 25.1% at those same time points (P = 0.0035). The RFA group had 29% decreased risk of death at 5 years compared to PEI based on the Cox proportional hazards model. The DFS was not significantly different between the two groups at all-time points (P = 0.96). The PEI group showed DFS rates of 32.4% at 3 years and 29.5% at 5, 7, and 9 years. The RFA group demonstrated DFS rates of 32.2% at 3 years, 26.3% at 5 years, 23.4% at 7 years, and 19.5% at 9 years. Conclusion: RFA and PEI have comparable 9-year OS and DFS in patients with HCC. However, at earlier time points, RFA has superior OS.

Percutaneous ethanol injection for liver metastases.

The liver is affected by two of the most common groups of malignant tumours: primary liver tumours and liver metastases from colorectal carcinoma or other extrahepatic primary cancers. Liver metastases are significantly more common than primary liver cancer, and the reported long-term survival rate after radical surgical treatment is approximately 50%. However, R0 resection (resection for cure) is not feasible in the majority of patients; therefore, other treatments have to be considered. One of these is percutaneous ethanol injection (PEI), which causes dehydration and necrosis of tumour cells, accompanied by small-vessel thrombosis, leading to tumour ischaemia and destruction of the tumour. To assess the beneficial and harmful effects of percutaneous ethanol injection (PEI) compared with no intervention, other ablation methods, or systemic treatments in people with liver metastases. We searched the following databases up to 10 September 2019: the Cochrane Hepato-Biliary Group Controlled Trials Register; the Cochrane Central Register of Controlled Trials (CENTRAL), in the Cochrane Library; MEDLINE Ovid; Embase Ovid; Science Citation Index Expanded; Conference Proceedings Citation Index - Science; Latin American Caribbean Health Sciences Literature (LILACS); and the Cumulative Index to Nursing and Allied Health Literature (CINAHL). We also searched clinical trials registers such as ClinicalTrials.gov, the International Clinical Trials Registry Platform (ICTRP), and the US Food and Drug Administration (FDA) (17 September 2019). Randomised clinical trials assessing beneficial and harmful effects of percutaneous ethanol injection and its comparators (no intervention, other ablation methods, systemic treatments) for liver metastases. We followed standard methodological procedures as outlined by Cochrane. We extracted information on participant characteristics, interventions, study outcomes, study design, and trial methods. Two review authors performed data extraction and assessed risk of bias independently. We assessed the certainty of evidence by using GRADE. We resolved disagreements by discussion. We identified only one randomised clinical trial comparing percutaneous intratumour ethanol injection (PEI) in addition to transcatheter arterial chemoembolisation (TACE) versus TACE alone. The trial was conducted in China and included 48 trial participants with liver metastases: 25 received PEI plus TACE, and 23 received TACE alone. The trial included 37 male and 11 female participants. Mean participant age was 49.3 years. Sites of primary tumours included colon (27 cases), stomach (12 cases), pancreas (3 cases), lung (3 cases), breast (2 cases), and ovary (1 case). Seven participants had a single tumour, 15 had two tumours, and 26 had three or more tumours in the liver. The bulk diameter of the tumour on average was 3.9 cm, ranging from 1.2 cm to 7.6 cm. Participants were followed for 10 months to 43 months. The trial reported survival data after one, two, and three years. In the PEI + TACE group, 92%, 80%, and 64% of participants survived after one year, two years, and three years; in the TACE alone group, these percentages were 78.3%, 65.2%, and 47.8%, respectively. Upon conversion of these data to mortality rates, the calculated risk ratio (RR) for mortality at last follow-up when PEI plus TACE was compared with TACE alone was 0.69 (95% confidence interval (CI) 0.36 to 1.33; very low-certainty evidence) after three years of follow-up. Local recurrence was 16% in the PEI plus TACE group and 39.1% in the TACE group, resulting in an RR of 0.41 (95% CI 0.15 to 1.15; very low-certainty evidence). Forty-five out of a total of 68 tumours (66.2%) shrunk by at least 25% in the PEI plus TACE group versus 31 out of a total of 64 tumours (48.4%) in the TACE group. Trial authors reported some adverse events but provided very few details. We did not find data on time to mortality, failure to clear liver metastases, recurrence of liver metastases, health-related quality of life, or time to progression of liver metastases. The single included trial did not provide information on funding nor on conflict of interest. Evidence for the effectiveness of PEI plus TACE versus TACE in people with liver metastases is of very low certainty and is based on one small randomised clinical trial at high risk of bias. Currently, it cannot be determined whether adding PEI to TACE makes a difference in comparison to using TACE alone. Evidence for benefits or harms of PEI compared with no intervention, other ablation methods, or systemic treatments is lacking.

Effects of radiofrequency ablation versus other ablating techniques on hepatocellular carcinomas: a systematic review and meta-analysis

BackgroundPercutaneous ablation has quickly arisen as one of the important alternative treatments for hepatocellular carcinoma (HCC). We aimed to compare the therapeutic effects of radiofrequency ablation (RFA) and other ablative techniques on HCCs.MethodsDatabases were searched to identify literature on complete tumor ablation (CTA), overall survival (OS), local tumor recurrence (LTR), and complications of RFA in the treatment of HCC, compared with those of microwave ablation (MWA), percutaneous ethanol injection (PEI), PEI plus RFA, cryoablation (CRA), laser ablation (LSA), and high-intensity focused ultrasound. Randomized controlled trials and high-quality cohort studies were included in the assessment.ResultsThe effects of MWA and CRA appeared to be similar to those of RFA, but lower rates of LTR and higher rates of CTA in large tumors compared with RFA were reported (P < 0.05). CTA rates were lower in patients treated with PEI (odds ratio [OR] 0.16, 95% confidence interval [CI] 0.06–0.42), and higher in those treated with PEI plus RFA (OR 2.28, 95% CI 1.19–3.60), with an increased incidence of fever (P < 0.05). LSA resulted in lower CTA rates (OR 0.32, 95% CI 0.13–0.81) and OS (hazard ratio 1.47, 95% CI 1.01–2.15), with a lower incidence of complications.ConclusionsCompared with RFA, identical effects were found in MWA and CRA groups. Fewer complications were observed in PEI and LSA group. PEI plus RFA appeared more effective, with a higher rate of complications. Well-designed randomized controlled trials are further needed to confirm above results.

Doxorubicin-eluting beads versus combined conventional transarterial chemoembolization and percutaneous alcohol injection in the treatment of large hepatocellular carcinoma

Introduction Hepatocellular carcinoma (HCC) is a primary tumor of the liver, which usually develops in the setting of chronic liver disease, particularly in patients with chronic hepatitis B and hepatitis C. Current guidelines recommend transarterial chemoembolization (TACE) as the standard treatment of Barcelona Clinic Liver Cancer-B patients. The aim of this work is to compare the efficacy, safety, feasibility, and cost-effectiveness of drug-eluting bead (DEB)-TACE versus combined conventional transarterial chemoembolization (c-TACE)+percutaneous ethanol injection (PEI) for improving the outcome of large HCC. Patients and methods In all, 75 patients with large HCC were included in this study: 30 patients were treated by combined c-TACE + PEI and 45 patients were treated by DEB-TACE. Results By comparison of the results of the combined c-TACE + PEI group with the DEB-TACE group, there was no significant difference in tumor response, with better results in the combined c-TACE + PEI group and significant decrease in the median value of the serum level of α-fetoprotein after treatment among patients treated with combined c-TACE + PEI (P = 0.004), and a statistically significant difference in the median value after treatment between the two groups (P = 0.036). Conclusion Results of combined c-TACE + PEI and DEB-TACE are comparable, but the cost of a DEB-TACE session is three times that of c-TACE + PEI, and thus cost-effectiveness analyses recommend the use of combined c-TACE + PEI (less cost) in the treatment of large HCC; in addition, there was a significant reduction in the level of α-fetoprotein after combined c-TACE+PEI treatment.

Percutaneous ethanol injection versus conservative treatment for benign cystic and mixed thyroid nodules.

To evaluate the efficacy and safety of percutaneous ethanol injection (PEI) in reducing the volume of cystic and mixed thyroid nodules. A total of 36 patients with nodules treated with PEI and 13 individuals who declined PEI and were followed clinically or received other non surgical treatment (control group). Assessments were performed at baseline (immediately before treatment in the PEI group or evaluation of the nodule on ultrasonography in the control group) at short-term (on average 30 days after the last injection in the PEI group), and long-term (on average 14 months after baseline in the PEI group or 26 months after baseline in the control group). In the PEI group, the mean baseline volume of 10.4 ± 9.8 cm3 reduced at short-term follow-up to 2.9 ± 3.1 cm3 (67.7 ± 19.9%, p < 0.001) and at long-term follow-up to 2.0 ± 2.5 cm3 (78.2 ± 19.5%, p < 0.01 versus baseline and p = 0.009 versus short-term follow-up). Both types of nodules showed similar degrees of reduction. In the control group, mean volume was 5.8 ± 3.4 cm3 at baseline and 6.2 ± 3.0 cm3 at long-term follow-up (p = 0.507). Compared with the control group, the PEI group showed larger reduction (p < 0.001). PEI is effective in reducing the volume of cystic and mixed benign thyroid nodules, with sustained long-term efficacy and better outcome when compared with conservative therapies. Treatment with PEI is a safe alternative, with minimal, transient and self-limited adverse events.

Hepatocellular carcinoma ≤ 4 cm treated with radiofrequency ablation with or without percutaneous ethanol injection

Background. To compare the survival of Chinese cirrhotic patients with hepatocellular carcinoma (HCC) ≤ 4 cm who underwent radiofrequency ablation (RFA) alone or a combination of RFA with percutaneous ethanol injection (PEI).Material and methods. Retrospective analysis was performed for 681 cases with HCC ≤ 4 cm who were treated with RFA alone or RFA combined with PEI (RFA + PEI) between 2004 and 2011.Results. As a result, 180 patients in each group were selected after propensity score matching (PSM). Higher overall survival (OS) and recurrence-free survival (RFS) rates were achieved by RFA + PEI compared with RFA alone (P = 0.019 and 0.009, respectively). The 1-, 3-, and 5-year cumulative OS rates were 78.0, 44.4, and 30.1% for patients in RFA group and 88.2, 58.0, and 41.1% for patients in RFA + PEI group, respectively. Besides, the 1-, 3-, and 5-year cumulative RFS rates were 77.0, 43.8, and 29.2% in RFA group, and 87.9, 57.6, and 38.4% in RFA + PEI group, respectively. The local recurrence, complete ablation and five-year mortality showed no distinct differences between RFA and RFA + PEI groups in three subgroups classified with tumor size. Moreover, Cox regression multivariate analysis results showed that sex and treatment approach were significantly related to OS, whereas sex, status of HBsAg, local recurrence, and number of tumor nodule were related to RFS.Conclusion. Therefore, the combination of RFA and PEI yielded better OS and RFS rates than RFA alone for Chinese patients with HCC ≤ 4 cm.

Vascular endothelial growth factor before and after locoregional treatment and its relation to treatment response in hepatocelluar carcinoma patients

ObjectiveTo evaluate vascular endothelial growth factor (VEGF) levels in hepatocellular carcinoma patients before and after transcatheter arterial chemoembolization (TACE) and percutaneous ethanol injection (PEI) and its relation to treatment response. MethodsA total of 40 patients with unrespectable hepatocelluar carcinoma were assessed clinically. Twenty patients were suitable to be treated by TACE, while other 20 patients were treated with PEI. Serum VEGF levels were measured before and 1 month after each procedure by ELISA. Response was assessed after 1 month according to Union Internationale Contre le Cancer evaluation criteria based on change in tumor size as measured by ultrasound. ResultsThere was no significant difference between TACE and PEI groups with regard to age, sex, tumor size, response to local therapy, or VEGF and alpha-fetoprotein before and after therapy. VEGF levels after TACE were significantly higher than before TACE [(298.1 ± 123.6) pg/mL vs. (205.8 ± 307.3) pg/mL; P = 0.001]. Also, VEGF levels were significantly higher after PEI than before PEI [(333.8 ± 365.6) pg/mL vs. (245.3 ± 301.8) pg/mL; P = 0.000]. Non-responders of both groups had significantly high VEGF levels than responder's, both before [(985.0 ± 113.2) pg/mL vs. (117.1 ± 75.3) pg/mL; P < 0.001] and after therapy [(1330.6 ± 495.7) pg/mL vs. (171.0 ± 94.7) pg/mL; P = 0.000)]. ConclusionsBoth TACE and PEI were associated with an increase in serum VEGF in hepatocelluar carcinoma patients. Higher levels of VEGF before and after therapy were found in non-responders, suggesting that VEGF is a useful marker in predicting treatment response.

The effects of percutaneous ethanol injection followed by 20-kHz ultrasound and microbubbles on rabbit hepatic tumors.

Low-frequency ultrasound (US) in combination with microbubbles (MBs) is able to inhibit the growth of VX2 rabbit liver tumors. In this study, we investigated the feasibility of using percutaneous ethanol injection (PEI) followed by low-frequency ultrasound and microbubbles (USMB) to inhibit VX2 tumor growth. Eighteen New Zealand rabbits with hepatic VX2 tumors were divided into three groups: PEI, low-frequency ultrasound and MBs followed by PEI (USMB + PEI), and PEI followed by USMB (PEI + USMB). PEI was performed by ultrasound-guided injection of 95% anhydrous alcohol into internal liver tumors in rabbits twice a week for 2 weeks. The US parameters were 20 kHz, 2 W/cm(2), 40% duty cycle, 5 min, and once every other day for 2 weeks. Magnetic resonance imaging (MRI) was used to observe tumors before and after treatment, to examine changes in the tumors, and to measure the diameters of the tumors. All animals were followed up for 180 days after tumor implantation. Autopsy was performed at the end of the scheduled follow-up or immediately after death. Anatomically observed metastatic sites included the liver, lung, abdomen, and pelvic cavity. The survival time of all rabbits was recorded. After 4 weeks of treatment, on MRI, the tumor diameters in the PEI, USMB + PEI, and PEI + USMB groups were 8.33 ± 1.83, 19 ± 2.61, and 4.5 ± 1.22 mm, respectively. There was a significant difference in tumor size indicated by MRI in the three groups. Tumor size was smaller in the PEI + USMB group than in the PEI and USMB + PEI groups, with t = 4.54, p = 0.0062, and t = 16.38, p < .0001, respectively. The PEI + USMB group showed the fewest metastasis sites (χ(2) = 11.7333, p = 0.0194) and the longest survival period (χ(2) = 7.448, p = 0.0241). Percutaneous ethanol injection followed by low-frequency ultrasound and microbubbles can be effective in inhibiting rabbit liver tumors and prolonging survival time.

Percutaneous ethanol injection or percutaneous acetic acid injection for early hepatocellular carcinoma.

Percutaneous ethanol injection or percutaneous acetic acid injection for early hepatocellular carcinoma.

Ultrasonic guided percutaneous ethanol injection with or without combined radiofrequency ablation for hepatocellular carcinomas

The aim of this retrospective study was to evaluate whether radiofrequency ablation (RFA) combined percutaneous ethanol injection (PEI) in the management of hepatocellular carcinoma (HCC) improves treatment outcomes. We retrospectively included 66 HCC patients who received RFA or RFA plus PEI from February 2011 to January 2014 in Jingmen No. 1 People's Hospital. Moreover, 31 cases received RFA plus PEI as the experiment group and 35 subjects treated with RFA aloe as the control group. The overall survival and treatment related complications were compared between the two groups. For RFA group, the 1-year, 2-year, and 3-year survival rate were 82.0%, 69.3%, and 30.7%, respectively, with the median survival time of 27.1 months. For RFA plus PEI group, the 1-year, 2-year, and 3-year survival rate were 97.1%, 73.9%, and 37.5%, respectively, with the median survival time of 33.6 months. The overall survival of the two groups was not statistical different with the hazard ratio of 1.48 (P > 0.05); three cases of treatment associated complications were found in RFA group with 1 abscess, 1 pleural effusion, and 1 portal vein thrombosis. Moreover, 2 cases of complication were recorded in RFA plus PEI group with 1 pleural effusion and 1 portal vein thrombosis. The complicated incidence rate was not statistical different between the two groups (P < 0.05). The combination treatment of HCC was safe and had a slightly higher primary effectiveness rate than RFA alone.

Radiofrequency Ablation Is Superior to Ethanol Injection in Early-Stage Hepatocellular Carcinoma Irrespective of Tumor Size

BackgroundRandomized trials suggest that radiofrequency ablation (RFA) may be more effective than percutaneous ethanol injection (PEI) in the treatment of hepatocellular carcinoma (HCC). However, the survival advantage of RFA needs confirmation in daily practice.MethodsWe conducted a population-based cohort study using the Taiwan Cancer Registry, National Health Insurance claim database and National Death Registry data from 2004 through 2009. Patients receiving PEI or RFA as first-line treatment for newly-diagnosed stage I-II HCC were enrolled.ResultsA total of 658 patients receiving RFA and 378 patients receiving PEI treatment were included for final analysis. The overall survival (OS) rates of patients in the RFA and PEI groups at 5-year were 55% and 42%, respectively (p < 0.01). Compared to patients that received PEI, those that received RFA had lower risks of overall mortality and first-line treatment failure (FTF), with adjusted hazard ratios (HRs) [95% confidence interval (CI)] of 0.60 (0.50-0.73) for OS and 0.54 (0.46-0.64) for FTF. The favorable outcomes for the RFA group were consistently significant for patients with tumors > 2 cm as well as for those with tumors < 2 cm. Consistent results were also observed in other subgroup analyses defined by gender, age, tumor stage, and co-morbidity status.ConclusionRFA provides better survival benefits than PEI for patients with unresectable stage I-II HCC, irrespective of tumors > 2 cm or ≤ 2 cm, in contemporary clinical practice.

Survival advantage of radiofrequency ablation for hepatocellular carcinoma: comparison with ethanol injection.

The aims of this study were to compare long-term prognosis of patients with hepatocellular carcinoma (HCC) treated with radiofrequency ablation (RFA) and percutaneous ethanol injection (PEI). Two hundred and thirteen patients with HCC were initially treated with PEI or RFA at Saga University Hospital between 1990 and 2004. The present study included 190 patients: 98 treated with PEI from 1990 to 1999, and 92 with RFA from 2000 to 2004. The association of treatment method with survival prognosis was evaluated by multivariate analysis. There were no significant differences in gender, etiology, and tumor stage between the two groups. Five-year survival rate in the PEI group was 40% and 51% in the RFA group. According to tumor stage, there were no differences in 5-year survival rate between the two groups for tumor stage I and III. For stage II patients, RFA had better survival than PEI (48% vs. 28%, p = 0.03). Multivariate analysis indicated that RFA was more effective for long-term survival than PEI in patients with tumor stage II (p = 0.04). Compared to PEI, RFA improved survival in patients with stage II HCC, indicating a therapeutic advantage of RFA.

Percutaneous ethanol injection for liver metastases

Primary liver tumours and liver metastases from colorectal carcinoma are the two most common malignant tumours to affect the liver. The liver is second only to the lymph nodes as the most common site for metastatic disease. More than half of the patients with metastatic liver disease will die from metastatic complications. Percutaneous ethanol injection (PEI) causes dehydration and necrosis of tumour cells accompanied by small vessel thrombosis, leading to tumour ischaemia and destruction. To study the beneficial and harmful effects of percutaneous ethanol injection compared with no intervention, other ablation methods, or systemic treatments in patients with liver metastases. We searched the Cochrane Hepato-Biliary Group Controlled Trials Register, Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library, MEDLINE, EMBASE, Science Citation Index Expanded, LILACS, and CINAHL up to December 2012. We included all randomised clinical trials assessing the beneficial and harmful effects of percutaneous ethanol injection versus no intervention, other ablation methods, or systemic treatments in patients with liver metastases. We extracted the relevant information on participant characteristics, interventions, study outcome measures, and data on the outcome measures for our review, as well as information on the design and methodology of the studies. Quality assessment of the trials fulfilling the inclusion criteria and data extraction from the trials retrieved for final evaluation were done by one author and checked by a second author. One randomised clinical trial was included, comparing transcatheter arterial chemoembolisation (TACE) + percutaneous intratumour ethanol injection (PEI) versus TACE alone. Forty-eight patients with liver metastases were included; 25 received the intervention with PEI and 23 received TACE alone.Mortality data were not reported. The trial reported the survival data after one, two, and three years. In the TACE + PEI group, 92%, 80%, and 64% of the patients survived after 1, 2, and 3 years respectively; in the TACE group, 78.3%, 65.2%, and 47.8% of the patients survived after 1, 2, and 3 years respectively. The hazard ratio was 0.57 (95% CI 0.19 to 1.67). The local recurrence was 16% in the TACE + PEI group and 39.1% in the TACE group, resulting in a relative risk (RR) of 0.41 (95% CI 0.15 to 1.07). Forty-five tumours (66.2%) out of 68 tumours in total shrunk by at least 25% in the TACE + PEI group versus 31 tumours (48.4%) out of 64 tumours in total in the TACE group (RR 2.08; 95% CI 1.03 to 4.2). The authors reported some adverse events, but with very few details. On the basis of one small randomised trial, it can be concluded that addition of PEI to TACE, as compared with TACE alone, in patients with liver metastases seems to bring no clear benefit in terms of survival and local recurrence. The size of the tumour necrosis was larger in the combined treatment group. No intervention-related mortality or major complications were reported. More trials are needed.

Survival of patients receiving radiofrequency ablation or ethanol injection for early-stage hepatocellular carcinoma.

e15043 Background: Randomized trials suggest that radiofrequency ablation (RFA) may be more effective than percutaneous ethanol injection (PEI) in the treatment of hepatocellular carcinoma (HCC). However, the survival advantage of RFA need confirmation in daily practice. Methods: We conducted a population-based cohort study using the Taiwan Cancer Registry, National Health Insurance claim database and National Death Registry data from 2004 through 2009. Patients receiving PEI or RFA as first-line treatment for newly-diagnosed stage I-II HCC were enrolled. Results: A total of 658 patients receiving RFA and 378 patients receiving PEI treatment were included for final analysis. The overall survival (OS) rates of patients in the RFA and PEI groups at 5-year were 55% and 42%, respectively (p&lt; 0.01). Compared to patients that received PEI, those that received RFA had lower risks of overall mortality and first-line treatment failure (FTF), with adjusted hazard ratios (HRs) [95% confidence interval (C.I.)] of 0.60 (0.50-0.73) for OS and 0.54 (0.46-0.64) for FTF. The favorable outcomes for the RFA group were consistently significant for patients with tumors &gt; 2 cm as well as for those with tumors &lt; 2 cm. Consistent results were also observed in other subgroup analyses defined by gender, age, tumor stage, and co-morbidity status. Conclusions: RFA provides better survival benefits than PEI for patients with unresectable stage I-II HCC, irrespective of tumors &gt; 2 cm or ≤ 2 cm, in contemporary clinical practice.

Curative effect of a comprehensive interventional treatment modality on hepatocellular carcinoma complicated with main branch portal vein tumor thrombosis

To explore the therapeutic efficacy of a combined treatment modality using transcatheter arterial chemoembolization (TACE) and percutaneous ethanol injection (PEI) to treat hepatocellular carcinoma (HCC) complicated with main branch intraportal vein tumor thrombosis (PVTT). Clinical data was collected retrospectively for patients diagnosed with and treated for HCC plus main branch PVTT at our hospital between January 2007 and January 2010. The total study population (n = 51) consisted of 38 males and 13 females, with an average of 50.1 years (range: 24-73). Among these patients, 26 had been treated with TACE + PEI (group A) and 25 had been treated with TACE alone (group B). Short-term changes in PVTT (i.e. disappearance, shrinkage, and/or stability) and tumor (i.e. complete response, partial response, and/or stable disease) were assessed by using the t-test (continuous variables) or the Chi-squared or Fisher's exact tests (categorical variables). Between-group differences in survival time were assessed by the Kaplan-Meier analysis and log-rank test. The follow-up time ranged from 3-24 months after treatment, and no serious treatment-related complications were recorded for any of the patients (0/51). The time of TACE treatment was significantly longer for the patients receiving the combination therapy (group A: 3.21.4 vs. group B: 2.40.9, t = 2.22, P = 0.032). The patients in group A received between 2-8 PEI treatments. The TACE + PEI combined treatment showed significantly better therapeutic efficacy for PVTT (group A: 19/26 vs. group B: 10/25, X2 = 5.685, P = 0.019). The tumor response was significantly better in patients treated with TACE + PEI at post-treatment month 3 (group A: 20/26 vs. group B: 18/25, X2 = 0.163, P = 0.705) and month 6 (group A: 17/20 vs. 10/19, X2 = 2.58, P = 0.027). Finally, the average survival time was significantly better in patients treated with TACE + PEI (group A: 12.856.02 months (range: 5-23) vs. group B: 8.653.39 months (range: 4-16), t = 3.051, P = 0.004). TACE + PEI combination therapy for main branch PVTT in HCC patients is more efficacious than TACE alone, and is associated with a longer survival time.

Therapeutic Efficacy and Safety of Percutaneous Ethanol Injection with or without Combined Radiofrequency Ablation for Hepatocellular Carcinomas in High Risk Locations

ObjectiveTo evaluate the therapeutic efficacy and safety of percutaneous ethanol injection (PEI) alone and combined with radiofrequency ablation (RFA) for hepatocellular carcinomas (HCCs) in high risk locations.Materials and MethodsWe performed PEI for HCCs in RFA-high risk locations, either alone or in combination with RFA. There were 20 HCCs (1.7 ± 0.9 cm) in 20 patients (PEI group: n = 12; PEI + RFA group: n = 8). We evaluated technical success, local tumor progression and complications in both groups.ResultsTechnical success was achieved in all HCCs in both groups. During follow-up, local tumor progression was found in 41.7% (5/12) in the PEI group, whereas 12.5% (1/8) for the PEI + RFA group (p = 0.32). Bile duct dilatation was the most common complication, especially when the tumors were in periportal locations; 55% (5/9) in the PEI group and 50% (2/4) in the PEI + RFA group (p = 1.00). One patient in the PEI group developed severe biliary stricture and upstream dilatation that resulted in atrophy of the left hepatic lobe. One patient treated with PEI + RFA developed cholangitis and an abscess.ConclusionCombined PEI and RFA treatment has a tendency to be more effective than PEI alone for managing HCCs in high risk locations, although the difference is not statistically significant. Even though PEI is generally accepted as a safe procedure, it may cause major biliary complications for managing HCCs adjacent to the portal vein.

Comparison of resection and ablation for hepatocellular carcinoma: A cohort study based on a Japanese nationwide survey

The treatment of choice for early or moderately advanced hepatocellular carcinoma (HCC) with good liver function remains controversial. We evaluated the therapeutic impacts of surgical resection (SR), percutaneous ethanol injection (PEI), and radiofrequency ablation (RFA) on long-term outcomes in patients with HCC. A database constructed on the basis of a Japanese nationwide survey of 28,510 patients with HCC treated by SR, PEI, or RFA between 2000 and 2005 was used to identify 12,968 patients who had no more than 3 tumors (≤ 3 cm) and liver damage of class A or B. The patients were divided into SR (n=5361), RFA (n=5548), and PEI groups (n=2059). Overall survival and time to recurrence were compared among them. Median follow-up was 2.16 years. Overall survival at 3 and 5 years was respectively 85.3%/71.1% in the SR group, 81.0%/61.1% in the RFA, and 78.9%/56.3% in the PEI. Time to recurrence at 3 and 5 years was 43.3%/63.8%, 57.2%/71.7%, and 64.3%/76.9%, respectively. On multivariate analysis, the hazard ratio for death was significantly lower in the SR group than in the RFA (SR vs. RFA:0.84, 95% confidence interval, 0.74-0.95; p=0.006) and PEI groups (SR vs. PEI:0.75, 0.64-0.86; p=0.0001). The hazard ratios for recurrence were also lower in the SR group than in the RFA (SR vs. RFA:0.74, 0.68-0.79; p=0.0001) and PEI groups (SR vs. PEI:0.59, 0.54-0.65; p=0.0001). Our findings suggest that surgical resection results in longer overall survival and time to recurrence than either RFA or PEIin patients with HCC [corrected].