Percutaneous Alcohol Injection Research Articles

Long-Term Results of Percutaneous Treatment of Hydatid Liver Cysts: a Single Center 17 Years Experience

Liver cystic echinococcosis is considered a relatively benign disease, nevertheless, treatment is mandatory in symptomatic cysts and recommended in active cysts because of the risk of severe complications. Surgery is still considered the gold standard treatment. In the last two decades percutaneous injection of scolicidal agents has been developed with excellent results in terms of disappearance of the cyst, very low side effects and low mortality rate. One hundred sixty eight patients with 225 liver cysts were studied. A total of 108 patients with 151 viable hydatid liver cysts underwent Double Percutaneous Aspiration and Injection of alcohol of the cyst without re-aspiration of the ethanol, which remained in situ. The mortality rate was 0.9% (1 patient), the overall morbidity was 8.6% with only 2.5% of major side effects. The mean hospital stay was very short (2.9 days). Follow-up ranged from 14 to 204 months (median 48 months). Ultrasonography showed complete disappearance of the cyst with reconstitution of liver parenchyma in 109 out of 225 (48.4%) cysts; in the remaining cysts a solid or a liquid findings were observed in 104 (46.2%) and 12 (5.3%), respectively, with a decreased volume of 50-80%. These data show that Double Percutaneous Aspiration and Injection of alcohol for hydatid liver cysts can achieve comparable results to open surgery. The low incidence of side effects shows that this technique is safe and cost effective, compared to radical or conservative surgery.

Coma éthylique secondaire à une sclérothérapie alcoolique

Simple serous renal cysts are an often asymptomatic benign disease, sometimes treated with ethanol sclerotherapy. We report a case of iatrogenic acute alcohol intoxication following percutaneous injection of alcohol into a renal cyst under local anesthesia.The percutaneous injection was guided by computed tomography. At the end of the procedure, the patient went into a coma due to alcohol intoxication: the cyst ruptured and ethanol was resorbed into the systemic circulation.Alcohol injection for sclerotherapy is used for several indications. This rare event has not previous been described, but should be known so that physicians can be prepared to manage it correctly.

Outcome of patients with hepatocellular carcinoma referred to a tertiary centre with availability of multiple treatment options including cadaveric liver transplantation

Hepatocellular carcinoma (HCC) is a primary cancer of the liver with an established causal link to viral hepatitis and other forms of chronic liver disease. The aim of this study was to analyse the determinants of outcome in patients with HCC referred to a tertiary centre for management. Two hundred and thirty-five prospective patients with HCC and minimum 12-month follow-up were studied. The cohort was heterogeneous, with 52% Caucasian, 40% Asian and 5% of Middle-Eastern origin. Independent predictors of outcome included tumour size and number, the presence of ascites or portal vein thrombosis, alpha-foetoprotein >50 U/L and an impaired performance status. Treatment was determined on an individual case basis by a multidisciplinary tumour team. Surgical resection was primary treatment in 43 patients, liver transplantation in 40 patients, local ablation (percutaneous radiofrequency ablation or alcohol injection) in 33 patients, transarterial chemoembolisation in 33 patients, chemotherapy or other systemic therapy in 30 patients and no treatment in 56 patients. After adjustment for significant covariates, both liver transplantation (P<0.001) and surgical resection (P=0.029) had a significant effect on patient survival compared with no treatment, but local ablation (P=0.410) and chemoembolisation (P=0.831) did not. Liver transplantation resulted in superior overall and, in particular, disease-free survival compared with surgical resection (disease-free survival 84 vs 15% at 5 years). In conclusion, both surgical resection and liver transplantation significantly improve the survival of patients with HCC, but improvements need to be made to the delivery of loco-regional therapy to enhance its effectiveness.

Liver-directed therapies for patients with primary liver cancer and hepatic metastases

Liver cancer, whether primary or metastatic, is a major cause of death throughout the world. The surgical management of these diseases varies according to the extent of disease and the overall health of the patient. Surgical resection of hepatic disease remains the only chance for cure. However, a large proportion of patients with liver cancer are unable to undergo a complete surgical resection. These patients are often treated with liver-directed therapies. Although not as effective as surgical resection, these approaches can help to improve the survival of patients. In patients with primary liver cancer, underlying liver disease often prohibits surgical intervention. However, survival advantages have been gained with the application of percutaneous alcohol injection and radiofrequency ablation (RFA). In patients with hepatic metastases, the number of metastases is often what prevents surgical resection. In these patients, RFA, cryoablation, and hepatic artery infusional therapy have all aided in prolonging survival. As chemotherapeutic agents improve and targeted therapies are developed, more patients will be able to undergo surgical management of their liver cancer, primary or metastatic.

Survival of patients with early hepatocellular carcinoma treated by percutaneous alcohol injection

Once small (<10 mm) nodules, suspicious for hepatocellular carcinoma, are detected in cirrhotics, the European Association for the Study of the Liver guidelines recommend to delay histological confirmation and treatment until they increase in size. To validate this policy by evaluating survival of 450 cirrhotics in Child-Pugh class A or B with unifocal 'early' hepatocellular carcinoma treated by percutaneous alcohol injection. Patients were sorted by nodular size into three groups: < or =10 mm (n = 36, group A), >10 to < or = 20 mm (n = 142, group B) and >20 to < or = 30 mm (n = 272, group C). Overall and tumour-free survivals were estimated by Kaplan-Meier method. In groups A, B and C, mean follow-up was 33 +/- 26, 34 +/- 22 and 35 +/- 25 months (P = 0.89), mean survival time was 63 +/- 54, 57 +/- 48 and 62 +/- 66 months (P = 0.69) and mean tumour-free survival was 44 +/- 47, 46 +/- 58 and 41 +/- 68 months (P = 0.51), respectively. When patients were sorted by Child status, mean survival time was 76 +/- 82 and 38 +/- 29 months in Child A and B (P < 0.0001). The comparable survival of percutaneous alcohol injection-treated patients with single, early hepatocellular carcinoma sorted by nodular size supports the European Association for the Study of the Liver 'wait-and-see' policy for patients with lesions <10 mm, and suggests that allowing the nodules to grow prior to taking further diagnostic or therapeutic actions would not harm these patients.

Selection criteria for liver transplantation in patients with hepatocellular carcinoma: Beyond tumor size and number?

Selection criteria for liver transplantation in patients with hepatocellular carcinoma: Beyond tumor size and number?

Intralesional Injection of Absolute Alcohol Into Symptomatic Vertebral Hemangiomas

The management of vertebral hemangiomas remains controversial. This report describes the successful management of spinal cord compression caused by an intraosseous and extraosseous vertebral hemangioma with the percutaneous injection of absolute alcohol. A 71-year-old woman presented with lower extremity weakness and sensory disturbance. Magnetic resonance imaging and computed tomography (CT) confirmed the presence of a vertebral hemangioma involving the Th11 vertebral body. A CT-guided percutaneous transpedicular injection of absolute alcohol into the affected vertebral body resulted in symptomatic and imaging improvement. CT-guided percutaneous transpedicular injection of absolute alcohol into symptomatic vertebral hemangiomas is a simple, safe, and effective technique for relieving compression and devascularizing the hemangioma.

Giant simple renal cyst complicated with hypertension

Solitary renal cysts are a common and usually asymptomatic occurrence in older patients. They may be associated with hypertension or abdominal disturbances, as they can be responsible for compression of surrounding tissues and distortion of renal vessels. This report presents an interesting case of a hypertensive patient with a solitary renal cyst of a marked size. Owing to the high risk of performing a surgical procedure in such a patient, a distinct therapeutic solution was opted for. Successful management of this case was achieved by a combination of percutaneous fluid aspiration and injection of alcohol and Vibramycin inside the cystic cavity. Percutaneous fluid evacuation combined with the administration of a sclerosing agent is suggested as a safe and effective alternative for cyst decompression and blood pressure normalisation.

Percutaneous alcohol injection in hepatocellular carcinoma: assessment of residual disease using contrast-enhanced ultrasonography: Guillermo González Sr., Catholic University of Chile School of Medicine, Santiago Chile; Marco Arrese Sr., Catholic University School of Medicine, Santiago Chile; Jorge Martinez, Catholic University, School of Medicine, Santiago; Manuel Alvarez, Alejandro Soza, Sergio Guzman, Catholic University School of Medicine, Santiago Chile

Percutaneous alcohol injection in hepatocellular carcinoma: assessment of residual disease using contrast-enhanced ultrasonography: Guillermo González Sr., Catholic University of Chile School of Medicine, Santiago Chile; Marco Arrese Sr., Catholic University School of Medicine, Santiago Chile; Jorge Martinez, Catholic University, School of Medicine, Santiago; Manuel Alvarez, Alejandro Soza, Sergio Guzman, Catholic University School of Medicine, Santiago Chile

Percutaneous Drainage of Simple Cysts of the Kidney: A New Method

Objective: The experience of our department on the treatment of solitary simple kidney cysts with continuous percutaneous drainage for 24 h and instillation of pure alcohol as a sclerotic agent is reported. The results are compared with those of previous years when the treatment consisted of percutaneous drainage and injection of pure alcohol. Patients and Methods: During the period 1992–2001, 252 patients (136 male, 116 female; aged 22–74 years) were treated at our department, and all had a solitary kidney cyst. They were treated by percutaneous drainage and then injection of pure alcohol for 20 min via a nephrostomy tube (which remained in position for 24 h). The mean follow-up period was 5 years. This cohort of patients was compared to another one of 238 patients who were treated with a previous method (126 male, 124 female; aged 28–79 years, mean 59 years). Results: In 71% of the patients the symptoms and the cyst both disappeared, in 22% there was no significant recurrence (i.e. cyst diameter <5 cm), and the remaining 7% presented significant recurrence (i.e. cyst diameter >5 cm). Most of the latter cases were treated again using the same method. Of the 73 patients with impaired kidney function, in 61 (83%) this appeared to have improved as a result of our treatment. Of the 61 patients with hypertension, in 29 (47%) this appeared to have improved. There was only 1 case with complications, which presented purulence of the cyst that required open surgery. In previous case series, which were treated with percutaneous drainage and injection of pure alcohol just after the puncture of the cyst – without continuous drainage of the cyst for 24 h – only 10% of the patients had no recurrence, 30% had no significant recurrence (volume of the cyst <20% of the pre-operative volume), and 60% of the patients had significant recurrence (volume of the cyst >20% of the pre-operative volume). Conclusions: Percutaneous drainage of solitary kidney cysts for 24 h followed by injection of pure alcohol, as a sclerotic agent, is an effective therapeutic method with only a few complications. It was therefore considered being the proffered method for the treatment of solitary kidney cysts.

Percutaneous alcohol ablation for liver metastasis

Ultrasound-guided percutaneous alcohol injection (PAI) is used in the treatment of hepatocellular carcinoma for lesions less than 3 to 5 cm in diameter. However, few studies in the literature have evaluated the place of PAI in the treatment of liver metastasis. Alcohol acts by causing coagulative necrosis, followed by the formation of fibrotic and granulomatous tissue and thrombosis of small vessels. The results of the various published studies are similar, with a complete necrosis rate lower than that obtained in hepatocellular carcinoma. Nevertheless, in more than 50% of cases of liver metastasis less than 4 cm in diameter, complete necrosis can be obtained, and PAI would seem to be a reasonable option for the treatment of small metastases of colorectal or mammary origin and for endocrine tumors when surgery is contraindicated. PAI could be a valuable alternative in the treatment of selected small metastases of the liver. However, the new techniques of local tumor destruction (interstitial laser photocoagulation (ILP), cryoablation, radiofrequency thermal ablation, and microwave destruction) will replace PAI for the treatment of liver metastasis in the near future. Semin Oncol 29:192-195. Copyright 2002, Elsevier Science (USA). All rights reserved.

Hydatid liver cyst: an 11-year experience of treatment with percutaneous aspiration and ethanol injection.

To report an 11-year experience of treatment of hydatid liver cysts with double percutaneous aspiration and injection of alcohol. Of the 129 patients with 174 hydatid liver cysts admitted to our department between January 1988 and January 1999, 79 patients with 119 vital hydatid liver cysts were selected for double percutaneous aspiration and injection of alcohol. Under ultrasonographic guidance, cystic cavities were first drained through fine needles, and then 95% sterile ethanol was injected and left in situ. The same procedure was repeated 3 days later without reaspiration of the injected alcohol. General anesthesia without endotracheal intubation was performed in 21 selected cases. Double percutaneous aspiration and injection of alcohol was completed in 78 patients with 118 hydatid liver cysts. In 1 case the procedure could not be accomplished because of an intracystic hemorrhage. A total of 254 punctures were performed, and the ethanol injected per session ranged between 12 and 250 mL. The mean hospital stay was 2.9 days (range, 2-7 days). The overall median follow-up was 48 months (range, 6-122 months). At the last ultrasonographic examination, 45.8% of the treated hydatid liver cysts had a solid pattern, 47.4% were no longer appreciable, and 6.8% had a minimal liquid component. Intracystic relapse occurred in 5% of the patients. In no case were any new cysts observed either in different hepatic segments or in any extrahepatic location. The morbidity rate was 9%, and 1 death occurred (mortality rate, 1.3%). Over a long period, double percutaneous aspiration and injection of alcohol proved to be a substantially safe, effective, and low-cost procedure for hydatid liver cyst treatment.

Cryoablation, percutaneous alcohol injection, and radiofrequency ablation for treatment of neuroendocrine liver metastases.

Neuroendocrine liver metastases are associated with slow clinical progression, prolonged patient survival, and symptoms of hormone oversecretion. Although surgical resection is the gold standard of treatment, most of the patients are not candidates for resection, and the 5-year survival of patients with neuroendocrine liver metastases is 11% to 40%. Cryotherapy, percutaneous alcohol injection, and radiofrequency thermal ablation are among the alternative regional treatment options available for these patients. The current role of these treatment options for neuroendocrine liver tumors are discussed in this review. Cryosurgery is the classic technique for local tumor destruction, mostly performed with open surgery. There has been limited experience with percutaneous alcohol injection for neuroendocrine liver metastasis. Radiofrequency thermal ablation is a relatively new modality that can be performed percutaneously or laparoscopically, and encouraging results have been obtained with it for treatment of neuroendocrine liver metastases.

Randomized control trials on chemoembolization for hepatocellular carcinoma: is there room for new studies?

Hepatocellular carcinoma (HCC) generally occurs in patients with cirrhosis. Curative options, such as liver transplantation, hepatic resection, and percutaneous alcohol injection, are applicable to a minority of cases. Because systemic chemotherapy and radiation therapy provide dismal results, transarterial chemoembolization (TACE) remains the sole approach to antagonizing the cancer growth in most patients. Although most tumors show an extensive necrosis after TACE, the beneficial effect on survival has not been properly substantiated, so that its application still remains a matter of debate. This review analyzes the results of randomized clinical trials on TACE. In most studies, TACE did not increase the survival of patients as compared with the palliative treatment. However, several methodologic and technical pitfalls may have adversely affected the results of these trials, such as inadequate patient selection and statistical power of the study design, a nonoptimal procedure, and treatment repetition not tailored to the cancer response and patient tolerance. Nonetheless, the literature will hardly be enriched by new trials including untreated patients because, wrong or right, TACE is currently considered the standard treatment of unresectable HCC. It seems more realistic to expect randomized studies comparing different techniques and time schedules of treatment, as well as TACE alone versus combined procedures.

Locoregional Management of Hepatocellular Carcinoma: Surgical and Ablation Therapies

The selection of an appropriate treatment strategy for patients with HCC depends on careful tumor staging and assessment of the underlying liver disease (Fig. 5). All patients with localized HCC (involvement of one single lobe, no vascular invasion or extrahepatic disease) should be evaluated for the potentially curative therapeutic options of partial hepatectomy or OLT. Candidates for partial hepatectomy must have no liver disease or Child's A cirrhosis, normal portal pressure, and normal serum bilirubin. For patients not meeting these criteria, OLT should be considered if there is a solitary lesion smaller than 5 cm in diameter or fewer than three lesions smaller than 3 cm. Local ablative therapies such as PEI, RFA, and TACE offer palliation for patients for whom surgical approaches are contraindicated. Percutaneous alcohol injection and RFA are minimally invasive and can be used on an outpatient basis, usually for tumor nodules smaller than 3 cm. When these therapies are used for small tumors, the survival rates can be similar to those achieved by partial hepatectomy. Transcatheter [figure: see text] arterial chemoembolization may be used as an interim treatment for patients waiting for OLT. Although TACE is often used for the palliation of large tumors, significant survival benefits have not yet been demonstrated for this indication.

Percutaneous interstitial thermotherapy of malignant liver tumors

Description of local ablative techniques such as laser-induced thermotherapy (LITT) and radiofrequency ablation in the percutaneous interstitial thermotherapy for malignant liver tumors. MR-guided LITT is currently performed by means of implantable percutaneous catheter systems. CT is used to control the insertion of the catheter. Irrigated administration systems are available both for LITT and for radiofrequency therapy. At present LITT enables a local tumor control of 97.2% for localized liver metastases without extrahepatic spreading patterns. In a group of 381 patients the average survival times were 45.7 months for patients with liver metastasis, 42.7 months for those with colorectal liver metastases, and 32 months for HCC tumors. The data for radiofrequency ablation confirm the high value for tumor control of hepatocellular carcinomas with poorer results for liver metastases. Percutaneous, MR-guided LITT permits good tumor control of liver metastases smaller than 5 cm and less than 5 in number. For HCC, at present percutaneous injection of alcohol, radiofrequency ablation, and LITT are equally effective.

Liver metastases: interventional therapeutic techniques and results, state of the art.

The liver is the most common site of metastatic tumour deposits. Hepatic metastases are the major cause of morbidity and mortality in patients with gastrointestinal carcinomas and other malignant tumours. The rationale and results for interventional therapeutic techniques in the treatment of liver metastases are presented. For the treatment of patients with irresectable liver metastases, alternative local ablative therapeutic modalities have been developed. Technique and results of local interventional therapies are presented such as microwave-, radiofrequency (RF)- and ultrasound ablation, and laser-induced interstitial therapy (LITT), cryotherapy and local drug administration such as alcohol injection, endotumoral chemotherapy and regional chemoembolisation. In addition to cryotherapy, all ablative techniques can be performed percutaneously with low morbidity and mortality. Cryotherapy is an effective and precise technique for inducing tumour necrosis, but it is currently performed via laparotomy. Percutaneous local alcohol injection results in an inhomogeneous distribution in liver metastases with unreliable control rates. Local chemotherapeutic drug instillation and regional chemoembolisation produces relevant but non-reproducible lesions. Laser-induced interstitial thermotherapy (LITT) performed under MRI guidance results in precise and reproducible areas of induced necrosis with a local control of 94%, and with an improved survival rate. Interventional therapeutic techniques of liver metastases do result in a remarkable local tumour control rate with improved survival results.

Echolaparoscopic-guided alcohol injection of liver metastases.

Ultrasound-guided percutaneous alcohol injection of liver metastases or hepatocellular carcinoma represents a well-established alternative to surgery when surgical resection is contraindicated. The aim of this report is to describe the technique of echolaparoscopic-guided alcohol injection of liver metastases in a patient undergoing palliative treatment for adenocarcinoma of the cardia. This procedure provides a more accurate staging of the disease and a safe approach to liver metastases with difficult anatomical location in patients unsuitable for surgical resection.

Practical considerations in the treatment of hepatocellular carcinoma.

Hepatocellular carcinoma (HCC) represents one of the most common neoplasms worldwide. To date, curative treatment options include liver transplantation or resection. Unfortunately, most patients are detected with nonresectable or -transplantable HCC due to disease extension or comorbid factors, and are therefore candidates only for palliative treatments. Palliative medical treatments, including systemic chemotherapy, immunotherapy or hormonal manipulation, have a borderline activity on HCC and cannot be recommended outside clinical trials. A high response rate has been reported with local therapies such as transcatheter arterial embolisation, intra-arterial chemotherapy or percutaneous alcohol (ethanol) injection, but as there is no clear evidence of a survival advantage for these treatment modalities, further investigations are required. Multidisciplinary treatment, including preoperative cytoreduction or postoperative adjuvant therapy, is currently under investigation, with encouraging survival results. HCC patients should be evaluated within clinical trials, possibly randomised and with homogeneous prognostic factors, in order that we may find the answer to all these important questions.

Preliminary study of percutaneous alcohol injection into the lung.

Although percutaneous ethanol injection is widely used to treat hepatic tumors, this technique has not been applied to lung tumors. We performed a preliminary experiment with percutaneous ethanol injection into the rabbit lung, and evaluated the local and systemic effects of absolute ethanol injection on pulmonary structures in order to assess the feasibility and safety of this technique as a local treatment for human lung tumors. Percutaneous injection of absolute ethanol into the rabbit lung was performed under CT guidance. The volume of ethanol injected ranged from 0.6 to 1.0 ml (approximately 0.2–0.5 ml/kg). Follow‐up CT scans were performed 1, 2, 7 and 30 days after the injection. The animals were killed at intervals (range: 3 h–30 days), and the lung was examined histologically. The ethanol was well tolerated and did not induce significant systemic side‐effects. All doses induced necrosis in the injected lung, but none was lethal. Although ethanol spilling into the thoracic cavity induced effusion and pleuritis, these reactions were manageable. Alcohol injection produced an area of necrosis surrounded by pulmonary edema associated with polymorphonuclear cells invasion within 24 h; moreover, granulation change, epithelial regeneration, and alveolar septal fibrosis had appeared by one week. The necrosis was sometimes multifocal, probably due to transbronchial spread of the injected ethanol. In conclusion, the feasibility and safety of absolute ethanol injection were confirmed. Neither severe systemic side effects nor lethal extensive necrosis were observed with injected ethanol; however, an unexpected side effect, multifocal necrosis, was seen. The latter reaction suggests that careful observation and care would be essential after alcohol injection into the lung.