achieve complete necrosis of HCC. [9][10][11][12][13][14] The long-term survival To assess the efficacy of ultrasound-guided percutanerate for patients with large HCC after TAE is low. [15][16][17] Thus, ous acetic acid (15%, 20%, 30%, 40%, and 50% in concenthere is a strong demand for other effective therapies and for tration) injection for a large nodular hepatocellular carimprovement of TAE results in the treatment of large HCC.
cinoma (HCC), percutaneous acetic acid injection was
Recently, we developed a technique called ultrasound (US)performed using 15% to 50% acetic acid in 28 patients guided percutaneous acetic acid injection (PAI) in which 15% who had one single nodular HCC larger than 3 cm or to 50% acetic acid is used for the treatment of small HCC one main tumor with fewer than two HCCs smaller than and reported that this was effective in the treatment of HCC 3 cm during the past 7.5 years; the main tumor was smaller than 3 cm 19,20 because none of the tumors treated slightly hypervascular in nine patients and was highly with PAI grew again, and the survival rates for patients after hypervascular, showing viable cancer cells despite PAI were better than those for untreated patients. 19-23 transcatheter arterial embolization in 19 patients. Dur-Herein, we report our experience of US-guided PAI in 28 ing the series of treatment sessions for each patient, the patients with nodular HCC larger than 3 cm that was slightly same concentration of acetic acid was used. Eight (89%) hypervascular (n Γ
9) or was highly hypervascular and of nine slightly hypervascular main tumors, 18 (95%) of showed viable cancer cells despite TAE (n Γ
19). 19 highly hypervascular main tumors, and all 14 small tumors were treated successfully. No serious complica-
PATIENTS AND METHODS tions occurred as a direct sequela to acetic acid injec-
Twenty-eight patients with nodular HCC ΓΊ3 cm in diameter untion. The 1-, 2-and 3-year recurrence rate from the origiderwent US-guided PAI using concentrations of a 15%, 20%, 30%, nal main tumor was 0%, 20%, and 20%, respectively, in 40%, and 50% acetic acid solution at the Third Department of Medipatients treated with percutaneous acetic acid injection cine, Saitama Medical School, Japan, and two affiliated hospitals in alone and 12%, 24%, and 24% in patients treated with Chiba City, Japan, during the past 7.5 years. Informed consent was percutaneous acetic acid injection after transcatheter obtained from each patient and a family member before treatment. arterial embolization (P Γ
NS). The 1-, 2-, 3-, 4-, and 5-Percutaneous acetic acid injection was performed on an inpatient year survival rates were 100%, 80%, 80%, 80%, and 0%, basis. Criteria for treatment with PAI included the following: (1) respectively, in the former and 90%, 81%, 81%, 61%, and nodular HCC lesion with a diameter ΓΊ3 cm, occurring singly or in association with no more than two small HCCs Γ΅3 cm, (2) US detec-
61% in the latter (P Γ
NS). Percutaneous acetic acid in-
tion of the lesion, and (3) no evidence of portal vein thrombosis or jection (15% to 50%) may be an effective therapy for extrahepatic metastases. The patients were 17 men and 11 women slightly hypervascular nodular HCCs larger than 3 cm aged 44 to 76 years (mean, 63 years). Twenty-six patients had histoand highly hypervascular nodular HCCs larger than 3 logically proven cirrhosis; the etiology of cirrhosis was alcoholic in cm that remain partly viable after transcatheter arterial 1, hepatitis B in 4, hepatitis C in 20, and non-B, non-C hepatitis in embolization. (HEPATOLOGY 1996;24:1379-1385.) 1. The underlying liver disease of remaining two patients was as follows: chronic active hepatitis C in 1 and non-B, non-C chronic persistent hepatitis in 1. All patients were classified on admission A large number of small hepatocellular carcinomas (HCCs) according to Child's grade for portal hypertension 24 ; for Child C, a less than 3 cm in diameter have been detected by an early single worst criterion was used (albumin Β°3 g/dL, total bilirubin detection screening program for HCC in endemic regions. [1][2][3] Β’3 mg/dL, massive ascites, or hepatic encephalopathy). Eighteen However, in practice more than two thirds of HCCs treated patients had Child class A disease, 5 had class B disease, and 5 had are still larger than 3 cm. 4 Hepatic resection 5-7 and transcathclass C disease. Three patients had undergone endoscopic sclerother- eter arterial embolization (TAE) [8][9][10][11][12][13][14][15][16][17][18] are widely carried out apy 25 for large and risky esophageal varices 26 shortly after HCC was and are effective means for treating large HCCs. Hepatic diagnosed. Seventeen patients had a solitary HCC lesion, 8 had one resection is indicated only in the patients with good hepatic small HCC, and 3 had two small HCCs in addition to the main tumor.
Diagnosis of HCC was made by biopsy with an 18-or 21-gauge needle functional reserve. [5][6][7] In contrast, the indication of TAE is (Hirata Sangyo, Tokyo, Japan) under US guidance. The baseline data much broader, although it is not indicated for HCC that is used were (1) US findings and measurements of two-dimensional size not hypervascular. 8-18 Furthermore, TAE alone often fails to of tumor, (2) serum a-fetoprotein (AFP) levels, (3) plasma proteins induced by vitamin K absence or antagonist II (PIVKA-II) levels, (4) angiographic findings, and (5) computed tomographic (CT) findings obtained from plain and contrast-enhanced imaging or dynamic im-Abbreviations: HCC, hepatocellular carcinoma; TAE, transcatheter arterial embolization; US, ultrasound; PAI, percutaneous acetic acid injection; AFP, a-fetoprotein; PIVKA-aging performed after administration of a bolus of contrast material II, proteins induced by vitamin K absence or antagonist II; CT, computed tomography; PEI, as described previously. 27 percutaneous ethanol injection.