C.S. Ho, R. Beecroft, K. Tan, J.R. Kachura, L. Dawson, P. Greig, D. Grant, M. Sherman, D. Wong, S. Gallinger, F. Wong; Toronto/CA

Purpose
Purpose: Conventional small volume alcohol injection and RF ablation are both effective and safe in treating small hepatomas 3 cm or less. However, optimal treatment for unresectable, exophytic or subcapsular medium (3 cm – 4.9 cm) and large (>5 cm) hepatocellular carcinomas remains a challenge. We have treated this group with large volume alcohol injection under conscious sedation. This study evaluates the efficacy and complication of this approach.

Material and methods
34 patients, 21 men and 13 women, aged 39 -82 years had cirrhosis (Child’s A or B) complicated by unresectable hepatomas. Under conscious sedation, a large volume of alcohol was injected into the lesion with an extendible, multi-pronged needle (Quadrafuse needle, Rex Medical. Philadelphia, PA). Real time ultrasound was used for guidance and monitoring of the injection. Each patient received 3 weekly injections or less, depending on the response to previous injection as assessed by contrast-enhanced ultrasound, CT or MR. If necessary, further treatment with RF ablation or conformal radiation was applied for those with incomplete necrosis. Follow up imaging was performed first at 2 weeks and subsequently at 3-month intervals.

Results
Results: An average total of 55 ml of alcohol was injected in an average of 2.3 sessions. Complete necrosis was noted in 19 (56%), near complete necrosis (90 % - 99%) in 12 (35%) and partial necrosis (50% -89%) in 3 (9 %). One patient died of respiratory failure 2 weeks after 50 ml of alcohol was injected. One patient had renal failure and hepatic encephalopathy and asymptomatic local gastric perforation; he responded to conservative treatment and surgery was not required. One patient had tumor seeding. At 30 months follow up, 5 patients had died from the disease. Local recurrence was found in 7 patients and new hepatomas in other parts of the liver in another 7, including one with pulmonary metastases.

Conclusion
Conclusion: Large volume of alcohol can be injected with a new extendible multi-pronged needle under conscious sedation. It is efficacious and relatively safe in treating unresectable medium and large hepatomas in the cirrhotic patients. We await furhter evaluation of its long-term survival benefit.