Percutaneous Ethanol Injection Injectables in the Treatment of Primary Liver Cancers

Reference work entry


Percutaneous local ablation therapy is the best treatment option for patients with early-stage hepatocellular carcinoma (HCC) who are not suitable for resection or transplantation. Percutaneous ethanol injection (PEI) is the first mainstream modality of ablation and used to be a standard alternative therapy for unresectable small HCCs since the 1980s. To achieve complete devitalization of the tumor, conventional PEI using a fine needle usually needs multiple treatment sessions dependent on the tumor size, typically 4–12 sessions at twice-weekly interval. Conventional PEI offers satisfactory local efficacy and long-term survival in treating tumors smaller than 3 cm, but unsatisfactory complete response of tumors larger than 3 cm, mainly because of the influence of intratumoral septa. There have been major efforts to develop new methods for solving this problem. Single-session high-dose PEI using a single needle, simultaneous multiple needles, and a multi-pronged needle was subsequently applied. The latest multi-pronged PEI injection devices achieve better local efficacy than conventional PEI and are able to treat early-stage or recurrent HCC up to 5 cm effectively and safely, even for lesions at high-risk locations. Combined use of PEI with radio-frequency ablation may potentially improve the local efficacy of both techniques. Compared with radio-frequency ablation, PEI has the advantages of minor side effects, simplicity, and low cost. Local efficacy of PEI has been improved by innovative technique. Therefore, PEI will continue to play a role in the treatment of HCC.


Complete Response Rate Percutaneous Ethanol Injection Radio Frequency Ablation Major Complication Rate Local Efficacy 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.


  1. 1.
    El-Serag HB, Mason AC. Rising incidence of hepatocellular carcinoma in the United States. N Engl J Med. 1999;340:745–50.CrossRefPubMedGoogle Scholar
  2. 2.
    Peto J. Cancer epidemiology in the last century and the next decades. Nature. 2001;411:390–5.CrossRefPubMedGoogle Scholar
  3. 3.
    Bosch FX, Ribes J, Diaz M, Cleries R. Primary liver cancer: worldwide incidence and trends. Gastroenterology. 2004;127(5 Suppl 1):S5–16.CrossRefPubMedGoogle Scholar
  4. 4.
    Bruix J, Sherman M. Management of hepatocellular carcinoma. Hepatology. 2005;42:1208–36.CrossRefPubMedGoogle Scholar
  5. 5.
    Llovet JM, Fuster J, Bruix J of the Barcelona-Clı′nic Liver Cancer Group. The Barcelona approach: diagnosis, staging, and treatment of hepatocellular carcinoma. Liver Transpl. 2004;10:S115–20.Google Scholar
  6. 6.
    Llovet JM, Burroughs A, Bruix J. Hepatocellular carcinoma. Lancet. 2003;362:1907–17.CrossRefPubMedGoogle Scholar
  7. 7.
    Zhou XD, Tang ZY, Yang BH, Lin ZY, Ma ZC, Ye SL, et al. Experience of 1000 patients who underwent hepatectomy for small hepatocellular carcinoma. Cancer. 2001;91:1479–86.CrossRefPubMedGoogle Scholar
  8. 8.
    Lang BH, Poon RT, Fan ST, Wong J. Perioperative and long-term outcome of major hepatic resection for small solitary hepatocellular carcinoma in patients with cirrhosis. Arch Surg. 2003;138:1207–13.CrossRefPubMedGoogle Scholar
  9. 9.
    Mazzaferro V, Regalia E, Doci R, et al. Liver transplantation for the treatment of small hepatocellular carcinoma in patients with cirrhosis. N Engl J Med. 1996;334:693–9.CrossRefPubMedGoogle Scholar
  10. 10.
    Llovet JM, Fuster J, Bruix J. Intention-to-treat analysis of surgical treatment for early hepatocellular carcinoma: resection versus transplantation. Hepatology. 1999;30:1434–40.CrossRefPubMedGoogle Scholar
  11. 11.
    Bruix J, Llovet JM. Prognostic prediction and treatment strategy in hepatocellular carcinoma. Hepatology. 2002;35:519–24.CrossRefPubMedGoogle Scholar
  12. 12.
    Fong Y, Sun RL, Jarnagin W, Blumgart LH. An analysis of 412 cases of hepatocellular carcinoma at a Western center. Ann Surg. 1999;229:790–800.CrossRefPubMedPubMedCentralGoogle Scholar
  13. 13.
    Lee WC, Jeng LB, Chen MF. Estimation of prognosis after hepatectomy for hepatocellular carcinoma. Br J Surg. 2002;89:311–6.CrossRefPubMedGoogle Scholar
  14. 14.
    Jarnagin WR, Fong Y. Repeat resection for liver tumors. In: Clavien PA, editor. Malignant liver tumors: current and emerging therapies. Boston: Blackwell Science; 1999. p. 150–8.Google Scholar
  15. 15.
    Lu MD, Yin XY, Xie XY, et al. Percutaneous thermal ablation for recurrent hepatocellular carcinoma after hepatectomy. Br J Surg. 2005;92:1393–138.CrossRefPubMedGoogle Scholar
  16. 16.
    Sugiura N, Takara K, Ohto M, Okuda K, Hirooka N. Ultrasound guided ethanol injection for the treatment of small hepatocellular carcinoma. Acta Hepatol Jpn. 1983;21:920.Google Scholar
  17. 17.
    Livraghi T, Festi D, Monti F, Salmi A, Vettori C. US-guided percutaneous alcohol injection of small hepatic and abdominal tumors. Radiology. 1986;161:309–12.CrossRefPubMedGoogle Scholar
  18. 18.
    Livraghi T. Role of percutaneous ethanol injection in the treatment of hepatocellular carcinoma. Dig Dis. 2001;19:292–300.CrossRefPubMedGoogle Scholar
  19. 19.
    Ebara M, Okabe S, Kita K, et al. Percutaneous ethanol injection for small hepatocellular carcinoma: therapeutic efficacy based on 20-year observation. J Hepatol. 2005;43:458–64.CrossRefPubMedGoogle Scholar
  20. 20.
    Lencioni R, Llovet JM. Percutaneous ethanol injection for hepatocellular carcinoma: alive or dead? J Hepatol. 2005;43:377–80.CrossRefPubMedGoogle Scholar
  21. 21.
    Livraghi T, Giorgio A, Marin G, et al. Hepatocellular carcinoma and cirrhosis in 746 patients: long-term results of percutaneous ethanol injection. Radiology. 1995;197:101–8.CrossRefPubMedGoogle Scholar
  22. 22.
    Sala M, Llovet JM, Vilana R, Bianchi L, Sole M, Ayuso C, Barcelona Clinic Liver Cancer Group, et al. Initial response to percutaneous ablation predicts survival in patients with hepatocellular carcinoma. Hepatology. 2004;40:1352–60.CrossRefPubMedGoogle Scholar
  23. 23.
    El–Serag HB, Marrero JA, Rudolph L, Reddy KR. Diagnosis and treatment of hepatocellular carcinoma. Gastroenterology. 2008;134:1752–63.CrossRefPubMedGoogle Scholar
  24. 24.
    Khan KN, Yatsuhashi H, Yamasaki K, et al. Prospective analysis of risk factors for early intrahepatic recurrence of hepatocellular carcinoma following ethanol injection. J Hepatol. 2000;32:269–78.CrossRefPubMedGoogle Scholar
  25. 25.
    Pompili M, Rapaccini GL, Covino M, et al. Prognostic factors for survival in patients with compensated cirrhosis and small hepatocellular carcinoma after percutaneous ethanol injection therapy. Cancer. 2001;92:126–35.CrossRefPubMedGoogle Scholar
  26. 26.
    Lencioni R, Pinto F, Armillotta N, et al. Long-term results of percutaneous ethanol injection therapy for hepatocellular carcinoma in cirrhosis: a European experience. Eur Radiol. 1997;7:514–9.CrossRefPubMedGoogle Scholar
  27. 27.
    Arii S, Yamaoka Y, Futagawa S, et al. Results of surgical and nonsurgical treatment for small-sized hepatocellular carcinomas: a retrospective and nationwide survey in Japan. The Liver Cancer Study Group of Japan. Hepatology. 2000;32:1224–9.CrossRefPubMedGoogle Scholar
  28. 28.
    Lencioni R, Vignali C, Caramella D, Cioni R, Mazzeo S, Bartolozzi C. Transcatheter arterial embolization followed by percutaneous ethanol injection in the treatment of hepatocellular carcinoma. Cardiovasc Intervent Radiol. 1994;17:70–5.CrossRefPubMedGoogle Scholar
  29. 29.
    Livraghi T, Benedini V, Lazzaroni S, Meloni F, Torzilli G, Vettori C. Long term results of single session percutaneous ethanol injection in patients with large hepatocellular carcinoma. Cancer. 1998;83:48–57.CrossRefPubMedGoogle Scholar
  30. 30.
    Shiina S, Hata Y, Niwa Y, et al. Multiple-needle insertion method in percutaneous ethanol injection therapy for liver neoplasms. Gastroenterol Jpn. 1991;26:47–50.PubMedGoogle Scholar
  31. 31.
    Lin SM, Lin CJ, Lin CC, Hsu CW, Chen YC. Radiofrequency ablation improves prognosis compared with ethanol injection for hepatocellular carcinoma < or = 4 cm. Gastroenterology. 2004;127:1714–23.CrossRefPubMedGoogle Scholar
  32. 32.
    Shiina S, Teratani T, Obi S, Sato S, Tateishi R, Fujishima T. A randomized controlled trial of radiofrequency ablation with ethanol injection for small hepatocellular carcinoma. Gastroenterology. 2005;129:122–30.CrossRefPubMedGoogle Scholar
  33. 33.
    Hines-Peralta A, Liu ZJ, Horkan C, Solazzo S, Goldberg SN. Chemical tumor ablation with use of a novel multiple-tine infusion system in a canine sarcoma model. J Vasc Interv Radiol. 2006;17:351–8.CrossRefPubMedGoogle Scholar
  34. 34.
    Ho CS, Kachura JR, Gallinger S, et al. Percutaneous ethanol injection of unresectable medium-to-large-sized hepatomas using a multipronged needle: efficacy and safety. Cardiovasc Intervent Radiol. 2007;30:241–7.CrossRefPubMedGoogle Scholar
  35. 35.
    Kuang M, Lu MD, Xie XY, et al. Ethanol ablation of hepatocellular carcinoma sized up to 5 cm by using a multi-pronged injection needle with high-dose strategy. Radiology. 2009;253:552–61.CrossRefPubMedGoogle Scholar
  36. 36.
    Kurokohchi K, Watanabe S, Masaki T, et al. Comparison between combination therapy of percutaneous ethanol injection and radiofrequency ablation and radiofrequency ablation alone for patients with hepatocellular carcinoma. World J Gastroenterol. 2005;11:1426–32.CrossRefPubMedPubMedCentralGoogle Scholar
  37. 37.
    Zhang YJ, Liang HH, Chen MS, et al. Hepatocellular carcinoma treated with radiofrequency ablation with or without ethanol injection: a prospective randomized trial. Radiology. 2007;244:599–607.CrossRefPubMedGoogle Scholar
  38. 38.
    Lencioni RA, Allgaier HP, Cioni D, et al. Small hepatocellular carcinoma in cirrhosis: randomized comparison of radio-frequency thermal ablation versus percutaneous ethanol injection. Radiology. 2003;228:235–40.CrossRefPubMedGoogle Scholar
  39. 39.
    Lin SM, Lin CJ, Lin CC, Hsu CW, Chen YC. Randomised controlled trial comparing percutaneous radiofrequency thermal ablation, percutaneous ethanol injection, and percutaneous acetic acid injection to treat hepatocellular carcinoma of 3 cm or less. Gut. 2005;54:1151–6.CrossRefPubMedPubMedCentralGoogle Scholar
  40. 40.
    Brunello F, Veltri A, Carucci P, et al. Radiofrequency ablation versus ethanol injection for early hepatocellular carcinoma: a randomized controlled trial. Scand J Gastroenterol. 2008;43:727–35.CrossRefPubMedGoogle Scholar
  41. 41.
    Livraghi T, Solbiati L, Meloni MF, Gazelle GS, Halpern EF, Goldberg SN. Treatment of focal liver tumors with percutaneous radio-frequency ablation: complications encountered in a multicenter study. Radiology. 2003;226:441–51.CrossRefPubMedGoogle Scholar
  42. 42.
    Tateishi R, Shiina S, Teratani T, et al. Percutaneous radiofrequency ablation for hepatocellular carcinoma. An analysis of 1000 cases. Cancer. 2005;103:1201–9.CrossRefPubMedGoogle Scholar
  43. 43.
    Llovet JM, Vilana R, et al. Increased risk of tumor seeding after radiofrequency thermal ablation for single hepatocellular carcinoma. Hepatology. 2001;33:1124–9.CrossRefPubMedGoogle Scholar
  44. 44.
    Lencioni R, Cioni D, Crocetti L, et al. Early-stage hepatocellular carcinoma in cirrhosis: long term results of percutaneous image-guided radiofrequency ablation. Radiology. 2005;234:961–7.CrossRefPubMedGoogle Scholar
  45. 45.
    Di Stasi M, Buscarini L, Livraghi T, et al. Percutaneous ethanol injection in the treatment of hepatocellular carcinoma: a multicenter survey of evaluation practices and complications rates. Scand J Gastroenterol. 1997;32:1168–73.CrossRefPubMedGoogle Scholar

Copyright information

© Springer Science+Business Media New York 2013

Authors and Affiliations

  1. 1.Department of Hepatobiliary Surgery and Division of Interventional UltrasoundThe First Affiliated Hospital of Sun Yat-sen UniversityGuangzhouChina
  2. 2.Institute of Diagnostic and Interventional UltrasoundThe First Affiliated Hospital of Sun Yat-sen UniversityGuangzhouChina

Personalised recommendations