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Background: Radiofrequency ablation (RFA) has been widely applied for the treatment of hepatocellular carcinoma and liver metastases. The reported mortality and morbidity rates are low. The aim of this study is to evaluate the safety and efficacy of RFA, and compare the results performed percutaneously versus surgically., Patients and Methods: From 2003 to 2006, 79 patients with hepatic malignancies (59 hepatocellular carcinoma, 20 liver metastases) with a total of 110 lesions underwent RFA in our centre. Postablation assessment by CT scan was performed in all patients at 1-, 3- and 6-month intervals. Post-procedural complications, recurrence and survival were analysed., Results: The patients' mean age was 60.0 years. In 46.8% of cases, we used a percutaneous approach; in 53.2% of cases, a surgical approach (8.9% laparoscopic; 44.3% open) was used if percutaneous approach was not feasible. The mean tumour size was 2.4 cm. Within the surgical group, 69% of patients received concomitant operative procedures such as cholecystectomy and hepatectomy. No treatment-related mortality was observed. Immediate complications occurred in five patients (6.3%), including gastric serosal burn (n = 1), ground pad superficial skin burn (n = 1), intra-abdominal bleeding (n = 2) and pleural effusion (n = 1). All patients except one attended subsequent follow-up, with a mean period of 16 months. Ablation was considered complete in 82.3% of patients (percutaneous approach 81.1%, surgical approach 83.3%, p = 0.72). Intrahepatic recurrence was observed in 52.3%, the majority of them located away from the RFA site. Extrahepatic recurrences were observed in 16.9% (percutaneous approach 16.7%, surgical approach 17.1%, p = 0.76). The overall one- and two-year survival rate was 93.7% and 74.4% respectively, and no statistically significant difference was observed between the two approaches., Conclusion: RFA is a safe and effective procedure for treating patients with malignant liver tumours. No difference in short term outcomes was observed between percutaneous and surgical approaches. A more prolonged follow-up study is required to assess longer-term outcomes.

A 45-year-old male received wedge resection for his small hepatocellular carcinoma in April 1989 and extended right lobectomy for tumor recurrence 8 months later. Unfortunately, recurrent hepatic tumor with lung metastases were found 18 months after the second operation. Both the hepatic and pulmonary recurrent tumors were resected and transcatheter arterial embolization was added for the residual hepatic tumors. He remained symptom free for another 18 months. However, mediastinal lymphadenopathy, superior vena cava thrombus with superior vena cava syndrome, cardiac and brain metastases developed subsequently. He died of increased intracranial pressure. It is rare for hepatocellular carcinoma to have mediastinal metastases, superior vena cava thrombus and superior vena cava syndrome.

Sepsis and liver abscess are serious complications following transarterial embolization (TAE) for hepatocellular carcinoma (HCC). However, the exact incidence and the necessity of antibiotic prophylaxis remain undetermined. Between November 1996 and November 1997, we prospectively studied bacterial infections in 231 HCC patients who underwent 287 angiographic procedures without antibiotic prophylaxis, including 176 TAEs and 111 hepatic arteriographies (HAs). Four of the 111 HAs were complicated by transient asymptomatic bacteremia. Of the 176 TAEs, 2 were associated with asymptomatic bacteremia, and 7 (4%) were associated with symptomatic bacterial infection, including 3 cases of sepsis, 2 of liver abscess, and 2 of infected biloma. For patients with HCC, TAE was associated with a higher risk of developing symptomatic bacterial infections than was HA (4% vs. 0, respectively; P = .03). Previous gastrectomy was the only possible risk factor for liver abscess. Finally, early diagnosis and treatment of these infectious complications usually result in successful outcome.

Transcatheter arterial embolization (TAE), a common treatment for patients with unresectable hepatocellular carcinoma (HCC), can provoke severe physical discomfort and psychologic stress. The purpose of this study was to investigate the effect of a combination of health education, muscle relaxation, and back massage on reducing physical and psychologic stress in HCC patients receiving TAE. A quasi-experimental design was used. Forty patients with HCC (30 men and 10 women) with a mean age of 57 +/- 12 years were recruited and randomly assigned to the control or experimental group. The effectiveness of the stress management program was evaluated using a knowledge questionnaire, a worry inventory, a state-trait anxiety inventory, and a physical distress scale. After completing the stress management program, the experimental group had a greater mean increase in knowledge score than the control group (5.1 vs 0.8, p < 0.0001) and a greater mean decrease in worry score (-8.2 vs 1.1, p < 0.0001). The mean decrease in the anxiety score in the experimental group was also significantly greater than in the control group before TAE (-5.8 vs 3.2, p < 0.001) and 2, 4, 6, and 7 days after TAE (-8.2 vs 7.1, p < 0.001; -8.7 vs 3.2, p < 0.001; -9.8 vs -2.1, p < 0.05; -11 vs -0.9, p < 0.05). The patients in the experimental group had a smaller mean increase in physical distress score than the control group at 2, 4, 6, and 7 days after TAE (34.7 vs 50.2, 20.9 vs 29.6, 10.6 vs 18.2, 3.9 vs 11.2, all p < 0.05). This stress management program effectively reduces the stress of HCC patients undergoing TAE.

Computed tomography (CT) during arterial portography (CTAP) is useful in detecting hepatic tumors but cirrhotic change may interfere with portal flow and the prediction of resectability. We evaluated the usefulness of CTAP in detecting hepatic tumors, especially hepatocellular carcinoma (HCC), in patients with or without cirrhotic change. Ninety-six patients with pathologically proven hepatic tumors were assessed, of whom 90 had hepatocellular carcinoma. The tumors had been previously detected by abdominal ultrasound and CT scans, after which the patients were referred for angiography and CTAP. The CTAP findings were compared with ultrasonographic, conventional CT, angiographic, and subsequent surgical and pathologic findings regarding size, number, and location of the hepatic lesions. CTAP detected 134 of 143 pathologically proven lesions. The overall sensitivity of CTAP in the 96 patients was 94%, with a false-positive rate of 22%. The detection rate of CTAP for tumors less than 2 cm in diameter was high (92%). The sensitivity and false-positive rate for CTAP in 60 cirrhotic patients were 94% and 23%, respectively, CTAP is a sensitive imaging modality for detection of hepatic neoplasms even in patients with cirrhosis, but its false-positive rate is high.

Objectives: To present the clinical and microbiological features of liver abscess after transarterial embolization (TAE) for hepatocellular carcinoma (HCC)., Methods: We retrospectively reviewed records of 452 TAE procedures in 289 patients with HCC over a 2-yr period., Results: Four men and one woman with a mean age of 68.4 yr were diagnosed with liver abscess 1-8 wk (mean 4.6 wk) after the embolization. The incidence was 1.1% (5/452). Common symptoms included fever, chills, and right upper quadrant pain. Serum aminotransferase, alkaline phosphatase, and gamma-glutamyltransferase levels and leukocyte count were frequently elevated. All the abscesses appeared as areas of hypodensity on CT scan and hypoechogenicity on ultrasonogram. The areas contained gas in the embolized tumor, which led to the suspicion and finally the diagnosis of abscess. In contrast to predominance of gram-negative aerobes in sporadic pyogenic liver abscesses, the causative microorganism was predominantly gram positive (60%). All patients were treated with parenteral antibiotics plus percutaneous aspiration, drainage, or operation, but one patient died from the abscess., Conclusions: For patients receiving TAE for HCC, few specific clinical or radiological features could readily differentiate patients complicated with liver abscess from those without. This may delay a timely diagnosis and lead to significant morbidity. Hence, in patients with risk factors, including old age, previous biliary tract disease, large tumor size (>5 cm), and gas forming in the embolized tumor, aspiration of the suspected focal hepatic lesion should be performed as soon as possible.

Objective: The aim of this study was to evaluate the long-term benefits of the aggressive treatments with resection or transarterial chemoembolization (TACE) for recurrent hepatocellular carcinoma (HCC)., Summary Background Data: Primary HCC is one of the most fatal malignancies in Taiwan. The result of resection for HCC remains unsatisfactory, primarily due to the high recurrence rate. To improve surgical results, recurrent HCC must be treated with aggressive resection or TACE., Methods: The authors evaluated the results of repeated hepatic resection among 25 patients with recurrent HCC and of TACE among 12 patients with resectable recurrent HCC. The outcomes of an additional 64 patients with unresectable recurrent HCC were also evaluated., Results: During the follow-up period from 2-112 months, 52% (13/25) of patients receiving repeat resection (group 1) were alive, whereas 42% (5/12) of patients receiving TACE (group 2) were alive. No perioperative deaths within 30 days after surgery occurred in the repeated resection group. The cumulative survival rates at 1, 2, 3, and 5 years after the first operation were 92%, 84%, 71.6%, and 65.1% in group 1 and 83.3%, 75%, 75%, and 22.5% in group 2. The survival rates at 6 months and at 1, 2, and 3 years after recurrence were 92%, 72%, 64%, and 44.8% in group 1 and 83.3%, 75%, 66.7%, and 48% in group 2. The survival of patients with unresectable recurrent HCC was much worse: 1-, 2-, 3-, and 5-year survival after surgery was 57.8%, 29.8%, 15.5%, and 0%; and 6-month and 1-, 2-, and 3-year survival after recurrence was 46.5%, 29.2%, 12.5% and 7.8%., Conclusions: More aggressive treatment with repeated hepatic resection can prolong survival time after recurrence of HCC in selected patients. However, TACE can also achieve good results although it is not thought of as curative.

Intratumor injection of absolute ethanol to treat small hepatocellular carcinoma sometimes results in incomplete necrosis of the tumor. Causes of this include inhomogeneous distribution of the ethanol and difficulty in identifying the tumor after previous ethanol injections. To solve these problems, the authors designed a multiple-side-hole needle for ethanol injection and implanted one or more small steel coils into the tumor before treatment to serve as a landmark. Six patients thus treated all showed adequate necrosis on follow-up computed tomography, biopsy, and angiography studies; initially elevated serum alpha-fetoprotein levels present in five patients were decreased. A resected surgical specimen obtained in one patient showed extensive necrosis of the tumor as well as of the surrounding healthy liver; only a small locus of equivocally viable cancer cells remained in the tumor margin.

Ten cases of large hepatocellular carcinoma (HCC) (largest diameter, 6.5-15 cm) were surgically resected from 3 to 19 days after transcatheter hepatic arterial embolization (TAE) for histologic assessment of the effectiveness. Another two patients, including one with a small HCC (3.5 X 3 X 3 cm) who died of complications, were also studied. The patients' ages ranged from 20 to 64 years, 11 were men and 1 was a woman, and all positive for serum hepatitis B surface antigen. All 11 cases with large HCC were symptomatic before the HCC was clinically diagnosed. Alpha-fetoprotein levels were elevated in ten cases but immediately dropped to normal levels after TAE and resection in eight cases. An effective massive tumor coagulative necrosis of 99% already occurred 3 days after TAE. A necrosis involving more than 95% of the whole tumor mass was demonstrated in eight cases: one was a large HCC taken from an autopsy specimen, and TAE was done three times. This strongly indicates the effectiveness of TAE on the destruction of HCC. However, the presence of viable residual tumors in 11 cases also strongly argues for the necessity for surgical resection whenever it is possible. The failure of a complete necrosis was related to the extracapsular extension, liver invasion, satellite nodules, and portal vein involvement, and probably related to collateral and portal vein blood supply.

Abdominal ultrasonography using a high-resolution linear-array real-time scanner was compared to computed tomography, celiac arteriography, and radionuclide imaging in 24 patients with a total of 33 hepatocellular carcinomas (HCC), 10 patients with cavernous hemangioma (12 tumors), and 2 patients with metastatic carcinoma of the liver (3 tumors), all smaller than 3 cm. Ultrasound proved to be the most sensitive method of detecting such small tumors. Most small HCCs were hypoechoic and most small hemangiomas hyperechoic. Aspiration cytology and/or biopsy under ultrasound guidance detected 92.3% of HCCs and 100% of hemangiomas. Intraoperative ultrasound was employed in 19 cases of small HCC and aided resection in 8. Real-time ultrasound may play a prominent role in early detection and diagnosis of small HCCs.

For the treatment of small hepatocellular carcinoma, intratumor injection of absolute ethanol under ultrasound guidance was performed in 27 tumors in 23 patients, with a tumor diameter of between 1.0 and 3.3 cm. The initially elevated serum alpha-fetoprotein levels in 15 patients decreased during treatment, with 13 returning to normal after this regimen. In the 6 patients who finally received surgical resection, 4 had complete necrosis of the tumor, while the other 2 had a small peripheral residual cancer nest. In the remaining non-resected 17 cases, follow-up CT, multiple biopsies and angiography revealed evidence of viable tumor in only 3 cases. After additional ethanol injections, these 3 cases were successfully treated. Inhomogeneous distribution of the injected ethanol and difficulty in identifying the tumor after previous injections accounted for the incomplete necrosis of the tumor. To cope with these problems, a steel coil was implanted in the tumor before treatment, and a needle with multiple side holes was used in the last 3 cases, with satisfactory results. Ethanol injection is promising and may even be curative in the treatment of small hepatocellular carcinoma.