title: Combination of repeated single-session percutaneous ethanol injection and transarterial chemoembolisation compared to repeated single-session percutaneous ethanol injection in patients with non-resectable hepatocellular carcinoma.
abstract: OBJECTIVE
  To evaluate the treatment effect of percutaneous ethanol injection (PEI) for patients with advanced, non-resectable HCC compared with combination of transarterial chemoembolisation (TACE) and repeated single-session PEI, repeated single-session PEI alone, repeated TACE alone, or best supportive care.
  
  
  METHODS
  All patients who received PEI treatment during the study period were included and stratified to one of the following treatment modalities according to physical status and tumor extent: combination of TACE and repeated single-session PEI, repeated single-session PEI alone, repeated TACE alone, or best supportive care. Prognostic value of clinical parameters including Okuda-classification, presence of portal vein thrombosis, presence of ascites, number of tumors, maximum tumor diameter, and serum cholinesterase (CHE), as well as Child-Pugh stage, alpha-fetoprotein (AFP), fever, incidence of complications were assessed and compared between the groups. Survival was determined using Kaplan-Meier and multivariate regression analyses.
  
  
  RESULTS
  The 1- and 3-year survival of all patients was 73% and 47%. In the subgroup analyses, the combination of TACE and PEI (1) was associated with a longer survival (1-, 3-, 5-year survival: 90%, 52%, and 43%) compared to PEI treatment alone (2) (1-, 3-, 5-year survival: 65%, 50%, and 37%). Secondary PEI after initial stratification to TACE (3) yielded comparable results (1-, 3-, 5-year survival: 91%, 40%, and 30%) while PEI after stratification to best supportive care (4) was associated with decreased survival (1-, 3-, 5-year survival: 50%, 23%, 12%). Apart from the chosen treatment modalities, predictors for better survival were tumor number (n < 5), tumor size (< 5 cm), no ascites before PEI, and stable serum cholinesterase after PEI (P < 0.05). The mortality within 2 wk after PEI was 2.8% (n = 3). There were 24 (8.9%) major complications after PEI including segmental liver infarction, focal liver necrosis, and liver abscess. All complications could be managed non-surgically.
  
  
  CONCLUSIONS
  Repeated single-session PEI is effective in patients with advanced HCC at an acceptable and manageable complication rate. Patients stratified to a combination of TACE and PEI can expect longer survival than those stratified to repeated PEI alone. Furthermore, patients with large or multiple tumors in good clinical status may also profit from a combination of TACE and reconsideration for secondary PEI.
authors.affiliation: Department of Gastroenterology, Hepatology and Endocrinology, Hannover Medical School, Germany.
authors.forename: Arne
authors.initials: A
authors.lastname: Dettmer
authors.forename: Timm-D
authors.initials: TD
authors.lastname: Kirchhoff
authors.forename: Michael
authors.initials: M
authors.lastname: Gebel
authors.forename: Lars
authors.initials: L
authors.lastname: Zender
authors.forename: Nisar-P
authors.initials: NP
authors.lastname: Malek
authors.forename: Bernhard
authors.initials: B
authors.lastname: Panning
authors.forename: Ajay
authors.initials: A
authors.lastname: Chavan
authors.forename: Herbert
authors.initials: H
authors.lastname: Rosenthal
authors.forename: Stefan
authors.initials: S
authors.lastname: Kubicka
authors.forename: Susanne
authors.initials: S
authors.lastname: Krusche
authors.forename: Sonja
authors.initials: S
authors.lastname: Merkesdal
authors.forename: Michael
authors.initials: M
authors.lastname: Galanski
authors.forename: Michael-P
authors.initials: MP
authors.lastname: Manns
authors.forename: Joerg-S
authors.initials: JS
authors.lastname: Bleck
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000970:Antineoplastic Agents / Q000008:administration & dosage / Q000627:therapeutic use; D006528:Carcinoma, Hepatocellular / Q000097:blood / Q000188:drug therapy* / Q000401:mortality / Q000473:pathology; D016461:Chemoembolization, Therapeutic / Q000009:adverse effects / Q000379:methods*; D002802:Cholinesterases / Q000097:blood; D002945:Cisplatin / Q000008:administration & dosage / Q000627:therapeutic use; D018450:Disease Progression; D004305:Dose-Response Relationship, Drug; D004317:Doxorubicin / Q000008:administration & dosage / Q000627:therapeutic use; D000431:Ethanol / Q000008:administration & dosage / Q000009:adverse effects / Q000627:therapeutic use*; D005260:Female; D006801:Humans; D007271:Injections, Intradermal; D008113:Liver Neoplasms / Q000097:blood / Q000188:drug therapy* / Q000401:mortality / Q000473:pathology; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D012997:Solvents / Q000008:administration & dosage / Q000009:adverse effects / Q000627:therapeutic use*; D016019:Survival Analysis; D016896:Treatment Outcome; D000509:alpha-Fetoproteins / Q000032:analysis
chemical_list: D000970:Antineoplastic Agents; D012997:Solvents; D000509:alpha-Fetoproteins; D000431:Ethanol; D004317:Doxorubicin; D002802:Cholinesterases; D002945:Cisplatin