A combination therapy of ethanol injection and radiofrequency ablation under general anesthesia for

Online Submissions: wig wignet coWorld Gastroenterol 2008 April 7; 14(13): 2037-2043world Journal of gastroenterology ISSN 1007-9327RAPID COMMUNICAToNA combination therapy of ethanol injection andradiofrequency ablation under general anesthesia for thetreatment of hepatocellular carcinomaKazutaka Kurokohchi, Seishiro Watanabe, Hirohito Yoneyama, Akihiro Deguchi, Tsutomu Masaki, Takashi HimotoHisaaki Miyoshi, Hamdy Saad Mohammad, Akira Kitanaka, Tomohiko Taminato, Shigeki KuriyamaKazutaka Kurokohchi, Seishiro Watanabe, Hirohito Yoneyama, energy could be applied during treatment under painAkihiro Deguchi, Tsutomu Masaki, Takashi Himoto, Hisaak free condition for the patientsMiyoshi, Hamdy Saad Mohammad, Shigeki Kuriyama,Department of Gastroenterology and Neurology, Kagawa UniversitySchool of Medicine, 1750-l Ikenobe, Miki-cho, Kita-gun, Kagawa@2008 WG. All rights reserved.Kazutaka Kurokohchi. Akira Kitanaka. Tomohiko Taminato, Key words: Combination therapy; Ethanol injection; Radio-Department of Laboratory Medicine, Kagawa University School of frequency ablation; General anesthesia, Local anesthesiaMedicine, 1750-l Ikenobe, Miki-cho, Kita-gun, Kagawa 761-0793Peer reviewers: Akihito Tsubota, Assistant Professor, InstituteAuthor contributions: Kurokohchi K designed research and of Clinical Medicine and Research, Jikei University School ofwrote the paper; Kurokohchi K, Watanabe S, Yoneyama H, Medicine, 163-1 Kashiwa-shita, Kashiwa, Chiba 277-8567, Japan;Deguchi A, Masaki T, Himoto T, Mohammad HS, and Kitanaka Luis Rodrigo, Professor, Gastroenterology Service, Hospital CentralA performed research; Miyoshi H analyzed data; Taminato T and de Asturias, c/Celestino villamil, s n, Oviedo 33.006, SpainCorrespondence to: Dr Kazutaka Kurokohchi, Department of Kurokohchi K, Watanabe S, Yoneyama H, Deguchi A, MasakiGastroenterology, Kagawa University School of Medicine, 1750-1 T, Himoto T, Miyoshi H, Mohammad HS, Kitanaka A, TaminatoIkenobe, Miki-cho, Kita-gun, Kagawa 761-0793T, Kuriyama S. A combination therapy of ethanol injection andapan kuroko@med. kagawa-uac jpradiofrequency ablation under general anesthesia forthe trea81-87-8912156FaX:+81-87-89121ment of hepatocellular carcinoma. World J Gastroenterol 2008Received: July 31, 2007 Revised: February 13, 200814(13):2037-2043AvailablefromUrl:http://www.wjgnetcom/1007-9327/14/2037.aspDoi:http://dx.doi.org/10.3748/wjg14203AbstracAIM: To summarize the effects of laparoscopic ethanolinjection and radiofrequency ablation(LEI-RFA), thora- INTRODUCTIONcoscopic(T-EI-RFA)and open-surgery assisted E1-RFA Hepatocellular carcinoma(HCC) is one of the most seri(o-EI-RFA)under general anesthesia for the treatmentof hepatocellular carcinoma(Hcc)ous malignancies worldwide), especially in Asian coun-tries due to the high exposure to hepatitis virus. Despiteintensive efforts to develop novel treatment modalities forMETHODS: Time-lag performance of RFA after ethanolinjection(Time-lag PET-RFA)was performed in all cases. Althoug Prognosis of HCC remains relatively poorThe volume of coagulated necrosis and the appliergy for total and per unit volume coagulated necrosiscutaneous acetate injection(PAD) are frequently used forwere examined in the groups treated under generalthe treatment of hCC. these treatment modalities are(group G)or local anesthesia(group L).considered to be effective for patients with relatively small,encapsulated HCC. By contrast, tumor ablation technolo-RESULTS: The results showed that the total applied gies such as microwave laser, and radiofrequency abla-energy and the applied energy per unit volume of whole tion (rFa), have been shown to be reliable and effectiveangulation necrosis oflarger in group G than those in the group L, resulting in primary HCC and metastatic liver cancer,4.Amonga larger volume of coagulated necrosis in the group G. these treatment modalities, it is now possible to obtainThe rate of local tumor recurrence within one year was中国煤化工 through innovextremely low in group GRFAlocalCN MH Ged necrosis in中CONCLUSION: These results suggest that EI-RFA, un- sessions without major complications compared withder general anesthesia, may be effective for the treat- PEI and PAl. However, in contrast to its efficacy, severalment of HCC because a larger quantity of ethanol and disadvantages have been pointed out, such as the limitedISSN 1007-9327 CN 14-1219/ World J Gastroenterol April 7, 2008 Volume 14 Number 13coagulated necrosis induced by RFA and frequent local Table1 Charactedstics of par邮p由tumor recurrences/ 3, 4. To overcome these weaknesses, wehave developed a novel combination therapy of percutaneousethanol injection and radiofrequency ablation(PEIRFA) and showed that combined use of ethanol prior tofale/Female7RFa was able to enhance the therapeutic effects with aAge yr)smaller energy requirement compared with RFA alone5201.25665Although PEI-RFA was shown to enlarge the area of co-4875agulated necrosis, there are HCC cases that are difficult to Tumor size(em)treat with percutaneous RFa due to the location of theHCC. For example, HCC Protruding from the surface ofRange1035the liver are difficult to treat with RFA percutaneously dueInjected ethanol (mL)to the risk of tumor bleeding. Furthermore, HCC locatedclosely to the diaphragm are difficult to treat with RFAChild-Pugh gradepercutaneously due to the poor visualization of the tumorby ultrasonography (US). For these HCC thus other appro- Bpriate RFA approaches are desirable. Furthermore, there croscopic and thoracoscopic approaches due to the locanaare some HCC thatbe treated even with both lapa-of the tumor, and open surgery-assisted RFA remains theonly appropriate treatment. For these kinds of HCC, we attachment hole beside the echo probe. Pure ethanolapplied the combination therapy of ethanol injection and (99.8%)was then slowly injected into the tumor. TheRFA(EI-RFA)to laparoscopic, thoracoscopic, and open- volume of injected ethanol was always kept below doublesurgery assisted treatments. We summarized and evaluated the estimated tumor volume. Five minutes after injectionthe effectiveness of laparocopic-EI-RFA (L-EI-RFA), of ethanol into the tumor, the abla.s e icrease of 20assisted-EI-RFA(O-EI-RFA)under general anesthesia.W every 2-3 min. After the end of the ablation(50 W ofpower output), the circulating cooling water was stoppedand the temperature of the rfa electrode was checkedMATERIALS AND METHODSThe ablation was performed under impedance controlThe ablation was terminated when the temperature of theL-EI-RFA was performed in eight patients(5 male and 3 RFA needle was >65Cfemale; mean age 67 years) with HCC protruding from thesurface of the left lobe of the liver(ranging from 1.0-3.0 Laparoscopic time-lag E-RFA(L-El-RFAcm in diameter). T-EI-RFA was performed in nine patients L-EI-RFA was performed for the HCC protruding(6 male and 3 female; mean age 69 years)with HCC from the surface of the liver. First, the laparoscope waslocated closely to the diaphragm(ranging from 1.0-3.5 cm inserted into the abdominal cavity beginning in the left-in diameter). O-EI-RFA was performed in five patients(4 upper portion of the navel. RFA electrode and PEI needlemale and 1 female mean age 63 years)with HCC located were inserted at a second abdominal site according toclosely to the diaphragm(ranging from 1.0-2.5 cm in the location of the tumor. A sonde was inserted into thediameter). P-EI-RFA was performed in 40 patients(27 abdominal cavity to lift up the liver when the HCC wasmale and 13 female; mean age 65 years). All these studies protruding from the reverse surface of the liver. Underwere conducted with informed consent at the time of laparoscopic observation, a RFA electrode was directlyenrollment. The characteristics of the enrolled patients are inserted into the tumor, and then a 21-gauge PEI needleshown in Table 1was inserted and ethanol was injectedTreatment of time-lag EY-RFAThoracoscopic time ag E-RFA(T-E1-RFAWe previously reported that time-lag performance T-EI-RFA was performed for HCC close to the rightRFA after ethanol injection(time-lag P-EI-RFA)was diaphragm. Patients were put under general anesthesia witheffective for the treatment of HCC Time-lag PEI- one-lung (eft lung) ventilation in a left-decubitus positionRFa was performed under the real-time US guidance Three ports for the thoracoscope, End-fire laparoscopicwith a 3.5-MHz sector probe(rOSHIBA, Xario Prime probe(ALOKA UST-52109), and water-pouring tool wereUltrasound, SSA-660A). RFA was performed by a Cool- inserted into the pleural cavity through the intercostalip RF System(RADIONICS, Burlington, USA),a RTC space. After putting the collapsed right lung aside by asystem(RF3000 Generator, Boston Scientific, USA), and lapRITa system(Model 90, USA)according to the method to th中国煤化工 probe was guidedgm, and the tumordescribed in our manuscripts.6. Briefly, a f7-gauge RECNMH Ged by US(ALOKAneedle with an electrode of 3 cm in length was inserted ProSow). nrter visualizing the tumor by US,into the center of tumor, followed by a 21-gauge PEI an RFa electrode was inserted into the tumor through theneedle inserted into the liver tumor through the same channel along the End-fire laparoscopic probe. A 21-gauge瓦数据mKurokohchi Ket a/ Ethanol injection and radiofrequency ablation under general anesthesiaTable 2 Comparison of the volume of coagulated necrosis and energy requirement between the groups treated with expandable andstraight electrodeT-s(am) EoH (mL)L(am) S(am) H(am) V(am) M(am) T-ENE O)T-ENE/ (/am) T-ENE/M (/am,GroupL(n=40)±083.0±1935±0.628±0430±05159±52101±8221565±963Group G(m15)21±0861±3436±1132±0632±0825±149159±12137207±205832409±2045394±2727P value0.1003100450060.100.11Twenty-four HCC were treated with time-lag PEI-RFA with straight type electrode, while 15 HCC were treatelectrode. After treatment, the longest and the shortest diameters, and theth time-lag PEI-RFA with expandable typapproximation volume of total and marginal coagulatheight of the coagulated necrosis were estimated by helical dynamic CT andmean# SD. Each abbreviation in the table is expressas follows: T-S Tumor size: EtOH: Amount ofol; L: Longest diameter; S: Shortest diameter; H: Height; V: Volume of coagulated necrosis; M: Volumeginal coagulation: D: Duration of ablation: T-ENE: Total energy requirement T-ENE/V: Energy requirement per unit volume for whole coagulation; T-ENE/M: Energy requirement per unit volume for inducing marginal coagulation.PEI needle was inserted and pure ethanol or lipiodol in both groups are summarized in Table 2. The tumor sizecontaining ethanol was injectedwas approximately 3 cm in diameter in both groups, andno significant difference was detected between groupsOpen surgery-assisted time lag E-RFA(O-EH-RFAAlthough the longest and the shortest diameter and theO-EI-RFA was performed for HCC which were difficult to height of the coagulated necrosis did not show a significanttreat with other EI-RFA approaches or when splenectomy difference between the groups, the mean values of all ofwas simultaneously performed to improve cirrhotic liver these parameters in group G were higher than those indysfunction accompanying severe esophageal varices or group L. Thus, the volume of total coagulated necrosisa decrease of platelet count. After exposing the liver and in group G was significantly larger than that in group L.confirming the surface location of liver tumors by US, the Furthermore, the volume of marginal coagulated necrosisRFA electrode was directly inserted into the liver tumors in group G was also larger than that in group L accordingand time-lag EI-RFA was performedto the analysis of parameters which affect the volume ofinduced coagulated necrosis in EI-RFA, both the quantityluation of therapeutic efficacyFive to seven days after treatment, plain or contrast were significantly larger than those in group LBecauseenhanced CT was performed to evaluate the response to both, the volume of coagulated necrosis and total applied,L-EI-RFA, T-EI-RFA, and O-EI-RFA. Tumor necrosis energy, were increased in group G compared with group L,was considered to be complete when no foci of early the applied energy per unit volume for whole and marginalenhancement were seen around the original regionscoagulated necrosis were comparable. These results suggestthat a higher volume of coagulated necrosis was inducedStatistical analysisgroupG compared with group L because higher amountsStatistical analysis was performed using Statview I( Version of ethanol and energy for ablation could be applied.5.0), statistical significance between the group L and groupG was analyzed by a Chi-square test for independence and Rate of local recurrence within a year in group G andLsignificant difference was accepted at P<0.05Among the 22 patients treated with EI-RFA under generalanesthesia(group G), local recurrence was observed inRESULTSonly one case(4.5%)within a year after the treatment Bycontrast, local recurrence was detected within a year inComparison of the volume of coagulated area and the applied four cases(10%)among the 40 cases treated with EI-RFAenergy requirement for total and unit volume coagulation in under local anesthesia(group L). Although the differencepatients treated with El-RFA under local anesthesia(group L of the rate of local recurrence between group andand general anesthesia( group G)group L did not reach statistical sigrGroup L (40 cases)received time-lag EI-RFA under local extremely low in group G In one case(patient No. 21)anesthesia, while group G(22 cases)received time-lag EI- with local recurrence, the volume of marginal coagulatedRFa under general anesthesia. The patients underwent RFA necrosis around the original tumor was lower than in casestherapy by means of the Cool-tip RF system, RTC system, without recurrenceand RITA system. No major adverse effects were observedin either group. Among treated cases, 40 cases in group L Comparison of the effects of L-El-RFA, T-El-RFA, andand 15 cases in group G( L-EI-RFA; 6 cases, T-EI-RFA; O-EA-RFA8 cases, O-El-RFA; 1 case)were treated with EI-RFa by Themeans of the Cool-tip RF system. Between these patients O-EI中国煤化工 A, T-EI-RFA, andtreated by the Cool-tip RF system, the effect of EI-RFA perfoCNMHGleft lobe of the liverwas compared using several parameters drawn from the (segment 2-4)and 1-El-krA was performed on the HCCeatments. Comparison of the amount of injected ethanol, of segment 8 of the liver close to the diaphragm(exceptthe volume of the induced coagulated necrosis, total applied for one HCC located in the segment 6).O-EI-RFA wasenergy for total and per unit volume coagulated necrosis performed on the liver HCC of segment 3, 7, and 8. TheISSN 1007-9327 CN 14-1219/R World J Gastroenterol April 7, 2008 Volume 14 Number 13le 3 Results of L-EF-RFA, T- EI-RFA and O-ElRFAT-S(am) Ins EtoH (mL) A-A(L H)(am) V(m) M(am)L-EI-RFA15Cool-tin3.2×27x26118100No. 23.0Coo-b4.2×42X42No. 3No 6%ss15Cool-tit3.0Cool-tip67X5.0x3737x37x341.0卟AA5827872230x40x4017,0T-EI-RFANo 93.7x2x3.219841x25×3.242X4.2x3.7No 12 S8ook-tip32x32x3.2171No 13 $830X30×25No 14 $83.5x35x3.54.5×3.0x35No 16 $820×20x2025x25×40O-EI-RFANo. 18 $31.5 RITA33×25×30890Cool-tip2x37No 20 5710 RTC30×25x2581No.21s31540x40x40ight HCC were treated with L-El-RFA, Nine HCC were treated with T-EI-RFA and five HCC were treated with-El-RFA. Location of the tumor, tumor size (T-S), instruments for ablation(Ins), amounts of injected ethanolEtOH), ablated area(A-A), (longest diameter(L)x shortest diameter(s)x height(H] volume of coagulatednecrosis( V) and volume of marginal coagulated necrosis(M) are shown.approximate estimated volume of the original tumor, vol- coagulated necrosis(Figure 1A and B). The product of theume of whole and the marginal coagulated necrosis were amount of ethanol and the applied energy was also posicalculated from the CT image after the treatments. In most tively correlated with the volume of coagulated necrosistreated cases, a larger volume of coagulated necrosis and(Figure 1D). These results clearly indicated that both themarginal coagulated necrosis was induced compared with amount of ethanol and applied energy were critical factorsthe volume of original tumor. In most patients treated that regulate the volume of coagulated necrosis in the EIwith a large amount of ethanol (over 7 mL), larger volume RFA under general anesthesia.of whole and marginal coagulated necrosis were induced inpatients such as No. 2,4, 5,9, 11, and 19. The volume of Representative case treated with L-EA-RFAwhole and marginal coagulated necrosis was comparable in By analyzing the effects of time-lag EI-RFA under gen-the patients treated with L-EI-RFA, T-EI-RFA, and O-El- eral anesthesia, one point became evident: Total appliedRFAenergy and the applied energy per unit volume of wholeand marginal coagulated necrosis were significantly largerRelationship between the amount of ethanol, appliedin patients treated under general anesthesia than in thoseenergy, and the volume of coagulated necrosistreated under local anesthesia. This lead to the inductionIn group G, the induced coagulated necrosisof a larger volume of coagulated necrosis. A representativewith the amount of ethanol and applied energy.case treated with T-EI-RFA was shown in our previousously showed that the amount of ethanol wasmanuscript". A case treated with L-EI-RFA is presentedcorrelated with the volume of coagulated necrosis in pa- One case with HCC successfully treated with L-EI-RFAtients treated with P-EI-RFA using an RFA instrument is shown in Figure 2. An HCC (2 cm in diameter)wasequipped with a straight electrode( Cool-tip RF system). located in the S2 region of the liver protruding from theIn the present study, the relationship between the amount reverse surface and with an enhanced early vascular phaseof ethanol or applied energy and the volume of induced (Figure 2A)via dynamic CT. The laparoscope was insertedcoagulated necrosis were evaluated in patients treated fromPortion of the abdomen into the abwith EI-RFA under general anesthesia. Furthermore, the: dor中国煤化工 by a sonde. An RFArelationship between the product of the amount of etha- electnol and the applied energy us the volume of coagulated intoC NMHGuaneously insertedng the depth of thenecrosis was also analyzed. The results showed that both inserted electrode by the linear type US. The electrode andthe amounts of injected ethanol and applied energy were needle were firstly inserted into the tumor from the uppersignificantly and positively correlated with the volume of surface of the liver(Figure 2B), and then inserted into the教据mKurokohchi K et al. Ethanol injection and radiofrequency ablation under general anesthesia20410246810121430000400005000060000700000100000200000300000400000500000Ethanol(mL)Energy (oule)Figurere creation ih the vovthe volume of coagulated necrosis induced and the amounts of ethanol injected or total applied energy or the product of the amounts ofnergy. All the amounts of ethanol, total applied energy, or the products of the amount of ethanol and total applied energy showed a significantpositiveume of coagulated necrosis (Ethanol vs volume, r=0.54, P=0.018; energy vs volume, r=0.61, P=0.0057; ethanol x energy vs volume,re 2 a case of HCC located on the reverse surface of the liver(S2 of the liver)treated with L-EI-RFA A HCC (2 cm in diameter)showed an enhancement in earvascular phase of helical dynamic CT (A): RFA electrode and PEl needle were firstly inserted from the surface of the liver( B)and secondly inserted from the reverseurface of the liver(C) After injecting the ethanol containing 15% lipiodol, RFA was performed. Dynamic CT after the treatment showed lipiodol deposit associated with theoriginal tumor and low density area was observed around the tumor(D); Laparoscopic observation of the tumor from the surface( E)and from the reverse surface(F)of theliver after the treatmenttumor from the reverse surface of the liver(Figure 2C). showed a lipiodol deposit associated with the tumor andWe previously reported the usefulness of injecting the the ablated region reached beyond the tumor (Figure 2Dmixture of ethanol and lipiodol to visualize the original A safety margin was shown to be sufficiently obtained bytumor by dynamic cr. Therefore, a mixture of ethanol L-EI-RFA. The laparoscopic findings for the tumor afterand lipiodol (15% Lipiodol in ethanol) was injected into the ablation are shown in Figure 2E and F.tumor. Five minutes after injection of ethanol containinglipiodol, RFA was started at 30 w, and the power output DisYH中国煤化工was stepwncreased to 80 W by a Cool-tip RF system.During ablation, the tumor was constantly lifted by a sonde HCCNMH Gd common malignanprevent the transmission of heat to the mesentery. cies worldwide". As a treatment for HCC, RFA nowAbdominal dynamic CT taken after the operation clearlylays a central role for local control of HCC, because rFa2042ISSN 1007-9327 CN 14-1219/R World J Gastroenterol April 7, 2008 Volume 14 Number 13can induce wider coagulated necrosis in a few sessions pain felt by the patients during the percutaneous treatmentmpared with PEI which is frequently used for relativelyly as well. Patients under pain- free conditions during treatsmall-encapsulated HCC. However, the region of coagu- ment may have a decreased rate of local tumor recurrencelated necrosis induced by RFA is still limited and only Recently, it was reported that there were no differences inconsidered applicable to tumors within a 3 cm diameter. tumor control and complications under general anesthesiaFurthermore, it is also pointed out that relatively frequent and analog-sedation in RFA treatment of pulmonary tu-local recurrences of tumor occur after RFA treatment. mors". This result is not in accordance with our resultsTherefore, the RFA technique could be further developed obtained during treatment of HCC. In the treatment ofto improve the therapeutic effects of this treatment. To HCC located near the surface of the liver, patients oftenenhance the therapeutic effect of RFA, several treatment complain about pain originating from the membrane ofmodalities have been applied in addition to local treat- the liver. In our patients, we usually use pentazocine andment. As one of the optional combination therapies, non-steroid anti-inflammatory drugs (NSAIDs)Gf neces-have developed a novel combination therapy of P-El- sary diazepam is also used on a case by case basis )for theRFa and showed that this combination therapy accurately percutaneous RFA treatment. Therefore, it may be betternlarged the area of induced coagulated necrosis. Total to consider stronger pain relief during the treatment ofapplied energy and the applied energy per unit volume ofercutaneous rfa treatmentwhole and marginal coagulated necrosis was significantly In conclusion, we compared the clinical effectslower in the P-EI-RFA than RFA alone. Furthermore, we amounts of ethanol, and applied energy in P-EI-RFA befound that the time - Isag performance of RFA after ethanol tween patients under general anesthesia and local anesthe-injection(time-lag P-EI-RFA) resulted in a lower energy sia. The volume of induced coagulated necrosis, amountsrequirement per total and unit volume of coagulated ne- of ethanol, and applied energy were significantly larger incross than without time-lag performance of RFA after the group treated under general anesthesia than that underethanol injection. In this regard, we suggest that time- local anesthesia. The rate of local tumor recurrence in thelag P-EI-RFA can induce wider coagulated necrosis with former group was kept at an extremely low level.a smaller energy requirement. Although P-EI-RFA wasshown to enlarge the area of coagulated necrosis, there areHCChat are difficult to treat with the percutaneousOMMENTSRFa due to the location of the HCC. For these situations,we applied the combined therapy of ethanol injection Radiofrequency ablation(RFA)plays a central role for the treatment ofand RFA(EI-RFA)with laparoscopic, thoracoscopic and hepatocellular carcinoma(HCC)because this newly developed technologyRFa under general, the number of local recurrences was will e oeb%ve to induce wider coagulated necrosis. However, severalopen-surgery assisted. Among 22 patients treated with El- appears very effecvery small [1 case (4.5%)] and its frequency was kept inResearch frontiersethanol, applied energy and the volume of coagulated ne- RFA treatments are performed percutaneously under local anesthesia in manycross showed that these parameters in the group treated cases. Local tumor recurence varies according to the location of tumor in the liver.with EI-RFA under general anesthesia were significantly size of tumors, and level of RFA technique. A few reports compared the effects oflarger than those in the group treated under local anes- RFA treatment under local and general anesthesiathesia. One of the most relevant differences between theEI-RFA under general anesthesia and local anesthesia is Innovations and breakthroughsThis report showed that the total appied energy and the applied energy per unitpresence or absence of pain felt by the treated patients. volume of whole and marginal coagulated necrosis were significantly larger in theWe have reported in a series of analyses that P-El-RFA group treated under general anesthesia (group G)resulting in a larger volume ofunder local anesthesia enabled a comparable coagulated coagulated necrosisnecrosis with smaller energy requirement relative to RFaalone. P-EI-RFA was likely to be less invasive than RFA Applicationsoneo!. However, in the present study, the rate of local Patients under pain -free condition during treatment may have a decreased rate ofecurrence was reduced in the patients treated under gen-al tumor recurrence. It thus may be better to consider stronger pain relief duringeral anesthesia compared with the patients treated undertreatment of percutaneous RFA treatmentlocal anesthesia. Taken collectively, these results suggest Peer reviewthat higher amounts of ethanol and eneunder pain-free conditions may result in a decreased rateDr. Kurokohchi and colleagues reported theof local tumor recurrences after RFA treatment. Indeed, under general anesthesia for HCC. This manuscript arouses interest for readersalthough we still believe that PEI-RFA is less invasive for and provides an important due to effectively treat patients with HChe treatment of HCC, we are sometimes obliged to ceasethe RFa treatment due to the pain felt by the patient during the percutaneous RFA treatment. Therefore, the results中国煤化工in the present study suggest that it is important to apply 1oma. Hepatol 2000; 32enough ethanol and energy for RFA treatment to decreasethe local recurrence after percutaneous treatment as wCNMH Gular carcinoma: too manoptions? )Clin Oncol 1994,323-1334as treatment under general anesthesia. For this purpose, it 3 Colleoni M, Gaion F, Liessi G, Mastropasqua G, Nelli P,beneficial to use anesthesia intravenously to decrease theManente P Medical treatment of hepatocellular carcinoma:数鵝Kurokohchi Ket al. Ethanol injection and radiofrequency ablation under general anesthesia2043any progress? Tumori 1994; 80: 315-326embolization Oncol Rep 2005; 13Bruix ], Hessheimer AJ, Former A, Boix L, vilana R, Llovet 19 Kurokohchi K, Watanabe S, Masaki T, Hosomi N, MiyauchiM. 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