Ethanol Injection in the Treatment of Liver Cancers

Hepatocellular carcinoma (HCC) is the most common primary liver cancer and the third leading cause of cancer-related death. Only 20% of patients with HCC are candidates for resection because of comorbidities, advanced cirrhosis, and multicentric disease. A number of liver-directed, non-resection therapeutic options exist, including: thermal ablation, percutaneous ethanol injection (PEI), transarterial chemoembolization, radioembolization, and external beam radiation. The American Association for the Study of Liver Diseases (AASLD) outlines the Barcelona Clinic Liver Cancer (BCLC) treatment pathway, which provides an evidence-based guide for non-resection therapies based on tumor and patient factors as well as the severity of liver disease. PEI was the most common form of ablation in the 1980–1990s as it was widely available, inexpensive, moderately effective, safe, and easy to use. Radiofrequency ablation and microwave ablation have replaced PEI as preferred ablative modalities because they result in more thorough tumor necrosis and reduced incidence of local recurrence. Despite the superior efficacy of modern thermal therapies, PEI is still quite effective and useful in select patients – namely those with small, well-circumscribed tumors in central locations of the liver where thermal ablation should not be employed.