Efficacy and safety of endoscopic ultrasonography-guided interventional treatment for refractory malignant left-sided liver tumors: a case series of 26 patients

Abstract

This study aimed to compare the efficacy and safety of EUS-guided ethanol injection and ¹²⁵I seed brachytherapy for malignant left-sided liver tumors which were difficult for trans-abdominal intervention. The study protocol was registered at Clinicaltrials.gov (NCT02816944). Twenty-six patients were consecutively and prospectively hospitalized for EUS-guided interventional treatment of refractory malignant left-sided liver tumors between June 2014 and June 2016. Liver masses were detected using EUS in 25 of 26 (96.2%) patients. EUS-guided interventional treatment was completed uneventfully in 23 of 26 (88.5%) patients using anhydrous ethanol injection (n = 10) or iodine-125 seed implantation (n = 13). Six months later, complete response was achieved in 15 of 23 (65.2%) patients and partial response in 8 of 23 (34.8%) patients. Patients with tumor residual have second-look EUS-guided interventional treatment (n = 5), radiotherapy (n = 2) or surgical resection (n = 1). Complete response was achieved after repeated interventional treatment in 3 of 5 patients who underwent second EUS-guided intervention; 2 patients required additional surgical resection but one succeed. No significant complications occurred. Therefore EUS-guided ¹²⁵I seed brachytherapy is an effective and safe treatment modality for radical operation or promising palliative control of malignant left-sided liver tumors refractory to trans-abdominal intervention.

Figure 1. EUS-guided iodine-125 brachytherapy for postoperative liver metastasis of cholangiocarcinoma.

(A) presence of a 1.3-cm, low-density liver mass located in the left lobe on CT scan (white arrows). US image failed to show the lesions due to the gas ahead; (B) identification of a 1.5 cm × 1.3 cm low-echodensity mass on EUS (white arrows); (C) EUS-guided implantation of iodine-125 particles (white arrows); (D) obvious downsizing of the liver disease on follow-up CT scan at 1 months (white arrows); and (E) disappearance of the liver disease on follow-up MRI scan taken after 12 months.

Figure 2. EUS-guided anhydrous ethanol ablation for postoperative liver recurrence of hepatocellular carcinoma.

(A) presence of a 1.5 cm × 1.1 cm postoperative liver recurrence located on the resection margin as shown on T₂-weighted MRI scans (white arrows), but conventional US image failed to show the lesions; (B) EUS-guided ethanol injection; and (C) arterial phase (arrowhead) and (D) parenchymal phase (arrowhead): non-enhanced liver disease on follow-up contrast CT scan revealed complete resolution of disease at 12 months.

Figure 3. EUS-guided anhydrous ethanol ablation for lesions in liver caudate lobe.

MRI imaging in liver caudate lobe showed a lesion of low T1 signal intensity (A) (arrowhead) and significant enhancement in arterial phase (B) (arrowhead). (C) at liver caudate lobe EUS scan showed a well-defined hypoechoic 1.9*1.6 cm lesion (arrows). (D) It indicated that 22G biopsy needle with EUS guidance was inserted into the lesion along with the needle sheath (arrowhead), and (E) diffuse increase in echogenicity covering the whole mass after the percutaneously punctured injection of anhydrous alcohol. After 1 month follow-up, MR scan was seen high T1-weighted signal intensity (F) (arrowhead) and no obvious enhancement during arterial (G) (arrowhead) and substance phase (H) (arrowhead). After 15 months follow-up, it showed high T1-weighted signal intensity (I) (arrowhead) and contrast material-enhanced MR images showed completed ablation without enhanced lesions (J) (arrowhead).