In two patients with large hepatocellular carcinoma who have survived for over five years while receiving percutaneous ethanol injection therapy (PEIT), ultrasonogram of nodules recurring in succession at different sites within the liver was studied. Because of hepatocellular carcinoma (HCC) 62 mm in diameter, case 1 had one trans-catheter arterial embolization, two PEITs and then excision of the liver. Necrosis rate of the removed tumor was more than 99%. Subsequently this case had 11 recurrent nodules. All the nodules had a tumor diameter less than 20 mm. Internal echo was hypoechoic in 8 and hyperechoic in 3 nodules. Posterior echo enhancement which was observed in one of the eight hypoechoic nodules was the only finding among several characteristic findings for HCC on ultrasonogram: other findings including marginal hypoechoic zone, mosaic pattern and lateral shadow were not observed. Case 2 had HCC 44 mm in diameter, which was increased to 60 mm while receiving PEIT. Angiography after nine PEITs revealed disappearance of tumor vessels; the patient was considered as being cured.
Subsequently, however, there were 8 recurrent nodules. The tumor diameter of the nodules was less than 20 mm, 21-30 mm, and 31 mm in 5, 2 and 1 nodule, respectively. The internal echo of the 5 nodules less than 20 mm in diameter was hypoechoic (2 nodules), isoechoic (2) and hyperechoic (1); the two isoechoic nodules had marginal hypoechoic zone. The internal echo of the two medium-size (21-30 mm) nodules was hyperechoic and mixed echo (1 each); the mixed-echo nodule showed marginal hypoechoic zone and mosaic pattern. The largest (31 mm) nodule showed mixed echo; marginal hypoechoic zone, mosaic pattern and lateral shadow were observed. The internal echo of the recurrent nodules had a tendency that hypoechoic internal echo was obtained more frequently from smaller nodules less than 20 mm in diameter and that incidences of hyperechoic and mixed echo were higher with increase in diameter of nodules. Ultrasonographic findings characteristic for HCC were obtained in isoechoic and mixed echo nodule, but not in hypoechoic and hyperechoic nodules.