Endoscopic ultrasound-guided radiofungal ablation and coil placement plus cyanoacrylate injection in the fear vessel of hepatocellular carcinoma, a new technique in endopathology. All patients with hepatocellular carcinoma should be evaluated for potential curative treatments. Bridge and down-staging local regional therapies are used to decrease tumor progression and reduce tumor burden in selected patients with hepatocellular carcinoma who are on waiting lists for liver transplantation or beyond the accepted transplant criteria. Studies have shown that for nodules, particularly those measuring between 3 and 5 cm, superiority of the combined therapy of transarterial plant embolization and radiofrequency or microwave ablation in comparison to monotherapy ablation or transarterial plant embolization. Endoscopic ultrasound-guided ablation devices were successfully used in the local treatment of small tumors located in the left and caudate lobe that were difficult to treat through a percutaneous approach. These local regional therapies of hepatocellular carcinoma are performed exclusively by interventional radiologists. We aimed to show that therapeutic management of two patients with hepatocarcinoma bigger than 3 cm with contraindication to liver transplantation and transarterial chemoembolization were exclusively treated with an endoscopic ultrasound approach. Two patients with child book A liver cirrhosis, portal hypertension, and the presence of hepatocellular carcinoma greater than 3 cm located in the left and caudate liver lobes respectively were treated in a combined manner. EUS guided arterial embolization and radiofrequency ablation. Tumor nutrition artery was identified using pulsed wave Doppler technique. Puncture and arteriography was performed using a 19 gauge fine needle aspiration needle and iodine contrast. Afterwards, a coil placement followed by the injection of 3 ampoules of 2-octyl cyanoacrylate with a total of 0.9 mm was performed. Finally, a 19 gauge 7 fringe radiofrequency electrode with a 10 mm active tip was introduced inside the lesion and ablation was performed in temperature controlled mode for 3 minutes at 75 watts until the entire lesion was covered with white bubbles. In the first case, no related early or late adverse events were noted, and a 3-month contrast-enhanced computer tomography follow-up showed no enhancement at the level of the ablation area was encountered. In the second case, an esophageal thermal injury was identified, and an over-the-scope clip was placed to prevent fissile deformation. One-month contrast-enhanced computer tomography revealed a 47x32mm hypodense image without enhancement, corresponding to the treated lesion and the correct placement of the coil into the artery. EUS-guided arterial embolization together with radiofrequency ablation of hepatocarcinoma were safely performed with technical success. Limitations related to device and accessories, as especially design coils and powerful ablation electrodes, are present but result seem promising. Additional studies are necessary to validate the benefits of this approach as a new technique in end-of-life pathology.

endoscopic ultrasound

hepatocellular carcinoma

radiofungal ablation

cyanoacrylate injection

local regional therapies