4. Guidelines for Chlorine Dioxide Intratumoral Injection in Liver Cancer

4.1 Indications

• 4.1.1 Chlorine dioxide intratumoral injection can be used as the primary treatment for liver cancer regardless of tumor size.

• 4.1.2 Suitable for patients who are unwilling or unable to undergo surgery.

• 4.1.3 Applicable for patients without severe bleeding disorders.

4.2 Contraindications

• 4.2.1 WBC < 3.0×10⁹/L, PLT < 60×10⁹/L.

• 4.2.2 Diffuse liver cancer with severe jaundice and ascites.

• 4.2.3 Severe cachexia.

• 4.2.4 KPS score < 40.

4.3 Pre-Treatment Preparation

• 4.3.1 Conduct comprehensive examinations:

  • Routine blood, urine, stool, and occult blood tests.

  • Clotting and prothrombin time/coagulation profiles.

  • Liver and kidney function tests, blood type, ESR.

  • Peripheral blood T lymphocyte subsets and hepatitis B tests.

  • Tumor markers: AFP, GGT, AFU, CEA, CA199, etc.

  • Abdominal ultrasound or CT, and ECG.

• 4.3.2 Review the patient's case to formulate a treatment plan, disinfect the treatment area, discuss the procedure, and obtain consent.

• 4.3.3 Administer pain, antiemetic, and hemostatic drugs intramuscularly 30 minutes before treatment. Use sedatives if necessary.

4.4 Needles and Auxiliary Equipment

• 4.4.1 Puncture needles: 23G×15.0 cm, 25G×9.0 cm; available options include 20G×9.0 cm, 22G×9.0 cm.

• 4.4.2 Syringes: 10 ml, 20 ml.

• 4.4.3 Use ultrasound or CT for larger tumors.

4.5 Procedure

• 4.5.1 Locate the tumor via ultrasound or CT, select the puncture site, and measure the puncture depth and angle.

• 4.5.2 For tumors ≤4 cm, conduct a single-point injection, dosing the tumor's volume (ml) × 30%; for larger tumors, use multiple points.

• 4.5.3 Disinfect the area, wear sterile gloves, apply sterile drapes.

• 4.5.4 Stabilize the skin, insert the needle to the tumor center.

• 4.5.5 Remove the needle core, attach the syringe, inject slowly, monitor distribution with imaging, then remove the needle.

• 4.5.6 Cover the puncture site with sterile gauze and secure.

• 4.5.7 Observe the patient for 5-10 minutes before returning to the ward.

4.6 Post-Treatment Care

• 4.6.1 Monitor for blood pressure, pain, seepage, bleeding, fever, and cardiopulmonary function during the first week.

• 4.6.2 Days 7-10 post-treatment, perform blood, urine, stool, and liver/kidney tests. Use imaging to assess improvement and check immune function at discharge.

• 4.6.3 For fever, use compound aminopyrine and dexamethasone; for pain, buclizine or morphine; for nausea, ondansetron or granisetron.

• 4.6.4 Implement liver protective measures.

4.7 Management of Complications

• 4.7.1 Use divided-point and layered injections for large tumors to increase drug concentration.

• 4.7.2 Manage intraportal hypertension with sodium and water restrictions, diuretics, and liver protection. Monitor closely.

• 4.7.3 For massive bleeding from tumor rupture, ensure rest, avoid straining, monitor vitals, and initiate hemostatics and resuscitation if needed.

• 4.7.4 Address local pain with appropriate management and pre-treatment communications to mitigate issues.

• 4.7.5 Treat fever with antipyretics and physical cooling.

• 4.7.6 For severe nausea, administer antiemetics and provide nutritional support.

• 4.7.7 For tumors near the gallbladder, induce gallbladder contraction pre-treatment to avoid perforation.

• 4.7.8 Use multi-point injections for large or margin-protruding tumors to minimize rupture risk.