Twenty-three patients with hepatocellular carcinoma less than 4.5 cm in diameter (32 lesions) were treated with a percutaneous injection of ethyl alcohol performed with ultrasound (US) guidance. No complications or sequelae occurred after 271 treatments. All lesions were smaller after 6-27 months follow-up. No evidence of hepatocellular carcinoma was present at fine-needle biopsy or contrast material-enhanced computed tomography (CT). No viable tumor cells were detected in four patients who subsequently underwent surgery. The 1-year survival rate of 12 patients was 91.7%. From these data, it can be concluded that percutaneous alcohol injection (PAI) is an appropriate first-line treatment for patients with small hepatocellular carcinoma lesions who are poor surgical risks. Given the risk of new nodular lesions occurring on resected livers and the risk of perioperative mortality, PAI might even be considered an alternative to surgery.