14.7 (12.6) Interventional radiology in the palliation of cancer Flashcards
List five types of procedures that can be performed by IR for palliative care patients
Drainage - Malignant obstruction of renal and biliary tract, pleural effusions, and ascites
Extraction - Retrieval or re-siting of venous lines
Feeding - Percutaneous gastrostomy
Infusion - Venous access - Hickman lines peripherally-inserted central catheter (PICC) lines; Regional, selective infusion of chemotherapeutic agents
Neurolysis - Celiac axis block in pancreatic cancer
Embolization - Hormone-producing metastases, primary hepatocellular carcinoma, skeletal metastases, bleeding tumors, etc.
Stenting - Malignant GI, biliary, ureteric and airway obstruction, superior or inferior vena caval obstruction, etc.
Tumour ablation - Liver, renal, lung, bony, and soft tissue tumours
Vertebroplasty - Vertebral metastasis, multiple myeloma, and osteoporosis
WP: DEFINES TV
FS:
Wound - venous access
Pain - celiac plexus block
Bleeding - embolization
Obstruction - stent / drain
SCC - tumor ablation
List three indications for antegrade pyleography + nephro tube placement (US guided)
malignant obstruction of the urinary tract
haemorrhagic cystitis secondary to chemotherapy (where it is desirable to divert the urine to ‘rest’ the bladder)
recto-vaginal or recto-vesical fistula caused by pelvic malignancy (diversion of urinary flow may assist in healing of the fistulas)
List 2 advantages of metal biliary stents over plastic biliary stents.
What is the disadvantage of metal stents?
Advantages of metal stents (2)
- Larger calibre thus lower failure rate (plastic stents (30-40%) vs metal stents (10-15%))
- Less cholangitis risk (30% in patients with plastic stents and 10% in patients with metallic stent)
Disadvantage
- Occluded metallic endoprostheses cannot be removed but their patency can be restored by the introduction of a second device inserted coaxially within the first.
- Occluded plastic stents can be replaced using a variety of endoscopic or percutaneous techniques.
List four general management strategies for malignant ascites
intermittent paracentesis permanent catheter (pleurx) shunt placement (e.g. TIPS) diuretics (more effective in transudate - SAAG>11)
Also 2 surgical: peritoneovenous shunt and HIPEC
List two indications for an IVC filter
- contraindication to anticoagulation
- recurrent VTE while on anticoagulation
- free-floating thrombus in the inferior vena cava
List 3 advantages of fluoroscopic over endoscopy guided placement of esophageal stent
- Accurate positioning under Xray guidance
- Ability to traverse tight stenosis/occlusions
- Ability to use small calibre catheters and wires -> minimize risk of perforation/bleeding
List 3 anatomical indications for placement of stent
GI X4
- Dysphagia in esophageal cancer
- Malignant esophageal fistula
- Gastroduodenal obstruction
- Acute colonic obstruction
AIRWAY X2
-Malignant airway obstruction (when surgical resection not possible) - tracheobronchial stenting
- Tracheo-esophageal fistula (stent in trachea)
VESSELS X2
- SVC syndrome (stent SVC after dilation)
- Inferior vena cava obstruction
When might central venous access be needed?
What is the advantage of fluiroscopic guidance versus surgical technique?*
- Feeding and medications (chemo, analgesia)
- Ensures that tip of catheter is always in the correct position (decreasing the need to reposition catheter)
List two situations where a GJ tube is preferred over a G tube
GOO
Gastroesophageal reflux
List 2 indications for vascular embolization (i.e. deliberate occlusion of arteries/veins by injection of embolic agents through selectively placed catheters)
stop internal bleeding +
alleviate distressing symptoms (e.g. hepatic embolization of met neuroendocrine tumor - stops flushing and diarrhea)
reduce tumor bulk*
What is a potential complication of devascularized tissue due to embolization (esp in liver or bone)? How to prevent?
Sepsis
Premedication with broad spectrum antibiotic
TACE (transcatheter arterial chemoembolization):
- What is it?
- It is the mainstay therapy for which cancer?
- List three symptoms that may occur after this procedure (e.g. post embolization syndrome indicating necrotic tissue)
- List 1 complication
- Embolic materials are mixed with chemos (embolization interrupts blood flow of tumor vascular bed –> ischaemia of the tumour cells + the contact time between chemo and cancer cells = greater therapeutic effect)
- Unresectable HCC
- discomfort and pain
fever for a few days
malaise - Abscess formation
What is the difference between celiac plexus block vs neurolysis
Block = temporary blocking nociceptors (bupivicaine, triamcinolone)
Neurolysis = permanent (alcohol)
Celiac plexus block:
3 minor complications
3 major complications
Minor:
transient increase in pain
transient diarrhoea
transient orthostasis
Major:
retroperitoneal bleed
abscess formation
transient or permanent paraplegia (due to injury or spasm of artery of adamkewitz - blood supply of anterior thoracolumbar spinal cord)
List three possible complications of vertebroplasty
temporary or permanent neurologic deficit
cement extravasation into spinal canal
Cement embolism
infection
bleeding from puncture site
allergic reaction
What is kyphoplasty and why is it done?
What is osteoplasty and why is it done?
Intravertebral inflation of balloon tamps prior to infusion of bone cement (improves pain + restores height of vertebrae + posture + reduce risk of fracture)
Injection of bone cement into paintful lytic lesion (improve pain, mobility, bone strengthening, reduce risk of fracture)
List three categories of percutaneous techniques of local tumor ablation
How does tumor ablation work?
- Chemical (ethanol, acetic acid, hot saline)
- Heat (RFA - radiofrequency ablation, electrocautery, interstitial laser therapy, microwave coagulation therapy, high-intensity focused ultrasound)
- freezing (cryotherapy)
These work by inducing cell death by COAGULATIVE NECROSIS
What is the advantage of tumor ablation over radiation, chemo?
What about advantage over surgery?
More effective for debulking tumors compared to radiation/chemo
Less invasive and can be repeated more often than surgery
What is the most common tumor ablation technique for HCC/liver mets? What are possible complications?
Thermal ablation (ie heating) –> bleeding and liver abscess
RFA has been found to effective for controlling what symptom in patients with kidney tumors?
persistent haematuria
List four possible complications of local RFA of RCC
Complications in kidney:
- haemorrhage
- abscess
- pain
- urinoma
Ureteral stricture may occur with a tumour touching the ureter
List 4 possible complications of local RFA of a lung tumour
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Pneumothorax (10–20%)
bleeding
fistula
haemoptysis
subcutaneous emphysema
effusions
fever
infection
pain
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FS: pain, bleeding, infection, pneumothorax
Name 5 organs (invaded with cancer) that can be treated with RFA
lung liver pancreas kidney adrenal bone
Which tumors respond best to arterial embolization
hormone secreting neuroendocrine tumors
