14.7 (12.6) Interventional radiology in the palliation of cancer

Question 1

List five types of procedures that can be performed by IR for palliative care patients

Answer 1

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

Question 2

List three indications for antegrade pyleography + nephro tube placement (US guided)

Answer 2

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)

Question 3

List 2 advantages of metal biliary stents over plastic biliary stents.

What is the disadvantage of metal stents?

Answer 3

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.

Question 4

List four general management strategies for malignant ascites

Answer 4

intermittent paracentesis 
permanent catheter (pleurx)
shunt placement (e.g. TIPS)
diuretics (more effective in transudate - SAAG>11)

Also 2 surgical: peritoneovenous shunt and HIPEC

Question 5

List two indications for an IVC filter

Answer 5

• contraindication to anticoagulation
• recurrent VTE while on anticoagulation
• free-floating thrombus in the inferior vena cava

Question 6

List 3 advantages of fluoroscopic over endoscopy guided placement of esophageal stent

Answer 6

1. Accurate positioning under Xray guidance
2. Ability to traverse tight stenosis/occlusions
3. Ability to use small calibre catheters and wires -> minimize risk of perforation/bleeding

Question 7

List 3 anatomical indications for placement of stent

Answer 7

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

Question 8

When might central venous access be needed?

What is the advantage of fluiroscopic guidance versus surgical technique?*

Answer 8

1. Feeding and medications (chemo, analgesia)
2. Ensures that tip of catheter is always in the correct position (decreasing the need to reposition catheter)

Question 9

List two situations where a GJ tube is preferred over a G tube

Answer 9

GOO
Gastroesophageal reflux

Question 10

List 2 indications for vascular embolization (i.e. deliberate occlusion of arteries/veins by injection of embolic agents through selectively placed catheters)

Answer 10

stop internal bleeding +

alleviate distressing symptoms (e.g. hepatic embolization of met neuroendocrine tumor - stops flushing and diarrhea)

reduce tumor bulk*

Question 11

What is a potential complication of devascularized tissue due to embolization (esp in liver or bone)? How to prevent?

Answer 11

Sepsis
Premedication with broad spectrum antibiotic

Question 12

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

Answer 12

1. 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)
2. Unresectable HCC
3. discomfort and pain
   fever for a few days
   malaise
4. Abscess formation

Question 13

What is the difference between celiac plexus block vs neurolysis

Answer 13

Block = temporary blocking nociceptors (bupivicaine, triamcinolone)

Neurolysis = permanent (alcohol)

Question 14

Celiac plexus block:
3 minor complications
3 major complications

Answer 14

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)

Question 15

List three possible complications of vertebroplasty

Answer 15

temporary or permanent neurologic deficit
cement extravasation into spinal canal

Cement embolism

infection

bleeding from puncture site

allergic reaction

Question 16

What is kyphoplasty and why is it done?

What is osteoplasty and why is it done?

Answer 16

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)

Question 17

List three categories of percutaneous techniques of local tumor ablation

How does tumor ablation work?

Answer 17

1. Chemical (ethanol, acetic acid, hot saline)
2. Heat (RFA - radiofrequency ablation, electrocautery, interstitial laser therapy, microwave coagulation therapy, high-intensity focused ultrasound)
3. freezing (cryotherapy)

These work by inducing cell death by COAGULATIVE NECROSIS

Question 18

What is the advantage of tumor ablation over radiation, chemo?

What about advantage over surgery?

Answer 18

More effective for debulking tumors compared to radiation/chemo

Less invasive and can be repeated more often than surgery

Question 19

What is the most common tumor ablation technique for HCC/liver mets? What are possible complications?

Answer 19

Thermal ablation (ie heating) –> bleeding and liver abscess

Question 20

RFA has been found to effective for controlling what symptom in patients with kidney tumors?

Answer 20

persistent haematuria

Question 21

List four possible complications of local RFA of RCC

Answer 21

Complications in kidney:
- haemorrhage
- abscess
- pain
- urinoma

Ureteral stricture may occur with a tumour touching the ureter

Question 22

List 4 possible complications of local RFA of a lung tumour

Answer 22

~~~
Pneumothorax (10–20%)
bleeding
fistula
haemoptysis
subcutaneous emphysema
effusions
fever
infection
pain
`

FS: pain, bleeding, infection, pneumothorax

Question 23

Name 5 organs (invaded with cancer) that can be treated with RFA

Answer 23

lung
liver
pancreas
kidney
adrenal
bone

Question 24

Which tumors respond best to arterial embolization

Answer 24

hormone secreting neuroendocrine tumors