Imaging in Oncology: 143 (Cancer Treatment and Research)
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When you click on a Sponsored Product ad, you will be taken to an Amazon detail page where you can learn more about the product and purchase it. To learn more about Amazon Sponsored Products, click here. Other physicians managing oncology patients can also benefit from the materials presented. Imaging in Oncology consists of scholarly reviews that describe the role of imaging in oncology for diagnosis, follow-up and image guided interventions. Experts in various fields of radiology have contributed to this book. The contents are organized into several sections based on the primary site of malignancy.
Each section includes scholarly reviews on the present role of modern imaging techniques in malignancies involving different parts of the body. This textbook serves as an up-to-date, attractive, broad overview book of oncologic imaging for radiologists and others involved in oncologic care, particularly medical oncologists and radiation therapists. Leading figures in the field describe both the techniques and applications against a spectrum of malignancies. This text serves as a resource for clinicians and radiologists involved in cancer care. Would you like to tell us about a lower price? If you are a seller for this product, would you like to suggest updates through seller support?
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Review From the reviews: Cancer Treatment and Research Book Hardcover: Springer; edition April 3, Language: Be the first to review this item Amazon Best Sellers Rank: Related Video Shorts 0 Upload your video. Customer reviews There are no customer reviews yet. Radiofrequency ablation RFA involves administration of electromagnetic energy in the radiofrequency range to a tumour by means of a locally placed electrode connected in a closed loop circuit to a monopolar or bipolar energy source [ 50 ].
Tissues immediately surrounding the electrode tip are heated to temperatures in excess of 60 degrees Celsius with consequent thermal damage to the surrounding tissues and cell death [ 50 ]. RFA has been demonstrated to be safe with a mortality rate of 0. While RFA is the most commonly used ablative means, other modalities are finding increasing clinical use.
Cryoablation results in cell death through the application of subfreezing temperatures, achieved by use of argon gas under high pressure [ 54 ]. Alternating cycles of freezing and thawing results in cell death due to the associated mechanical stresses upon cell membranes with phase change and ice formation and microvascular thrombosis induces tissue ischaemia which limits bleeding [ 55 ]. Though direct comparison of modalities is difficult, as a therapeutic tool, microwave ablation has been shown comparable in efficacy to RFA, particularly for the treatment of hepatocellular carcinoma [ 57 ], however, RFA achieves a lower local recurrence rate, higher survival rate, and extensive necrosis after only a few treatment sessions [ 58 ].
Potential added benefits of microwave ablation over RFA include larger tumour ablation volumes, optimal heating of cystic masses, and less procedural pain [ 59 ]. The involutional changes that occur following necrosis should be monitored by serial imaging following ablation, with specific postablation CT and MR imaging protocols being developed at many institutions in an effort to confirm completeness of ablation and to detect residual or recurrent disease [ 8 , 60 ]. Malignancy can induce dysfunction of many organs and bodily systems.
Though debilitating, a significant portion of these complications are reversible, many by minimally invasive IR methods. Such treatment can relieve symptoms, alleviate pain, and improve operability of patients, thus having a significant positive impact on quality of life. The majority of patients presenting with malignant biliary obstruction have an underlying pancreatic neoplasm extrinsically compressing the distal bile duct and can be treated by endoscopic means [ 61 ].
Metastatic disease at the hepatic hilar nodes or in the peripancreatic nodes may cause obstructive jaundice from extrinsic pressure on the proximal portions of the biliary tree and may require percutaneous intervention if less invasive endoscopic means fails to achieve adequate biliary decompression. Contrast injection into an intra-hepatic bile duct at percutaneous transhepatic cholangiography will delineate the anatomy of the biliary tree, determining the location of obstruction, and helping to guide intervention [ 62 ].
Percutaneous transhepatic biliary drainage PBD is an effective method for the primary or palliative management of many biliary abnormalities demonstrated with cholangiography. This procedure involves selective cannulation of the biliary tree with catheter manipulation, then placement of a catheter or stent to facilitate internal or external drainage of biliary flow and so allow decompression of the biliary system [ 8 ]. The percutaneous treatment of biliary lesions is frequently staged, requiring several sessions to achieve therapeutic goals, though, in the majority of patients, liver function indices improve following a single treatment [ 62 ].
PBD can be associated with major complications including sepsis, haemorrhage and localised infective and inflammatory processes abscess, peritonitis, cholecystitis, and pancreatitis [ 64 ]. The incidence of complications is higher in the oncology than in the general population, perhaps related to advanced malignancy and the potential presence of coexisting immunosuppression [ 64 , 65 ]. The longer the duration of PBD is the more likely the patient is to develop cholangitis [ 67 ].
Prior to initiating percutaneous biliary procedures, all patients should be administered appropriate prophylactic antibiotics to minimise septic complications, including cover for escherichia coli, klebsiella, enterococcus, streptococcus, enterobacter and pseudomonas aeruginosa [ 8 ]. Malignant ureteral obstruction is an ominous sign in the cancer patient and may be due to extrinsic tumor compression, retroperitoneal adenopathy, or direct tumor invasion [ 69 ].
Ureteral obstruction can be induced by a wide range of malignancies, most commonly those of gastrointestinal, urologic, or gynaecologic origin, and may be unilateral or bilateral. Management requires urinary decompression, often by means of percutaneous nephrostomy PCN. PCN is the most common renal intervention performed by IR and, by providing direct access to the urinary tract, allows drainage of tract contents as well as providing access for further uroradiologic intervention via the route established [ 70 ].
Indications for PCN in the emergent setting include urinary tract sepsis, pyonephrosis, deteriorating renal function, or electrolyte disturbances such as hyperkalemia and metabolic acidosis [ 8 ]. Potential benefits of urinary decompression and diversion by this means include reduction in the incidence of gram-negative septicaemia due to renal obstruction, partial recovery of renal function, reversal of metabolic disturbance, and reduced inpatient admission times. Image guidance may be provided with fluoroscopy, ultrasound, or often a combination of both modalities [ 71 ] Figure 4.
The size and type of the drainage catheter should be chosen appropriately according to the nature of the fluid to be drained [ 70 ]. In cases of malignant ureteric obstruction, when retrograde stenting is unsuccessful or not feasible, percutaneous dilatation of the stricture may be achieved antegradely through the PCN tract where, under fluoroscopic guidance, a catheter is manipulated across the stenotic region and the lesion is progressively dilated by catheter advancement, ureteral dilator, or by inflating balloons of appropriate diameter and length [ 70 ].
After dilatation, an internal ureteral stent, or internal-external nephroureteral catheter is placed to prevent restenosis [ 70 , 72 ]. Plastic stents are favoured over metal ones because they induce less urothelial hyperplasia and can be easily replaced. The rate of successful completion of PCN in oncology is mainly determined by the degree of dilatation of the collecting system and by the patient's body habitus [ 74 ].
Patient is post total abdominal hysterectomy and bilateral salpingo-oophorectomy. Patients with head, neck, or oesophageal malignant lesions are, due to luminal obstruction or swallow impairment, frequently unable to tolerate adequate oral intake and require nutritional support, often by gastrostomy or gastrojejunostomy [ 75 ]. The interventional radiologist can play an important role in the provision of enteral alimentation to these patients Figure 5.
Percutaneous image-guided placement of feeding tubes has demonstrated higher technical success rates and is considered safer than endoscopic or surgical placement [ 76 ]. In addition, it may be successfully performed in patients in whom conventional endoscopy is impossible [ 75 ]. Tube dislodgement is relatively common; however, if the tract is established for more than two weeks, it is frequently possible to access the tract and reinsert the tube without the need for repuncture of the stomach [ 8 ].
Complication rates are similar with gastrostomy and gastrojejunostomy. The presence of ascites in such patients mandates paracentesis prior to procedure as peritoneal fluid leads to technical difficulty and the risk of pericatheter leakage and the possibility of peritonitis [ 80 — 82 ].
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Gastropexy is advised prior to gastrostomy to reduce the likelihood of catheter dislodgement from the anterior abdominal wall and to reduce risk of peritonitis and peri-catheter leakage [ 8 , 80 , 82 ]. Contrast injection following placement of percutaneous gastrojejunostomy tube confirms that the tip of the tube is in excellent position in the jejunum arrow. Note the gas-filled stomach white arrow and the locking pigtail catheter in stomach which serves to maintain catheter in position and prevent dislodgement.
Malignant pleural effusions, often related to pleural and lymphatic involvement, are a significant source of morbidity in the oncology patient, presenting with dyspnoea, cough, and chest pain [ 83 ]. As a malignant pleural effusion is a preterminal event with a mean survival of three months, the usual aim of treatment is palliation, and relief of symptoms and prevention of recollection [ 84 , 85 ].
Successful drainage can be achieved by IR with catheter placement under fluoroscopic, ultrasound or CT guidance. Image-guided needle aspiration of pleural fluid collections may also be performed to evaluate for the presence of malignant cells using cytology, thus aiding in the initial diagnosis of malignancy or staging of known disease [ 85 ]. Therapeutic thoracocentesis provides temporary symptomatic relief until the effusion reaccumulates, as is often the case in the setting of malignant effusions, necessitating a repeat procedure. Definitive treatment requires pleurodesis [ 86 ]. Prevention of recurrent pleural effusions can be achieved by chemical or talc pleurodesis.
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Prior to pleurodesis, large effusions require drainage to optimise success rates of pleurodesis and to prevent accumulation of therapeutic agents within the pleural space. Based on efficacy and the likelihood of recurrence, thoracoscopic pleurodesis is the preferred technique but has the drawback of requirement for a general anaesthetic [ 86 ]. IR pleurodesis, entailing instillation of the sclerosing agent via a thoracostomy tube once complete evacuation of the effusion has occurred, can be performed at the bedside and is generally well tolerated [ 8 ].
Interventional Radiology and the Care of the Oncology Patient
Available evidence supports the need for chemical sclerosants to achieve successful pleurodesis, with talc as the agent of choice [ 86 ]. Other agents employed include tetracycline, bleomycin, and mustine. A significant source of cancer-related morbidity, particularly in advanced disease, is pain. Patients who have pain that is not controlled by these means, or who have well-controlled pain but with intolerable analgesic side effects, may benefit from interventional pain management measures. As techniques expand, IR is assuming an evolving role in the management of cancer-associated pain.
However, while IR has a role in the treatment of oncological pain, it is noteworthy that IR interventions may themselves be a source of significant pain and discomfort among patients, particularly procedures involving drainage of the renal and biliary tracts [ 92 ]. Optimal analgesia during and after such procedures is essential.
Percutaneous vertebroplasty, in recent years, has emerged as an effective minimally invasive treatment for severe and refractory pain secondary to vertebral fracture [ 93 , 94 ]. In particular, its use has been met with considerable success in the treatment of painful osteoporotic vertebral compression fractures, where fracture stability is achieved by introduction of cement. It has also found less frequent use in the treatment of fractures secondary to neoplastic disease [ 94 , 95 ]. Osteolytic processes, such as myeloma, often induce fractures, resulting in instability and pain.
Vertebroplasty has been shown to reduce requirements for analgesia and is now being utilised in the treatment of vertebral fractures which result from malignant osseous infiltration [ 95 ].
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The more significant complications include leakage of cement into the spinal canal, pulmonary embolus, and pulmonary oedema. Neuropathic pain associated with upper abdominal visceral tumours is frequently poorly responsive to analgesic therapy [ 97 ]. When resistant to analgesics, celiac ganglion neurolysis and nerve block can achieve successful palliation of pain in the majority of patients, particularly that related to pancreatic, gastric, oesophageal, and biliary malignancies [ 97 ].
Agents employed include local alcohol and phenol, which induce permanent nerve root destruction, and triamcinlone, which causes reversible nocireceptor blockade [ 98 ]. A variety of imaging modalities can be used to guide celiac axis block; CT is most commonly used with either an anterior or posterior approach, dependent on operator experience and anatomic considerations in the individual patient [ 99 ]. Malignancy is an established risk factor for venous thromboembolism.
Vena caval filters, intravascular devices designed to prevent pulmonary embolus by trapping venous emboli, are an accepted method of managing venous thromboembolism in the oncology patient.
Indications for insertion include the occurrence of a lower limb deep venous thrombosis in patients for whom anticoagulation is contraindicated, in those in whom a complication of anticoagulation has occurred, or in those who develop recurrent PEs despite adequate anticoagulation [ ]. Empirical use is not at present supported in the literature.
Recent developments in endovascular technologies have provided radiologists with an assortment of minimally invasive, catheter-based strategies to manage venous thrombus, including both deep venous thromboses and pulmonary emoboli. These percutaneous treatment methods for venous thrombotic conditions include catheter-directed thrombolysis, percutaneous mechanical thrombectomy devices, and adjuvant venous angioplasty and stenting.
Catheter-directed thrombolysis therapy involves the use of infusion catheters and wires to achieve local high-dose delivery of thrombolytic agents to the thrombus with the aim of achieving more rapid lysis. This allows a more predictable thrombolytic effect with a lower risk of haemorrhagic complications and with higher patency rates than systemic thrombolysis, with the added benefit of ability to visualise the entire venous system prior to and after administration of the pharmacologic agent [ ].
Percutaneous mechanical thrombectomy may be used as a primary therapy for an acute thrombotic event, for thrombus involving large vessels such as the vena cava, or, more commonly, for patients in whom, despite conventional anti-coagulation or catheter-directed therapy, there is persistent thrombus. Such therapy also has a role in patients with contraindications to continuous anti-coagulation or the use of thrombolytic agents. It is however suggested that, in the absence of contraindications to the use of thrombolytic agents, mechanical thrombectomy devices should be used in conjunction with pharmacological thrombolysis [ ].
Mechanical, chemical, and hybrid pharmacomechanical thrombectomy devices are available for clot extraction with variable success rates [ ], though further discussion of these devices is outside the scope of this paper. With the expanding application of minimally invasive techniques to the investigation and management of malignancies, the interventional radiologist is assuming a more prominent role in the multidisciplinary team that cares for the patient with cancer.
The use of IR techniques in oncology patients should be evidence based to ensure optimal outcome and minimise potential complications. National Center for Biotechnology Information , U. Journal List Radiol Res Pract v. Published online Mar O'Neill , Owen J. O'Connor , Max F. Ryan , and Michael M. Received Oct 30; Accepted Jan This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Abstract Interventional Radiology IR is occupying an increasingly prominent role in the care of patients with cancer, with involvement from initial diagnosis, right through to minimally invasive treatment of the malignancy and its complications. Introduction Management of malignancy is now in the domain of the multi-disciplinary team and Interventional Radiology IR is occupying a prominent role in this environment [ 1 , 2 ].
Interventional Radiology in the Diagnosis of Cancer Appropriate treatment of malignancy is dependent on a timely definitive diagnosis and on accurate staging of disease. Open in a separate window. Interventional Radiology in the Treatment of Cancer 3. Central Venous Access An integral part of care of the cancer patient is intermediate and longer-term vascular access as a means of medication, chemotherapy, or parenteral nutrition administration, as well as allowing repeated blood sampling without need for venepuncture.
Arterial Embolisation Techniques Minimally invasive image-guided cancer treatments as an adjunct or alternative to surgery are increasingly being used in the management of malignancy [ 25 , 26 ]. Gene Therapy Advances in molecular oncology and tumour immunology have facilitated the development of gene therapy in the treatment of malignancy [ 44 ]. Ablative Techniques Local tumour ablation is an alternative method of achieving tumour control in those patients with early stage malignant disease, particularly in the liver, who are not candidates for resection.
Interventional Radiology in the Management of the Complications of Cancer Malignancy can induce dysfunction of many organs and bodily systems. Biliary Obstruction The majority of patients presenting with malignant biliary obstruction have an underlying pancreatic neoplasm extrinsically compressing the distal bile duct and can be treated by endoscopic means [ 61 ].
Renal Obstruction Malignant ureteral obstruction is an ominous sign in the cancer patient and may be due to extrinsic tumor compression, retroperitoneal adenopathy, or direct tumor invasion [ 69 ].
The tumor ablation process needs to inactivate not only the whole tumor tissue but also the surrounding 5 mm normal tissue, namely the ablation margin AM. Annals of Vascular Surgery. Nowadays, malignant tumors are a global health concern; also, the morbidity and mortality rates associated with malignant disease have increased considerably in recent years. Epub ahead of print. Didn't get the message? With the development of multimodality ultrasound imaging technology, the diagnostic ability of ultrasound is also increasing.
Upper Gastrointestinal Obstruction Patients with head, neck, or oesophageal malignant lesions are, due to luminal obstruction or swallow impairment, frequently unable to tolerate adequate oral intake and require nutritional support, often by gastrostomy or gastrojejunostomy [ 75 ]. Pleural Space Intervention Malignant pleural effusions, often related to pleural and lymphatic involvement, are a significant source of morbidity in the oncology patient, presenting with dyspnoea, cough, and chest pain [ 83 ].
Pain A significant source of cancer-related morbidity, particularly in advanced disease, is pain. Venous Thromboembolic Disease Malignancy is an established risk factor for venous thromboembolism. Conclusion With the expanding application of minimally invasive techniques to the investigation and management of malignancies, the interventional radiologist is assuming a more prominent role in the multidisciplinary team that cares for the patient with cancer.
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Interventional Radiology and the Care of the Oncology Patient
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