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Interventional Procedures
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
Reducing theNeeds
forConventional Surgery
GökhanKahraman , ÖzgürÖzen ,
andAliHarman
41
41.1 Introduction
As equipment quality and technology advances,
interventional radiology (IR) offers clinicians a
growing number of procedure options. Diagnostic
(Table41.1) and therapeutic (Table41.2) procedures are performed in a minimally invasive fashion. Compared to conventional surgery, IR
procedures guide treatment through less invasive
methods. As IR procedures are minimally invasive generally, they do not require an inpatient
hospital stay. Due to the lack of large incisions,
procedures result in fewer side effects and shorter
recovery time. Using imaging methods, such as
uoroscopy, ultrasonography, computed tomography, and magnetic resonance imaging in IR procedures provide accurate diagnosis and/or
treatment. Local anesthesia is the most commonly
used anesthesia method in IR procedures providing a lower incidence of anesthesia-related complications. General anesthesia is rarely required.
IR procedures are divided into two main
groups: vascular and nonvascular, comprised of
both diagnostic and therapeutic interventions.
The most common vascular interventional
radiological procedure is diagnostic angiography.
Therapeutic vascular interventional procedures
G. Kahraman (*) · Ö. Özen · A. Harman
Department of Radiology, Baskent University Faculty
of Medicine, Ankara, Turkey
Table 41.1 Diagnostic interventional radiology procedures
Biopsy
Taking of sample cells or tissues for examination from
a percutaneous or transvenous approach to determine
the presence or extent of a disease
Cholangiography
Imaging of thebile duct by x-rays and an injection of
contrast medium to look for areas of blockage
Angiography
Imaging of the blood vessels with the use of contrast
media
include recanalization of narrowed or blocked
vessels (percutaneous transluminal angioplasty
(PTA), stenting, thrombolysis), or occluding vessels (embolization) to diminish tumoral/abnormal vascularization or block active hemorrhage.
Pulmonary thromboembolism caused by deep
vein thrombosis can be prevented by placing
retractable metallic lters in the inferior vena
cava.
Chemoembolization and radioembolization
are unique embolization processes tailored to cancer patients. In chemoembolization, following the
selective catheterization of the feeding artery,
chemotherapeutics and embolization agents are
injected. In radioembolization, the same procedure is performed with the injection of agents
with attached radioactive isotopes. These procedures are usually used to treat liver tumors.
Transjugular intrahepatic portosystemic shunt
(TIPS) is also applied by interventional radiolo-
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2021
O. N. Dilek et al. (eds.), Prophylactic Surgery, https://doi.org/10.1007/978-3-030-66853-2_41
487
488
G. Kahraman et al.
Table 41.2 Therapeutic interventional radiology
procedures
Ablative procedures
Chemoembolization
Radioembolization
Radiofrequency ablation
Cryoablation
Microwave ablation
Vascular
Balloon angioplasty/stent
Endovascular aneurysm repair
Embolization
Thrombolysis
IVC lters
Dialysis
TIPS (transjugular intrahepatic portosystemic shunt)
Biliary intervention
Placement of catheters in the biliary system
Placement of permanent indwelling biliary stents
Cholecystostomy
Catheter placement
Central venous catheter placement
Drainage catheter placement
Radiologically inserted gastrostomy or jejunostomy
Genitourinary
Percutaneous nephrostomy placement
Percutaneous nephroureteral stent placement
Ureteral stent exchange
gists to selected end-stage chronic liver patients
to relieve portal hypertension and related
conditions.
It is vital to provide vascular access when continuous or intermittent medication is required
(such as chemotherapy) or when a high blood
exchange volume is required (such as dialysis).
Vascular access is provided by inserting a port
catheter for cancer patients and hemodialysis catheters for end-stage renal disease patients. Imaging
guidance not only improves the success rate, but
also reduces complications of these procedures.
The second leading group of interventional
radiological procedures is nonvascular procedures. The diagnostic nonvascular interventional
radiological procedure is an imaging-guided
biopsy. A biopsy removes tissue or uid samples
from target organs, such as the thyroid, prostate,
liver, pancreas, lung, kidney, or tumors, located
in other organs. Imaging methods, such as ultrasound, computed tomography (CT), or magnetic
resonance imaging (MRI), are used as guidance.
A biopsy is a procedure that is carried out to
reach a denitive diagnosis in many diseases.
Therefore, it is of great importance in the diagnosis and future management of neoplasia-related
diseases.
Therapeutic nonvascular interventional radiological procedures include tumor ablative procedures, such as radiofrequency (RF) or microwave
ablation, abscess and cyst drainage, catheterization of kidney, gallbladder, bile ducts, etc.
Ablative procedures are treatments that utilize
image guidance to place a needle into a target tissue such as a tumor, which will deliver the ablative effect. Electrical currents are most commonly
passed through an electrode in the needle to create a region of heat that destroys tumor cells. This
method is often used, especially in the treatment
of liver tumors. However, it is a method that can
potentially be used in many tumors.
Hereditary cancer syndromes are characterized by early-stage tumors that account for
3–20% of all cancers [1]. The management of
these syndromes is carried out in a multidisciplinary fashion. IR can contribute signicantly to
the management of patients with hereditary cancer syndrome in diagnostic, therapeutic, and palliative procedures. The imaging methods
recommended for screening of these syndromes
will be discussed in the next chapter.
In the present chapter, standard interventional
procedures used for managing cancer will be discussed. First, an overview of percutaneous biopsy
methods will be presented, followed by therapeutic interventional procedures used as an alternative to conventional surgical methods in treating
malignancies and palliative interventional procedures applied in oncology patients.
41.2 Percutaneous Biopsy
Percutaneous biopsy is a commonly used interventional procedure for obtaining tissue samples.
Using medical imaging for guidance allows correct localization of the needle and targeted tumor
[2–4]. Image-guided percutaneous biopsy is less
invasive and less expensive than surgical
methods.
41 Interventional Procedures Reducing theNeeds forConventional Surgery
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489
The most typical indication of percutaneous
biopsy is the diagnosis of malignancies, such as
a primary tumor, tumor staging, metastatic disease, and posttreatment recurrence. Other indications include establishing the diffuse
parenchymal disease’s nature, obtaining material
for microbiological analyses in suspected or
known infections, and providing molecular analysis material [5–7].
Relative contraindications of percutaneous
biopsy include coagulopathy, patient inability to
cooperate, signicant comorbidities, and pregnancy. These conditions increase the risk of complications; therefore, they should be corrected
[5]. Absolute contraindications, which are rare,
are as follows: lack of safe access, refusal of consent, and noncorrectable coagulopathy [7].
There are two types of needle biopsy: coreneedle biopsy and ne-needle aspiration (FNA).
They differ in the amount of tissue acquired.
FNA provides a smaller tissue sample than coreneedle biopsies.
Needle selection depends on the suspected
pathology and the experience of the operator. A
wide variety of needles are available for percutaneous biopsy. Needles can be classied accord-
ing to diameter or gauge, length, tip conguration,
and sampling mechanism [5].
Smaller-gauge needles (20–25 gauges) provide sufcient cytological material and often sufcient histological material. When multiple
punctures are required, they can be used safely.
They also reduce bleeding risk and complications
while reaching the target lesion. It is easier to
reach the lesion with larger-gauge needles (14–
20 gauges). They generally provide a better sample for cytology and histology with fewer
punctures—however, the risk of bleeding
increases as needle diameter increases [
8, 9].
Needle tips are classied as the non-cutting
type used for aspiration and the cutting type used
for core biopsy. Aspiration needles are the most
frequently used biopsy needles. They are designed
to provide samples primarily for cytologic analysis. Core biopsy needles (14–20 gauge) are larger
in diameter and are used to obtain tissue samples
(0.1–0.4mm and below) for histological analysis
rather than cytologic analysis [10].
Medical imaging methods, such as ultrasound, CT, and MRI, and uoroscopy allow
sampling of difcult-to-reach small lesions
safely (Figs.41.1 and 41.2) [11].
a
Fig. 41.1 CT-guided percutaneous FNA biopsy of the
pancreatic cystic complex mass. Contrast-enhanced CT
images (a) provide a better view of the mass’s solid com-
b
ponent (arrow). Thus, the biopsy was taken from the correct localization (b). FNA biopsy was reported as serous
cystadenoma
490
ab
Fig. 41.2 CT-guided percutaneous core-needle biopsy of paraaortic conglomerated lymph nodes (a) (arrow). With the
patient prone, a core-needle biopsy was performed using a posterior paravertebral approach (b)
G. Kahraman et al.
41.3 Image-Guided Ablation
tive technique to treat osteoid osteomas. RFA
provides relief to the majority of patients with
Image-guided tumor ablations (IGTA) induce
tumor cell death. Various energy sources, including RF energy, microwave, irreversible electroporation (IRE), and cryoablation, are used for
IGTA.IGTA can be used to treat many types of
cancer, including lung, liver, kidney, prostate,
breast, and bone cancer [12–17].
Chemical ablation is an ablative method that
causes protein denaturation and cell death by
injecting ethanol and acetic acid into tumor cells.
US-guided percutaneous ethanol injection can be
used as an alternative procedure in managing primary hyperparathyroidism caused by parathyroid
adenoma and parathyroid hyperplasia in patients
with increased surgical risk and patients with a
previous history of neck surgery [18].
Radiofrequency ablation (RFA) is an ablative
procedure designed to destroy the tumor by heating (Fig.41.3). The conversion of radiofrequency
waves into heat is the mechanism of RFA.RFA
increases the local tissue temperature, which
causes tumor cell death. RFA can be used to treat
both primary tumors and metastases. RFA is useful in the treatment of patients with lung, liver,
kidney, and bone cancers. It is feasible and safe in
unresectable pancreatic cancer and cholangiocarcinoma [19, 20]. It can be used in combination
with chemotherapy in the treatment of hepatocellular carcinoma. Also, RFA is an efcient alterna-
painful bone metastases [21].
Microwave ablation uses energy also within
the radiofrequency spectrum that causes polar
molecule oscillation in tissue and heats faster
than RFA. As a result, coagulation necrosis
develops in tumor tissue. It is a well-established
procedure for treating many benign and malignant tumors and lesions [22].
Cryoablation is a treatment that uses low temperatures to destroy tumor cells. In cryoablation,
tumor tissue is frozen with temperatures reaching
−20°C, and cell deaths occur. It can treat several
malignancies, including prostate, bone, kidney,
and breast cancers [15, 23, 24].
IRE is an ablative procedure using nonthermal
energy (electrical eld) to create innumerable permanent and lethal nanopores in the cell membrane
to destroy cellular homeostasis that induces apoptosis. This method does not cause necrosis as in
all other ablation procedures which induce necrosis by heat or radiation. It is preferred, especially
in regions where extracellular matrix, blood ow,
and nerves are desired to be protected [25]. IRE
can be safely performed in patients with tumors of
the liver, pancreas, lung, and kidney [26–29].
Other ablative methods include high- intensityfocused ultrasound and laser ablation. Highintensity- focused ultrasound is a technique that
uses ultrasonic waves to heat tissue [30, 31].
41 Interventional Procedures Reducing theNeeds forConventional Surgery
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491
Fig. 41.3 CT-guided RFA of metastatic lesion in the right lobe of the liver
41.4 Embolization
tumors. It may also be used to treat uterine
broids, aneurysms, and other conditions [
Most chemotherapy is administered through a
peripheral/central vein that circulates the whole
body causing systemic effects in reaching the target tumor. With some tumors, a more targeted
and higher dose of chemotherapy could be
applied by selectively catheterizing the feeding
artery(ies) of the tumor and injecting medication
directly without the cost of systemic side effects.
This method is called intra-arterial chemotherapy
[32, 33].
Transarterial embolization (TAE) is a procedure in which cell death occurs by occlusion of
the artery feeding the tumor with embolization
materials (gelatin sponges, beads, microparticle,
alcohol, glue). TAE is used to treat unresectable
liver cancer, kidney cancer, and neuroendocrine
Transarterial chemoembolization (TACE) is a
procedure in which chemotherapy and embolic
agents are injected into a blood vessel feeding the
tumor to occlude the tumor’s blood supply and
trap the chemotherapy within the tumor for
enhanced potency [
formed in patients with asymptomatic, multifocal, or large HCC without extrahepatic metastasis
or vascular invasion [35]. The combined use of
RF or microwave ablation plus TACE effectively
treats patients with hepatocellular carcinoma
(Fig. 41.4). This approach may provide better
survival results than monotherapy [36].
Radioembolization is a minimally invasive procedure in which small microspheres (glass or resin)
loaded with a radioactive isotope, Yttrium-90
33].
34]. TACE can be safely per-
492
G. Kahraman et al.
a
c d
b
Fig. 41.4 The combination of TACE and RFA. (a)
Ultrasonography of slightly hyperechoic liver lesion
(arrow) adjacent to the gallbladder (biopsy-proven hepatocellular carcinoma). (b) Hypervascular liver lesion
(arrow) revealed by digital subtraction angiography of the
(Y-90), are injected into the vessels feeding the
tumor. Radioembolization combines embolization
and radiation therapy to treat cancers. High-lethal
radiation dose causes cell death. Beads loaded with
Y-90 occlude blood vessels feeding the tumor and
deliver a high dose of radiation to the tumor while
sparing the normal tissue. Radioembolization can
be performed as radiation segmentectomy and
radiation lobectomy. Radiation lobectomy aims to
induce nondiseased lobe’s growth to provide an
adequate liver function to allow surgical resection
[37]. Portal vein embolization (occluding the portal
vein with embolization agents) also can be applied
to induce hypertrophy of the nondiseased lobe [38].
hepatic artery. (c) Angiography after drug-eluting beads
(DEB)-TACE treatment. (d) Ultrasonography of the liver
lesion (arrow) whose borders were chosen more clearly
after DEB-TACE treatment. RFA was performed immediately after TACE in a single session
41.5 Palliative Interventional
Procedures
Cancer-related pain can be alleviated by interventional procedures in patients unresponsive
to or unable to tolerate systemic opioids. The
quality of life is improved through pain alleviation (Fig. 41.5). Interventional procedures
include neuraxial analgesia (by epidural and
intrathecal routes), vertebroplasty, kyphoplasty,
RFA, and cryoablation for vertebral pain, sympathetic blocks for abdominal cancer-related
pain (celiac plexus block and superior hypogastric plexus block), and peripheral nerve blocks
41 Interventional Procedures Reducing theNeeds forConventional Surgery
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493
Fig. 41.5 Celiac ganglion block. The needle is passed
through the aorta’s anterior and posterior walls through a
posterior paravertebral approach (arrow). A contrast agent
(paravertebral blocks, blocks in the head region,
plexus blocks, and intercostal blocks). Patients’
symptoms can be signicantly reduced by
reopening the vital pathways, such as blood
vessels, esophagus, and biliary tract invaded by
tumors [39].
41.6 Diseases Treated
withInterventional
Procedures
41.6.1 Thyroid Cancer
Some studies show the clinical efcacy and
safety of ablative procedures in nodule-volume
reduction, improvement in symptoms, and cosmetic appearance [40]. There is not sufcient scientic evidence on its effectiveness in the
treatment of thyroid carcinomas.
injection was performed to assess the spread (short arrow)
around the aorta before alcohol injection
41.6.3 Breast Cancer
RFA is an interventional procedure in small,
solitary, localized breast cancer. However, no
studies have been conducted to directly compare RFA to the current surgical resection standard [42].
41.6.4 Lung Cancer
Lung metastases and inoperable primary lung
cancers can be treated with ablative methods. It
is an option for selected cases that are not suitable for surgery or radiation therapy because of
their general health or the tumor’s size/location
[43, 44].
41.6.5 Liver Cancer
TACE, radioembolization can treat primary liver
41.6.2 Parathyroid Adenomas
tumors (hepatocellular carcinoma and cholangiocarcinoma) and liver metastasis, TACE combined
Parathyroid adenomas can be treated with ablative procedures and ethanol injection [18, 41].
with RFA, portal vein embolization, and ablative
procedures [45].
494
G. Kahraman et al.
41.6.6 Pancreatic Cancer
Patients with inoperable or borderline resectable,
locally advanced pancreatic adenocarcinoma can
be treated with IRE [46].
41.6.7 Kidney Cancer
Primary kidney cancers can be treated with ablative procedures. Treatment success is similar to
partial nephrectomy [47]. The TAE method
reduces the size of benign kidney tumors such as
angiomyolipoma and minimizes rupture and
bleeding risks [48].
41.6.8 Adrenal Gland Tumors
Treatment of hemorrhagic adrenal tumors with
presurgical embolization methods provides
stabilization of patients for elective surgery
[49]. Embolization procedures can also reduce
the tumor burden, minimize bleeding risk
before surgery, and alleviate cancer-related
pain [50].
41.6.9 Prostate Cancer
Transarterial chemoembolization is a new, safe,
and effective procedure for inoperable prostate
cancer. Prostate cancers can be treated with ablative techniques and IRE [51, 52].
41.6.10 Bone Cancer
Bone metastases (spine, pelvis, long bones) can
be treated with ablative methods with or without
vertebroplasty. These procedures can be curative
in benign pathologies, such as osteoid osteoma,
and palliative in malignant cases, such as bone
metastasis pain. Embolization methods can also
be used to reduce the risk of bleeding before surgery [53].
41.7 Conclusion
IO is essential in managing patients with hereditary cancer syndrome, diagnosing and treating
the malignancy or related complications, and palliation. Also, it provides new treatment possibilities for patients with hereditary cancer syndrome
and can be combined with conventional oncological therapies. Moreover, it can reduce the
need for conventional surgery and allow physicians to provide precision cancer treatment. It has
great therapeutic potential. As a result, physicians involved in the management of oncological
patients should know interventional procedures.
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