Interventional radiology in the gynaecologicaloncology patient

Harjit Singh MD

Assistant Professor of Radiology and SurgeryPenn State College of Medicine, Hershey, Pennsylvania 17033, USA

The use of radiologically guided percutaneous procedures has greatly reduced the morbidityand mortality of gynaecological oncology patients. Certain procedures, previously requiringmajor surgery, can now be performed with little patient discomfort, with conscious sedationinstead of general anaesthesia, and frequently on an outpatient basis. In this chapter, diagnosticand therapeutic arteriography and venography will be discussed as well as radiologicallyguided genitourinary interventions. This represents an overview of what is available to thegynaecologist from the interventional radiologist in his/her practice.

Key words: angiography; embolization; uterine ®broids; central venous access; inferior venacava ®lter; pelvic congestion syndrome; nephrostomy; vesicovaginal ®stula.

The following passage is from Angiography (edited by Herbert Abrams1):

Uterine Arteriography. Technique: The instruments devised by Seldinger are used. These consistof a blunt-ended cannula, a needle which ®ts accurately into the cannula but is a few millimeterslonger; a ¯exible metal guide about 60 cm long; a polyethylene tube (No. 205) about 30 cm long,®tted with an adapter for the attachment of a syringe. The adapter consists of a nut and screwportion ®tted with a tap. The femoral artery is punctured where pulsation is best felt, that is,generally 2 to 4 cm below the inguinal ligament. . . . Prior to the introduction of the guide, sterilegloves are donned and the patient's thigh is covered with a sterile towel.1

Interventional radiology, as a subspeciality, has contributed to the care of patientsover the past 40 years in many di�erent ways. The techniques have been greatlyre®ned since the days of Dr Abrams. The use of radiologically guided percutaneousprocedures has greatly reduced the morbidity and mortality of gynaecologicaloncology patients. Certain procedures, previously requiring major surgery, can nowbe performed with little patient discomfort, with conscious sedation instead of generalanaesthesia, and frequently on an outpatient basis. In this chapter, diagnostic andtherapeutic arteriography and venography will be discussed as well as radiologicallyguided genitourinary interventions.

ARTERIOGRAPHY

Originally used as a pre-operative diagnostic tool, angiography is now also used in atherapeutic capacity. Not only is the blood supply to a certain region of particular

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importance to the gynaecological surgeon, but those same pathways have been used todeliver therapeutic agents directly to a tumour mass. Whether it is for embolicmaterial to control haemorrhage2 or for the delivery of chemotherapeutic agents todi�erent types of malignancy3,4, angiography now plays a crucial role in the manage-ment of complex gynaecological patients.

Diagnostic arteriography of the pelvis is usually used to evaluate the blood ¯ow tothe pelvic viscera if variant anatomy is suspected or multiple prior surgeries are notedin the patient's history. Most frequently, it is used to map the vasculature prior totranscatheter therapy (Figure 2). It can also be useful in diagnosing unusual conditionsrelated to the patient's primary malignancy.5

Transcatheter embolization has been used for over 20 years to control haemorrhagefrom many di�erent sites in the body, including post partum haemorrhage, pelvicmalignancies which have eroded into adjacent vascular structures and, more recently,to control perfusion to visceral structures and the tumour masses which arise fromthem. The experimental infusion of chemotherapeutic agents has had promising earlyresults in advanced cervical cancer. The embolization of the uterine arteries (uterineartery embolization, UAE) has demonstrated promise in very early clinical use tocontrol the size and symptoms of uterine ®broids.6

Technique overview

Diagnostic arteriograms are performed on an outpatient basis. The patients arebrought to the hospital on the morning of the procedure. The interventionalistperforms a directed history and physical examination and discusses the procedure withthe patient. The small but de®nite risks of infection, bleeding, contrast reaction, renalinsu�ciency and vascular injury are explained to the patient. Appropriate labs arenoted including blood urea nitrogen (BUN), creatinine, platelet count and coagulationstudies (PT/PTT). The patient is then brought to the interventional suite where theyare placed on a procedure table and the region of the right common femoral artery atthe right groin is prepped and draped (as for the operating room). Utilizing conscioussedation and local anaesthesia, the patient is made comfortable for the procedure.Access is obtained to the common femoral artery using a bevelled, hollow needle.Once intra-arterial access has been established, a modi®ed Seldinger technique is usedto place a catheter in the artery. Once access is secure, the catheter is used to performeither a non-selective or selective arteriogram.

For therapeutic procedures, a selective study is performed by placing a catheterdirectly into the vessel of interest and injecting contrast material. The therapeuticmaterial, such as an embolization coil, is passed on infused through the catheter untilthe desired e�ect is achieved. A follow-up arteriogram is performed to ensure that theappropriate e�ect has been achieved.

When the procedure has been completed, the catheter is withdrawn, andhaemostasis at the puncture site is achieved by manual compression. The patient isthen observed for at least 6 hours (for diagnostic arteriograms) and usually overnightfor therapeutic procedures.

Arteriographic anatomy of the pelvis

Perfusion to the pelvic visceral structures is predominantly via the internal iliacarteries from each side. The internal iliac arteries divide into two main trunks, theanterior and posterior divisions. The anterior division consists of three main branches

280 H. Singh

and the visceral branches. The main branches include the obturator artery, the inferiorgluteal artery (which provides branches to the sciatic nerve outside the pelvis and canarise from the superior gluteal artery 25% of the time), and the internal pudendalartery. The visceral branches supply the bladder (as the superior and inferior vesicalarteries), internal genital arteries (in the female known as the uterine arteries), andthe middle haemorrhoidal artery. The posterior division consists of the superiorgluteal artery, iliolumbar artery and the lateral sacral arteries.7

Special focus ± uterine artery embolization

As a procedure for speci®cally treating uterine leiomyomata, UAE is relatively new.Embolotherapy for female genital tract haemorrhage from malignancy was ®rstreported in 1979, with several papers following in the 1980s describing percutaneouscontrol of bleeding from other causes. It wasn't until the 1990s that pre-operativeembolization of ®broids was performed. In the original series of patients by Ravina etal, embolization was frequently performed several days to weeks in advance. Thepatients frequently cancelled their scheduled operations secondarily to a markedimprovement of their symptoms ± leading some to suggest that this could be ade®nitive therapy.8 Several health centres in the United States have performed over100 UAE procedures to this point.9

The ideal patient for the UAE procedure is a perimenopausal woman, in her late 30sto early 40s, with complaints of excessive menstrual bleeding and anaemia, with orwithout urinary frequency or rectal pressure. Ultrasound or MRI reveals several smallto medium sized ®broids, none of which is the pedunculated sub-serosal subtype. Thepatient has already failed traditional medical therapy, possibly even myomectomy, anddoes not wish to proceed with a hysterectomy. The excessive bleeding has alreadybeen evaluated, frequently including endometrial biopsy, and all other causes havebeen excluded. Finally, the patient is not interested in future child-bearing.

In our protocol, the patient is ®rst evaluated in our outpatient clinic to assesswhether she is an appropriate candidate for the procedure. After discussing UAE withthe patient, and after developing an appropriate plan in conjunction with the referringgynaecologist, the UAE is scheduled as an outpatient procedurewith an overnight stay.The patient is brought to the short-stay ward in our medical centre. Intravenous accessis obtained, and pain medication, antibiotics and a single dose of steroids areadministered to control post-embolization symptoms. The patient is brought to theangiography suite, and pelvic arteriography is performed using the above technique.The uterine arteries are subselectively catheterized and embolized using polyvinylalcohol particles to complete stasis (Figure 1). After the procedure, the patient isplaced on prn narcotics and round-the-clock NSAIDs are started, again, to help controlpost-embolization symptoms. The patient is typically discharged the next morning andasked to stay on the NSAIDs for 7 days. She is also given a prescription for oralantibiotics for 7 days as well, to help prevent a post-embolization abscess. The patientis scheduled to follow-up with the interventional radiologist in 7 days, particularly toaddress issues of pain control, and is scheduled to see her gynaecologist in 3 months,including a repeat ultrasound to evaluate the change in ®broid size.

Technical success has been reported in several series at 96±98%. Symptomaticimprovement, either complete relief of symptoms or a signi®cant reduction insymptoms, is seen in about 85% of patients. Follow-up imaging demonstrates areduction in overall uterine size of �50% and a reduction in the size of the ®broids of�60%.9,10

Interventional radiology 281

Figure 1. (A) A selective injection of the left internal iliac artery. The arrow indicates the uterine arterywith its typical arteriographic appearance. (B) There has been selection of the left uterine artery withinjection of contrast. Here, the arrows outline the blush of the patient's dominant ®broid. (C) The leftuterine artery has been embolized to stasis. (D±F) Similar studies on the right side in the same patient.

282 H. Singh

VENOGRAPHY

Diagnostic venography in the oncology patient is usually used in conjunction with aninterventional procedure such as central venous access placement or inferior vena cava®lter placement.

Central venous access

One of the areas where the interventional radiologist can contribute the most to thegynaecological oncology patient is in the placement and management of central venousaccess devices. The original arguments against central venous access placed outside theoperating room, particularly those suggesting increased infection rates, have beenunfounded.11 Interventional radiology practices have now become the primary servicefor the placement of all central venous access in many hospitals in large part due tosame-day or next-day service and the decreased cost of placing the access in theinterventional radiology suite. At our institution, we have placed over 1100 centralvenous access devices in the last 12 months. This includes over 400 PICC lines and125 chest ports (Figure 2). More and more hospitals are using the traditional `angio lab'for services traditionally o�ered elsewhere, and as the trend continues, many clinicianswill turn to their interventional radiology practices for their central venous access care.

Pelvic congestion syndrome

Pelvic congestion syndrome is in the di�erential diagnosis of causes of chronic pelvic pain(CPP). Other causes include endometriosis, pelvic adhesions, atypical menstrual pain,urological disorders, irritable bowel syndrome and psychosocial issues. Frequently, thecause is not clearly de®ned. If non-invasive testing is performed appropriately,treatment regimens can be utilized to help these patients. Duplex scanning is extremelyimportant for clueing the clinician in to the right diagnosis. Of critical importanceduring the ultrasound examination is the performance of a Valsalva manoeuvre duringultrasound imaging. If re¯ux is noted in the ovarian veins, the diagnosis is suspected.(Ultrasound is frequently performed in the supine position, however, and this can leadto a false-negative study.) Percutaneous catheter-directed venography of the ovarianveins should then be performed, and if the ovarian vein valves are noted to beincompetent, embolization is performed. The main vein and all its adjacent collateralsare embolized, thereby preventing re¯ux and venous congestion (Figure 3). Othercollaterals will drain the pelvic structures. Recent studies have demonstrated very hightechnical success rates of�95%with at least some symptomatic relief noted in 75±80%ofpatients.12,13

Special focus ± inferior vena cava ®lters

The association of malignancy and thromboembolic disease has been well studied in theliterature, starting with Trousseau in the 19th century. The authors of a recent papernoted an increased incidence of thrombosis associated with breast cancer, testicularcancer, lung cancer, ovarian cancer and non-Hodgkin's lymphoma. For patients withbreast cancer, for example, the risk of thrombosis is 0.04% per month, a relative risk of4, compared with the general population.With chemotherapy, the relative risk rises to140.14 Age andmalignancy are also related to the incidence of venous thrombosis. In onestudy, the risk of venous thrombosis almost doubled in patients with stage II breast

Interventional radiology 283

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284 H. Singh

cancer if the patients were over 50.15 Although many of these patients can be treatedwith the traditional algorithm of heparinization and warfarin administration, patientswith a contraindication to anticoagulation, patients with a complication of anti-coagulation, or debilitated patientswith a large clot burden (inwhomembolizationmaybe fatal), are better served with placement of an inferior cava ®lter.16

Figure 3. Pelvic congestion syndrome. Note the left and right ovarian veins with distension and ®lling tothe level of the pelvis (A, B). Each of these is coil-embolized, frequently with a large number of coils (C, D).The post-placement ®lm demonstrates the large number of coils required to accomplish stasis in the ovarianveins (E).

Interventional radiology 285

Technically, access is obtained to either the internal jugular or common femoral vein(although other sites are used less commonly). An initial vena cava study should beperformed in order to determine several key points. They include (i) the level of thecon¯uence of the iliac veins, (ii) the level of the in¯ow of the renal veins and anyaccessory renal veins, (iii) the diameter of the inferior vena cava, and (iv) whetherthere is any evidence of inferior vena cava (IVC) clot. When these points are noted,one of the available ®lters is advanced to the infra-renal IVC and deployed (Figure 4).Technical success for vena cava ®lter placement is �98%. Clot trapping ability for allthe available ®lters is �97%, with a relatively low complication rate and including anIVC thrombosis rate of �5%.17

URINARY INTERVENTIONS

It is not uncommon for patients with pelvic malignancy to present with urinaryobstruction. Clinically, the patient presents with ¯ank pain and/or fever. Ultrasoundreveals a dilated kidney and ureter, and decompression is frequently the next step,whether it is antegrade percutaneously or in a retrograde fashion (via cystoscopy).

Percutaneous decompression is performed with the patient placed prone on theprocedure table and the a�ected ¯ank draped appropriately. Access is ®rst obtained tothe renal collecting system with a 22g Chiba needle. That is used to opacify the renalcollecting system. From here, a mid-pole posterior calyx is chosen and de®nitive accessis performed. Initially, a nephrostomy drainage catheter is placed (Figure 5); however,several options are available for continued decompression. Nephroureteral stents arecatheters which have a proximal loop in the kidney and then extend down the ureter,with a second loop in the bladder. An internal double-J stent, which extends from thekidney to the bladder completely internally, can also be placed percutaneously(Figure 6). In the female patient, the internal double-J stent can be changed under¯uoroscopic guidance through the bladder without cystoscopic assistance by theinterventional radiologist.

Recently, the discussion in the literature has shifted from whether percutaneousnephrostomy is possible to whether it is warranted. Several studies have focused onquality of life issues and whether urinary diversion can improve the quality of life inpatients with pelvic malignancy. Harrington et al felt that, if careful patient selectionwas carried out, there is a de®nite bene®t.18 They pointed to the speci®c criteriaproposed by Fallon et al19 which can help guide the clinician to those patients whowillbene®t from nephrostomy catheter placement. The criteria include: (i) patients withundiagnosed malignant disease, (ii) prostatic and cervical primary tumours, (iii)patients in whom there is an available treatment modality with a reasonable change ofresponse, (iv) patients with localized disease, or (v) patients who request interventionas a means of prolonging life for legal or ®nancial reasons. Although optimistic in theirpaper, a more recent paper does not project the same optimism, and careful patientselection remains a critical step.20

Special focus ± vesicovaginal ®stula

In patients with pelvic disease, who have undergone surgery, frequently with radiationtherapy, the formation of a vesicovaginal ®stula is not uncommon. Treatment plans canoften be involved and di�cult for the patient. The initial step is to provide analternative route for urinary drainage in the form of bilateral percutaneousnephrostomies. This usually allows for healing of the ®stula. However, occasionally

286 H. Singh

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Interventional radiology 287

this may not completely divert the urine, necessary for adequate healing. Recently, inpatients in whom the prognosis is not favourable, and in whom the urinary leakage is asigni®cant quality of life issue, coil embolization of the ureters has been found to bevery useful in achieving a dry perineum and improving quality of life.21 Access anddrainage of the kidney is performed in a routine fashion. Through this access, coils areplaced via a delivery catheter to the distal ureter. The epithelial response is fairlybrisk, and that response in combination with the mechanical obstruction from the coilsresults in complete urinary diversion away from the pelvis.21

SUMMARY

The increasing demand on clinicians to care for patients with shorter inpatient staysand a shift to the outpatient setting has the medical profession scrambling for ways to

22 g needle

21 g needle Wire Wire DrainageCatheterAir in Posterior

Calyx

Figure 5. Diagrammatic demonstration of the technique for placement of a percutaneous nephrostomycatheter. After the wire is advanced into place, a nephrostomy catheter is introduced into the kidney, overthe wire.

Figure 6. A nephro-ureteral stent and an internal double-J stent.

288 H. Singh

treat their patients in a less invasive fashion. Interventional radiology, a subspecialitydevoted to the treatment of patients in a minimally invasive fashion for the past 30years, is poised to help the clinicians best achieve that goal. From arteriography withembolization to percutaneous nephrostomy access, the increasing role of interven-tional radiology in the care of the gynaecological oncology patient will allow for morecare to be performed on an outpatient basis with decreased morbidity.

The special focus procedures discussed in this paper are areas of interest, whetherfrom an early clinical experience or from a commonly requested service, and are topicsto be discussed between interventional radiologists and gynaecologists. A co-operativeenvironment between the two specialities will only bene®t the patient.

REFERENCES

1. Abrams HL. Angiography, p 699. Boston: Little, Brown and Company, 1961.2. Bakri YN & Linjawi T. Angiographic embolization for control of pelvic genital tract hemorrhage. Acta

Obstetrica et Gynecologica Scandinavica 1992; 71: 17±21.3. Yamashita Y, Takahashi M, Bussaka H et al. Balloon-occluded arterial infusion therapy in the treatment

of primary and recurrent gynaecological malignancies. Cardiovascular Intervention and Radiology 1989; 12:188±195.

Practice points

. arteriography can be a useful tool to the gynaecological surgeon in patients whohave unusual or altered anatomy, may have vascular involvement by theirprimary diagnosis, or are candidates for therapeutic or pre-operativeembolization

. the placement of central venous access devices and inferior vena cava ®lters bythe interventional radiology section can be bene®cial to both the practitionerand the patient in terms of ease of scheduling and procedural cost without anydi�erence in success and complication rates compared with intraoperativeplacement

. percutaneous management of patients with pelvic malignancy and urologicalobstruction is safe and e�ective, giving the patient many options for urinarydiversion and optimizing patient comfort. Careful screening is very important inthe triage of these patients

Research agenda

. larger series are needed to assess the e�ectiveness of arterialchemoembolization protocols for pelvic malignancies

. uterine ®broid embolization holds great promise for the treatment ofsymptomatic ®broids but only in a select patient population. Larger data poolswith long-term data are needed regarding clinical cost e�ectiveness andrecurrence of symptomatic ®broids

. clearer diagnostic algorithms are needed for pelvic congestion syndrome tobetter delineate which patients have symptoms clearly related to venouscongestion and who would bene®t from percutaneous intervention

Interventional radiology 289

4. Nagata Y, Nagata Y, Ishigaki T et al. Transcatheter arterial infusion therapy combined with radicalhysterectomy in the treatment of advanced cervical cancer. Cardiovascular Intervention and Radiology1993; 16: 14±18.

5. Fujimoto M, Ohya Y, Abe I et al. Renovascular hypertension caused by lymph node metastasis in patientwith uterine cervical cancer: case report. Angiology 1993; 402±405.

6. Goodwin S, Vedantham S, McLucas B et al. Preliminary experience with uterine artery embolization foruterine ®broids. Journal of Vascular and Interventional Radiology 1997; 517±526.

7. Kadir S. (Ed). Atlas of Normal and Variant Angiographic Anatomy, pp 98±100. Philadelphia: W.B. Saudersand Company, 1991.

8. Ravina RH, Bouret JM, Fried D et al. Value of preoperative embolization of uterine ®broma: report of amulticenter series of 31 cases. Contracept Fertil Sex 1995; 23: 45±49.

9. Hutchins RL & Worthington-Kirsch R. Embolotherapy for myoma-induced menorrhagia. Obstetrics andGynecology Clinics of North America 2000; 2: 397±405.

10. Siskin G, Stainken B, Dowling K et al. Outpatient uterine artery embolization for symptomatic uterine®broids: experience in 49 patients. Journal of Vascular and Interventional Radiology 2000; 305±311.

11. Simpson K, Hovsepian D & Picus D. Interventional radiologic placement of chest wall ports: results andcomplications in 161 consecutive placements. Journal of Vascular and Interventional Radiology 1997;189±195.

12. Cordts PR, Eclavea A, Buckley PJ et al. Pelvic congestion syndrome: early clinical results aftertranscatheter ovarian vein embolization. Journal of Vascular Surgery 1998; 28: 862±868.

13. Capasso P, Simons C, Trotteur G et al. Treatment of symptomatic pelvic varices by ovarian veinembolization. Cardiovasc Intervent Radiol 1997; 20: 107±111.

14. Shlebak AA & Smith DB. Incidence of objectively diagnosed thromboembolic disease in cancer patientsundergoing cytotoxic chemotherapy and/or hormonal therapy. Cancer Chemotherapy and Pharmacology1997; 39: 462±466.

15. Levine NM, Gent M, Hirch J et al. The thrombogenic e�ect of anticancer drug therapy in women withstage II breast cancer. New England Journal of Medicine 1988; 318: 404.

16. Ihnat D, Mills J, Hughes JD et al. Treatment of patients with venous thromboembolism and malignantdisease: Should vena cava ®lter placement be routine? Journal of Vascular Surgery 1998; 28: 800±807.

17. Savader SJ. Tutorial 23 ± Inferior Vena Cava Filters. Trerotola SO, Savader SJ, eds. SCVIR Syllabus Series ±Venous Interventions. Faifax, USA: SCVIR Publishing, 1995, 276±292.

18. Harrington KJ, Pandha HS, Kelly SA et al. Palliation of obstructive nephropathy due to malignancy.British Journal of Urology 1995; 76: 101±107.

19. Fallon B, Olney L & Culp DA. Nephrostomy in cancer patients: to do or not to do? British Journal ofUrology 1980; 52: 237±242.

20. Shekarriz B, Shekarriz H, Upadhyay J et al. Outcome of palliative urinary diversion in the treatment ofadvanced malignancies. Cancer 1999; 85: 998±1003.

21. Farrell T, Wallace M & Hicks M. Long term results of transrenal ureteral occlusion with use of gianturcocoils and gelatin sponge pledgets. Journal of Vascular and Interventional Radiology 1997; 449±452.

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