Cancer treatment

There are many types of cancer, and cancer can start any place in the body. IR treatments for cancer are options if you are not a candidate for surgical treatments, if you don’t want surgery, or if your cancer has not responded to cancer drugs. IR may also be used to diagnose cancer (for example in an image-guided biopsy), to drain infections and abnormal collections of fluid in the chest and abdomen, or to place devices such as chest ports so that those who must receive regular infusions of chemotherapy drugs can have them delivered directly into the bloodstream.

The most common cancer therapies I perform are chemoembolizations or radioembolizations for either primary hepatic neoplasms (HCC) or metastatic tumors to the liver. Additionally, I perform ablations (cryoablations, microwave, or radiofrequency ablations) for primary or metastatic disease to the soft tissues, lung, liver, kidney or bone.

Chemoembolization is a minimally invasive treatment using image guidance to deliver a chemotherapy agent and a blood vessel blocking agent (embolic) through the blood vessel supplying the tumor to stop its blood supply and to deliver chemotherapy in the same setting. This procedure is mostly used for the treatment of liver cell cancer.

Radioembolization, or selective internal radiation therapy (SIRT), is a treatment used to destroy tumors. A tiny catheter is used to inject radioactive beads into the blood vessels that supply the tumor. The beads give off radiation over a very short distance, which concentrates inside the tumor, helping to reduce radiation exposure to the rest of the body. This treatment may also be referred to as Y-90 because it commonly uses a radioactive isotope called yttrium 90.

Microwave ablation uses electromagnetic waves to destroy a tumor. The tumor is localized via image guidance and then a thin microwave antenna (“needle”) is placed directly into the tumor. A microwave generator emits an electromagnetic wave through the antenna and these waves agitate water molecules. The heat that is generated by this reaction causes cell death and tumor killing. Radiofrequency ablation (RFA) or cryoablation use different energies to kill tumors. The differences between the three modalities may depend on patient factors, location and extent of tumor and the affiliations of the medical center.

Fluid Management

Minimally invasive procedures in order to deal with fluid accumulation is common place for interventional radiologists. Routine procedures include aspirations when a single needle is used to sample fluid for diagnostic tests in the hopes there is no recurrence. Other procedures include leaving drainage tube in place which can be used to instill medications to prevent fluid from reaccumulating. This is called sclerosis. Alternatively, some devices are left in placed to allow patient’s to drain at home. This is called a PleurX or tunneled peritoneal or pleural drain. These are all same day procedures.

Occasionally, the clinical picture is more complex and fluid recirculation is needed. A tunneled peritoneovenous shunt or Denver shunt may be what is best. Alternatively, other patients with chronic ascites and liver failure may be best treated with a Transjugular Intrahepatic Portosystemic Shunt (aka TIPS), a complex procedure performed in the interventional radiology suite which requires hospitalization in most cases and extensive workup between IR and gastroenterology prior to the procedure. Lastly, some patients have disruption or leaks from the lymphatic system. IR has pioneered a technique called thoracic duct embolization to reduce and in many cases resolve the leakage of chyle. This procedure was developed at the University of Pennsylvania where I trained.

Men’s health

Interventional radiology offers safe, nonsurgical options to treat conditions that affect men’s quality of life including enlarged prostate and varicoceles. Because interventional radiology treatments do not require large incisions, they can often be safer and, at times, more effective than open surgery. In addition, most men will be treated and discharged within the same day, getting back to their life as quickly as possible.

Prostate artery embolization (PAE) is a safe and effective single day treatment option, approved by the AUA for patients to reduce the size of the prostate and improve lower urinary tract symptoms (LUTS) related to benign prostatic hyperplasia (BPH). Symptoms may include frequent urination, the urgency to urinate, poor urine stream, and incomplete emptying of the bladder. I have over 3 years of experience performing this procedure for patients with bleeding after radiation, Foley dependent patients and typically symptomatic men w LUTS. Some patients have been able to come off their medications completely while others now enjoy an improved quality of life. We utilize cone-beam CT, a critical technological component to improve outcomes.

Symptoms of varicocele can include abnormal enlargement of veins in scrotum, dull ache or pain in the scrotum. The abnormal enlargement of the veins can also lead to decreased fertility. Varicocele embolization is a safe and effective outpatient procedure which blocks the blood flow to the enlarged veins within the scrotum.

Vertebral compression fractures

Vertebral compression fractures occur when the bones in your spine collapse. These fractures can be caused by osteoporosis or cancer. Major consequences of compression fractures include back pain, hunchback, and height loss.

Vertebroplasty and kyphoplasty are treatment options for spine fractures involving inserting needles into a fractured vertebral body and injecting cement directly into the bone to stabilize the fracture and allow it to heal. On occasion, ablation can be done at the same time if the fracture is pathologic, such as those due to metastatic disease to the spine.

COMPLEx ivc filter removal

IVC filter placement is a preventative tool placed inside a huge vein in the abdomen called the inferior vena cava to trap any blood clots that may break free from the veins in the legs and potentially reach the heart or the lungs. An IVC filter is one of the many treatments used to prevent a pulmonary embolism (PE, a blood clot that travels to the lungs) and should only be placed in patients that cannot receive blood thinners or in patients in whom blood thinning treatment has failed.

Filters come in essentially two flavors, permanent or temporary. Temporary filters often need to be removed once a patient’s risk for PE has resolved or they return to systemic anticoagulation. Filter removal may be simple or complex. IR has pioneered the field of complex filter removal. Complex filter removal usually requires venous access in one or two sites in the abdomen and may utilize devices like a snare, balloon and forceps for optimal filter removal.

Pulmonary AVM

Hereditary hemorrhagic telangiectasia (HHT) is a genetic disorder that results in unusual growth of blood vessels of the mouth, nose, skin and organs. There are different types of HHT, including arteriovenous malformations (AVMs) and telangiectasias. Pulmonary AVM form in a subset of patients with HHT, are abnormal direct connections between the artery and vein, and require prompt treatment to decrease the risk of stroke amongst other complications. I was fortunate to train at the University of Pennsylvania which is a major center for patients with complex pulmonary AVMs. The procedure involves the catheterization of the pulmonary artery and embolization using various techniques to stop the blood flow. Almost as important as the procedure is the workup, genetic counseling and preventative measures to ensure the current and future risk of “paradoxical emboli” are reduced.

women’s health

Interventional radiology can treat a variety of conditions for women including uterine fibroids, infertility, chronic pelvic pain and varicose veins. Historically, traditional surgery was sometimes the only treatment available to alleviate many of the life-altering symptoms caused by these conditions. Thankfully we now have rigorously studied, minimally invasive, targeted treatments for these conditions, often with less pain and shorter recovery time than open surgery.

A uterine fibroid (leiomyoma) is a benign growth in the uterus that can alter a woman’s period in many different ways. Symptoms include uterine pressure or pain, heavy menstrual bleeding, abdominal enlargement or a bloated feeling, pain during or following intercourse, constipation and an urge to urinate frequently amongst others. Because most women will not exhibit every potential symptom, diagnosis is usually confirmed by using imaging of the pelvis, with transvaginal ultrasound or MRI. Uterine Fibroid Embolization (UFE) is a safe and effective potentially same day treatment for symptomatic uterine fibroids. Under sedation and under X-ray guidance, a small catheter is used to access the blood vessel carrying blood to the tumor through a small incision in the wrist or groin. Once the catheter is in the proper position, small particles are used to block the small vessels and deprive the fibroid of nutrients shrinking the fibroid. After undergoing uterine fibroid embolization, you’ll be sent home with oral pain medication to use for an additional few days. Most women are back to their normal activity in about one week.

Chronic pelvic pain that occurs because of pelvic congestion syndrome is often felt below the belly button in the pelvis. A number of conditions can cause chronic pelvic pain, including enlarged varicose veins in the ovaries and pelvis. If the valves of the veins in the pelvis are weak or damaged, blood can pool in your veins, which causes them to swell. When this happens near the pelvis, it is called pelvic congestion syndrome. Women with pelvic congestion syndrome often experience pain during or following intercourse.

Pelvic congestion syndrome usually affects women who have previously been pregnant because the ovarian and pelvic veins widened to accommodate the increased blood flow from the uterus during pregnancy. After the pregnancy, some of these veins remain enlarged and fail to return to their previous size, causing them to weaken, allowing blood to pool.

 Ovarian vein embolization is a same-day treatment through a small incision in your groin or wrist. A small catheter is passed through your veins to reach the enlarged pelvic veins responsible for the congestion. The catheter allows the introduction of embolic agents, medications that seal off the vein, relieving the painful pressure. After treatment, women can return to normal activities immediately.

Dialysis Access Interventions

Interventional radiology is one of a few specialties that routinely care for hemodialysis patients providing procedures relating to catheter access or management as well as fistula or graft interventions. These same day procedures often require the use of IV contrast, small catheters, balloons and occasionally stents to maintain proper flow trough the hemodialysis circuit. We work closely with the patients nephrologist to ensure the access is healthy for as long as possible.

Over the last few years there has been impressive work done with regards to percutaneous fistula creation. This is a new and exciting chapter for interventional radiologist. Stay tuned.