ADVERTISEMENT
The Role of Interventional Oncology in Patients With Gynecologic Malignancies
Abstract: The primary treatment of gynecologic malignancies has typically involved surgical resection and chemotherapy with the role of interventional radiologists primarily relegated to obtaining a tissue diagnosis. That paradigm is now shifting as interventionalists have become increasingly involved in local tumor control, primarily via thermal ablation. Thermal ablation techniques can also be used for the palliation of painful osseous metastases. Interventional strategies to manage refractory malignant ascites include creation of a peritoneovenous shunt and placement of an indwelling drainage catheter. Catheter-directed embolization is primarily reserved for patients with pelvic hemorrhage as a consequence of their advanced disease.
Key words: gynecologic malignancy, thermal ablation, embolization
____________________________________________
Although surgical cytoreduction and chemotherapy constitute the primary treatments for patients with gynecologic malignancies, especially of ovarian primaries, there is a definite but often unrecognized role for interventional oncology. One of the principal ways interventionalists participate in the care of these patients is through image-guided biopsy. While this may seem like a relatively trivial task, it has been shown that up to 20% of women undergoing surgical debulking for suspected ovarian cancer are found to have metastases from a nongynecologic source.1 By delivering a tissue diagnosis in a noninvasive manner and possibly avoiding unnecessary laparoscopy, the service becomes invaluable to patients and providers. Image-guided biopsy, however, has been elucidated in multiple publications. The subjects discussed herein include percutaneous techniques for local tumor control, treatment of refractory ascites, management of hemorrhage, and palliation.
Local Control
There is a well-established association between overall survival in women with advanced ovarian cancer and aggressive cytoreduction, as indicated by the diameter of the largest residual tumor.2 However, aggressive cytoreduction is often not possible. One study showed that optimal debulking (residual tumor <1 cm) was only achievable in 16% of cases.3
Given the challenges associated with reaching significant cytoreduction with surgery and chemotherapy alone, the potential role of radiofrequency ablation for achieving local control has been evaluated. In one small retrospective study evaluating the efficacy of RFA in women with stage III and IV ovarian cancer with liver metastases, the authors were able to achieve high technical effectiveness and primary efficacy (83% and 80%, respectively) with a mean disease-free progression interval of 2.5 months.4 It should be noted that the study cohort was only made up of 6 patients. Aware of the study limitations, the authors go on to support the use of a “test of time,” approach first advocated by Livraghi et al5 for metastatic colorectal cancer, whereby lesions may be ablated and then followed closely with imaging surveillance. Such a strategy would theoretically limit unnecessary hepatic resections in the event of futility due to rapid progression of extrahepatic disease or absence of additional disease (Figure 1).
Compared to radiofrequency ablation (RFA), there is relatively little in the literature regarding the use of cryoablation for the treatment of gynecologic malignancies. Of these limited studies, one by Goering et al found no significant difference in 3-year survival between patients with noncolorectal metastases treated with surgery alone and those treated with either cryoablation alone or with surgery (49% vs 62%, P=.57). The same study demonstrated that the 3-year local hepatic tumor-free survival was 19% for genitourinary tumors compared to 32% for neuroendocrine tumors and 20% for other soft tissue tumors.6
Management of Malignant Ascites
Apart from increased mortality associated with high tumor burdens, patients with gynecologic malignancies often have high degrees of morbidity. One common cause of morbidity in these patients is recurrent ascites, which can manifest as abdominal discomfort, orthopnea, and lower-extremity edema. Medical therapies such as sodium restriction and diuretic use are usually ineffective and multiple hospital visits are required for repeat large-volume paracentesis.7 However, these large-volume drainages can increase the chance of infection as well as the risk of hypotension and acute renal failure from excessive protein loss and large fluid shifts.8
There is a potential role for interventionalists, however, the creation of transjugular intrahepatic portosystemic shunts (TIPS) is not typically performed in the setting of malignancy.9 There have been reports of peritoneovenous shunts placed by interventional radiologists. The most commonly reported complications include shunt occlusion, post shunt coagulopathy, deep venous thrombosis, catheter breakage, and leakage.10 Bratby et al reported successful shunt placement in all 26 patients in a series who presented with intractable ascites. Shunt dysfunction was reported 8 times in 7 patients and revision was successful 5 times for 4 patients. They reported an 80.1% overall shunt patency rate.11
Another strategy available for interventionalists in the treatment of intractable ascites is the placement of an indwelling peritoneal drainage catheter. Multiple systems are now commercially available, such as Tenckhoff or PleurX (CareFusion). Tapping et al investigated the safety and efficacy of PleurX catheters for the management of malignant ascites and reported 100% technical success and no major complications. The mean dwelling time of the catheters in their study was 113 days and the annual event rate was 0.45. Decreased catheter patency was found to be associated with concurrent renal disease and chemotherapy (Figure 2).12
Management of Pelvic Hemorrhage
In addition to disease control and symptom management, the interventionalist also has a role in the treatment of intractable hemorrhage, an uncommon but potentially grave complication of gynecologic malignancies. Because of the extensive collateral network involving the internal iliac artery, both proximal ligation and subselective embolization are futile. Instead, the anterior division of both internal iliac arteries should be embolized, with appropriate care taken to avoid non-target embolization of the posterior division to avoid neurological complications.
In the largest published case series of transcatheter arterial embolization for treatment of hemorrhage from gynecologic malignancies, 83 of 108 patients had complete cessation of bleeding following treatment (77%), while another 25 patients reported a reduction in bleeding following embolization.13 The embolizations were performed with either Gelfoam or 250-590 micron polyvinyl alcohol (PVA) particles (Figure 3).
Palliation of Osseous Metastases
Palliation of painful metastases is another potential role for the interventional oncologist. Recent studies have demonstrated that thermal ablation using either RFA or cryoablation provided significant pain relief. Furthermore, patients who reported symptomatic relief lived longer than those who did not respond to the treatment (11.2 months vs 4.3 months).14
Relative advantages of cryoablation compared to RFA include analgesic effect of cold and the ability to reliably see the ablation zone intraprocedurally, which has particular value when the target lesion is adjacent to critical structures, such as the spine.15 Regardless of the technique used, a mixture of polymethacrylate and tantalum powder may be injected into the lesion under CT or fluoroscopic guidance to protect against pathologic fracture and also to provide additional pain relief (Figure 4).16
Conclusion
The mainstays of therapy for gynecologic malignancies have long included surgical and medical oncologic management. However, as interventional oncologists have expanded their repertoire, they have been able to more actively participate in the care of this patient population.
The potential roles are varied and range from providing local cytoreduction, which was previously primarily surgical, to palliation. Given the importance of these roles, it is imperative that both radiologists and collaborating clinicians are aware of the services that may be rendered.
Editor’s Note: Disclosure: The authors report no financial relationships or conflicts of interest regarding the content herein. Address for correspondence: Please email all inquiries to Quazi Z. Al-Tariq, MD, quaziat@uw.edu.
Suggested citation:Al-Tariq QZ, Park JK. The role of interventional oncology in patients with gynecologic malignancies. Intervent Onc 360. 2014;2(12):E82-E87.
References
1.Brown DL, Zou KH, Tempany CM, et al. Primary versus secondary ovarian malignancy: imaging findings of adnexal masses in the Radiology Diagnostic Oncology Group Study. Radiology. 2001;219(1):213-218.
2.Griffiths CT. Surgical resection of tumor bulk in the primary treatment of ovarian carcinoma. Natl Cancer Inst Monogr. 1975;42:101-104.
3.Bristow RE, Montz FJ, Lagasse LD, Leuchter RS, Karlan BY. Survival impact of surgical cytoreduction in stage IV epithelial ovarian cancer. Gynecol Oncol. 1999;72(3):278-287.
4.Gervais DA, Arellano RS, Mueller PR. Percutaneous radiofrequency ablation of ovarian cancer metastasis to the liver. indications, outcomes, and role in patient management. AJR Am J Roentgenol. 2006;187(3):746-750.
5.Livraghi T, Solbiati L, Meloni F, Ierace T, Goldberg SN, Gazelle GS. Percutaneous radiofrequency ablation of liver metastases in potential candidates for resection: the “test-of-time approach.” Cancer. 2003;97(12):3027-3035.
6.Goering JD, Mahvi DM, Niederhuber JE, Chicks D, Rikkers LF. Cryoablation and liver resection for noncolorectal liver metastases. Am J Surg. 2002;183(4):384-389.
7.Akinci D, Erol B, Ciftci TT, Akhan O. Radiologically placed tunneled peritoneal catheter in palliation of malignant ascites. Eur J Radiol. 2011;80(2):265-268.
8.Rosenberg S, Courtney A, Nemcek AA Jr, Omary RA. Comparison of percutaneous management techniques for recurrent malignant ascites. J Vasc Interv Radiol. 2004;15(10):1129-1131.
9.Anaokar JM, Raman SS. Interventional strategies in the treatment of gynecologic cancers. In ST Kee, R Murthy, DC Madoff, eds. Clinical Interventional Oncology. Philadelphia, PA: Elsevier; 2014:180-186.
10.Martin LG. Percutaneous placement and management of peritoneovenous shunts. Semin Interven Radiol. 2012;29(2):129-134.
11.Bratby MJ, Hussain FF, Lopez AJ. Radiologic insertion and management of peritoneovenous shunt. Cardiovasc Interven Radiol 2007; 30(3): 415-418.
12.Tapping CR, Ling L, Razack A. PleurX drain use in the management of malignant ascites: safety, complications, long-term patency and factors predictive of success. Br J Radiol. 2012;85(1013):623-628.
13.Pisco JM, Martins JM, Correia MG. Internal iliac artery: embolization to control hemorrhage from pelvic neoplasms. Radiology. 1989;172(2):337-339.
14.Grieco CA, Simon CJ, Mayo-Smith WW, Dipetrillo TA, Ready NE, Dupuy DE. Image-guided percutaneous thermal ablation for the palliative treatment of chest wall masses. Am J Clin Oncol. 2007;30(4):361-367.
15.Al-Tariq QZ, Genshaft S, Kee ST. Metastatic disease. In ST Kee, R Murthy, DC Madoff, eds. Clinical Interventional Oncology. Philadelphia, PA: Elsevier; 2014:271-281.
16.Rybak, LD. Fire and ice: thermal ablation of musculoskeletal tumors. Radiol Clin North Am. 2009;47(3):455-469.
