Some of the procedures  include:

Some of the diseases and conditions we treat are:

To make a referral please download and complete the referral form, then fax the completed form to 304-598-4996.

Treatments for Blocked Blood Vessels

angiostentIn many cases, interventional radiologists can open blocked or narrowed blood vessels caused by peripheral arterial disease or other conditions. For example, in some patients, high blood pressure is caused by blockage in the artery to the kidney, a condition known as renal vascular hypertension. Interventional radiologists can often treat blocked blood vessals without surgery. In most cases, hospitalization and general anesthesia are not required. There is no surgical incision –just a small nick in the skin — and no stitches are needed. Often, patients may return to normal activity shortly after the procedure.

Inventors of Angioplasty and Stenting

As the inventors of angioplasty and the catheter-delivered stent, which were first used in the legs to treat peripheral arterial disease, interventional radiologists pioneered minimally invasive modern medicine.

Angioplasty and Stenting Definition

balloon_stentIn this technique, the interventional radiologist inserts a very small balloon attached to a thin catheter into a blood vessel through a small nick in the skin. The catheter is threaded under X-ray guidance to the site of the blocked artery. The balloon is inflated to open the artery. Sometimes, a small metal scaffold, called a stent, is inserted to keep the blood vessel open.

stent_illustrationBalloon angioplasty and stenting have generally replaced open surgery as the first-line treatment because randomized trials have shown interventional therapy to be as effective as surgery for many arterial occlusions. In the past seven to ten years, a very large clinical experience in centers around the world has shown that stenting and angioplasty are preferred as a first-line treatment for more and more processes throughout the body.

Thrombolytic Therapy

This treatment is used if the blockage in an artery is caused by a blood clot. Thrombolytic drugs that dissolve clots are injected through a catheter to eliminate the clot and restore blood flow.

Smoking and Vascular Disease

Although most people are well aware of the risk of cancer from smoking, few people realize the damage smoking causes throughout the body’s vascular system. Smoking damages the blood vessels and smokers are at risk for all vascular diseases including peripheral arterial disease, stroke, heart attack, abdominal aortic aneurysm and subsequent death.

Atherosclerosis – Hardening of the Arteries

Atherosclerosis, or hardening of the arteries, occurs when cholesterol and scar tissue build up, forming a substance called plaque inside the arteries that narrows and clogs the arteries, causing decreased blood flow. Because atherosclerosis is a systemic disease, people are likely to have blocked arteries in multiple areas of the body. These people are at increased risk for heart disease, aortic aneurysm, peripheral arterial disease, stroke, renal hypertension and kidney failure.

Interventional Radiologists are Vascular Disease Experts

Interventional radiology is a recognized medical specialty by the American Board of Medical Specialties. Interventional radiologists are board-certified physicians with extensive training in vascular disease diagnosis, management and treatment. Their board certification includes both Vascular and Interventional Radiology and Diagnostic Radiology which are administered by the American Board of Radiology. This training marries state-of-the-art imaging and diagnostic expertise, coupled with clinical experience across all specialties and in-depth knowledge of the least invasive treatments.

Clot-Busting Treatment Prevents Permanent Leg Damage

Deep vein thrombosis (DVT) is the formation of a blood clot, known as a thrombus, in the deep leg vein. It is a very serious condition that can cause permanent damage to the leg, known as post-thrombotic syndrome, or a life-threating pulomnary embolism. In the United States alone, 600,000 new cases are diagnosed each year. One in every 100 people who develops DVT dies. Recently, it has been referred to as Economy Class Syndrome due to the occurrence after sitting on long flights.

The deep veins that lie near the center of the leg are surrounded by powerful muscles that contract and force deoxygenated blood back to the lungs and heart. One-way valves prevent the back-flow of blood between the contractions. (Blood is squeezed up the leg against gravity and the valves prevent it from flowing back to our feet.) When the circulation of the blood slows down due to illness, injury or inactivity, blood can accumulate or pool, which provides an ideal setting for clot formation.

dvt_clot_illustration

Risk Factors

  • Previous DVT or family history of DVT
  • Immobility, such as bed rest or sitting for long periods of time
  • Recent surgery
  • Above the age of 40
  • Hormone therapy or oral contraceptives
  • Pregnancy or post-partum
  • Previous or current cancer
  • Limb trauma and/or orthopedic procedures
  • Coagulation abnormalities
  • Obesity

Symptoms

  • Discoloration of the legs
  • Calf or leg pain or tenderness
  • Swelling of the leg or lower limb
  • Warm skin
  • Surface veins become more visible
  • Leg fatigue

Post-thrombotic Syndrome

Post-thrombotic syndrome is an under-recognized, but relatively common sequela, or aftereffect, of having DVT if treated with blood thinners (anticoagulation) alone, because the clot remains in the leg. Contrary to popular belief, anticoagulants do not actively dissolve the clot, they just prevent new clots from forming. The body will eventually dissolve a clot, but often the vein becomes damaged in the meantime. A significant proportion of these patients develop permanent irreversible damage in the affected leg veins and their valves, resulting in abnormal pooling of blood in the leg, chronic leg pain, fatigue, swelling, and, in extreme cases, severe skin ulcers. While this use to be considered an unusual, long-term sequela, it actually occurs frequently, in as many as 60-70 percent of people, and can develop within two months of developing DVT. There is increasing evidence that clot removal via interventional catheter-directed thrombolysis in selected cases of DVT can improve quality of life and prevent the debilitating sequela of post-thrombotic syndrome.

Deep Vein Thrombosis Treatments

Early Treatment With Blood Thinners Is Important to Prevent a Life-threatening Pulmonary Embolism, but Does Not Treat the Existing Clot

Blood Thinners

Early in treatment, blood thinners are given to keep the clot from growing or breaking off and traveling to the lung and causing a life-threatening pulmonary embolism by blocking the oxygen supply causing heart failure. Contrary to popular belief, blood thinners (anticoagulants) do not actively dissolve the clot, but instead prevents new clots from forming. Over time, the body will dissolve the clot, but often the vein becomes damaged in the meantime. To prevent permanant leg damage, patients can get catheter-directed thrombolysis treatment.

Seek a Second Opinion From an Interventional Radiologist if Leg Pain Continues Beyond Seven Days

It is important for DVT patients to be evaluated by an interventional radiologist to determine if catheter-directed thrombolysis is needed to remove the clot. This treatment is highly effective when performed within 10 days after symptoms begin.

Catheter-directed Thrombolysis (Clot-Busting) Treatment

Catheter-directed thrombolysis is performed under imaging guidance by interventional radiologists. This procedure, performed in a hospital’s interventional radiology suite, is designed to rapidly break up the clot, restore blood flow within the vein, and potentially preserve valve function to minimize the risk of post-thrombotic syndrome. The interventional radiologist inserts a catheter into the popliteal (located behind the knee) or other leg vein and threads it into the vein containing the clot using imaging guidance. The catheter tip is placed into the clot and a “clot busting” drug is infused directly to the thrombus (clot). The fresher the clot, the faster it dissolves – one to two days. Any narrowing in the vein that might lead to future clot formation can be identified by venography, an imaging study of the veins, and treated by the interventional radiologist with a balloon angioplasty or stent placement.

In patients in whom this is not appropriate and blood thinners are not medically appropriate, an interventional radiologist can insert a vena cava filter, a small device that functions like a catcher’s mitt to capture blood clots but allow normal liquid blood to pass.

Efficacy

Clinical resolution of pain and swelling and restoration of blood flow in the vein is greater than 85 percent with the catheter-directed technique.

If you have been diagnosed with Deep Vein Thrombosis or DVT, click to see if you may be eligible to participate in the ATTRACT Study. National physician experts are enrolling patients in this study to determine the best treatment for blood clots.

Information can also be found on the SIR Foundation Web site.

Kidney cancer is the eighth most common cancer in men and the tenth in women. The most common type of kidney cancer is renal cell carcinoma that forms in the lining of the renal tubules in the kidney that filter the blood and produce urine. Approximately 85 percent of kidney tumors are renal cell carcinomas. When kidney cancer spreads outside the organ, it can often be found in nearby lymph nodes, lungs, bones or liver, as well as the other kidney.

The current gold standard treatment is laparoscopic partial nephrectomy surgery. However, some patients could benefit from minimally invasive, kidney-sparing treatment, such as those with high surgical risk, underlying illnesses, multiple recurrent tumors, borderline kidney function or only one kidney.

Additionally given the recent success of percutaneous cryoablation, patients with kidney cancer may elect to avoid surgery and have their tumor treated this way. The urologist and interventional radiologist work together in a multidisciplinary team to determine whether a less invasive percutaneous ablation can be done safely and effectively.

Prevalence and Risk Factors

More than 32,000 Americans each year are diagnosed with kidney cancer-many of them don’t have symptoms. Typically, those with kidney cancer are past the age of 40 and twice as often are men.

Other risk factors include:

  • Smoking
  • Obesity
  • High blood pressure
  • Long-term dialysis
  • Von Hippel-Lindau syndrome

Symptoms

The incidence of kidney cancer is on the rise. Fortunately, the availability of modern imaging technology has led to more frequent detection of small, asymptomatic tumors that otherwise would be undetected. Often, small tumors do not cause symptoms and are discovered on CTs, MRIs or ultrasounds that are performed for some other reason, such as standard imaging studies (CT or ultrasound) performed during many emergency room visits. These small tumors are often the best candidates for nonsurgical treatment options. Common symptoms may include:

  • Blood in the urine
  • Side pain that does not go away
  • A lump or mass in the side of the abdomen
  • Weight loss
  • Fever
  • Feeling very tired

Kidney Cancer Diagnosis

In addition to a basic physical exam, urine test and blood tests, several other techniques can be used to diagnose kidney cancer. CT scan, MRI or ultrasound can be performed to see inside the body and identify a tumor. An image-guided needle biopsy can be done to remove tissue samples and look for cancer cells. At the time of diagnosis, 25 to 30 percent of patients have metastases.

In a biopsy, a sample of tissue from the tumor or other abnormality is obtained and examined by a pathologist. By examining the biopsy sample, pathologists and other experts also can determine what kind of cancer is present and whether it is likely to be fast or slow growing. This information is important in deciding the best type of treatment. Open surgery is sometimes performed to obtain a tissue sample for biopsy. But in most cases, tissue samples can be obtained without open surgery with interventional radiology techniques.

Needle biopsy

Needle biopsy, also called image-guided biopsy, is usually performed using a moving X-ray technique (fluoroscopy) computed tomography (CT), ultrasound or magnetic resonance (MR) to guide the procedure. In many cases, needle biopsies are performed with the aid of equipment that creates a computer-generated image and allows radiologists to see an area inside the body from various angles. This stereotactic equipment helps them pinpoint the exact location of the abnormal tissue.

Needle biopsy is typically an outpatient procedure with very infrequent complications; less than 1 percent of patients develop bleeding or infection. In about 90 percent of patients, needle biopsy provides enough tissue for the pathologist to determine the cause of the abnormality.

Advantages of needle biopsy include:

  • With image guidance, the abnormality can be biopsied while important nearby structures such as blood vessels and vital organs can be seen and avoided.
  • The patient is spared the pain, scarring and complications associated with open surgery.
  • Recovery times are usually shorter and patients can more quickly resume normal activities.
x-ray_of_needle_biopsy
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An X-ray of a needle inserted into the lung to obtain a sample for biopsy.

Large core needle biopsy. In this technique, a special needle is used that enables the radiologist to obtain a larger biopsy sample. This technique is often used to obtain tissue samples from lumps or other abnormalities in the breast that are detected by physical examination or on mammograms or other imaging scans. Because approximately 80 percent of all breast abnormalities turn out not to be cancer, this technique is often preferred by women and their physicians because it:

  • is less painful and requires less recovery time than open surgical biopsy
  • avoids the scarring and disfigurement that may result from open surgery

A similar technique called fine needle aspiration can be used to withdraw cells from a suspected cancer. It also can diagnose fluids that have collected in the body. Sometimes, these fluid collections also may be drained through a catheter, such as when pockets of infection are diagnosed.

Many interventional radiology procedures for the diagnosis and treatment of cancer can be performed on an outpatient basis or during a short hospital stay. In many cases, the procedures:

  • offer new cancer treatment options
  • are less painful and debilitating for patients
  • result in quicker recoveries
  • have fewer side effects and complications.

Kidney Cancer Treatments

As vascular experts, interventional radiologists are uniquely skilled in using the vascular system to deliver targeted treatments via catheter throughout the body. In treating cancer patients, interventional radiologists can attack the cancer tumor from inside the body without medicating or affecting other parts of the body. For breast cancer, interventional radiologists use thermal ablation, as well as some laser therapy, to kill the cancer cells. Although the devices used are FDA approved, research to evaluate the long-term effects of these treatments is still ongoing.

Cryoablation

Recent interventional cryoablation data are showing near 100 percent efficacy for tumors up to four centimeters if localized to the kidney. Larger localized tumors can also be successfully treated with cryoablation depending on size and location. Ablated lesions show as dead tissue (scar) with no recurrences at one-year follow-up on imaging, after one treatment. The one-year benchmark is an established and well-accepted benchmark within the medical community.

Studies are ongoing to compare cryoablation to partial nephrectomy, and it is expected that the two treatments will be shown to be equivalent in the future. The interventional radiology treatment is less invasive and easier on the patient. This treatment spares the majority of the healthy kidney tissue and can be repeated if needed.

The treatment has an excellent safety profile, and most patients are sent home the same day as the procedure or go home the next day. The most common complication is a bruise (hematoma) around the kidney that goes away by itself.

These interventional treatments also offer valuable benefits to those patients with advanced or metastatic renal cell carcinoma. While not considered curative for these patients, the lesions can be re-treated as needed. Studies are underway on combination treatments. One such study uses cryoablation to kill the primary kidney tumor and immune system stimulation to treat any metastases. Traditional chemotherapy drugs and radiation are generally ineffective for kidney cancer.

Cryoablation is delivered directly into the tumor by a probe that is inserted through the skin using imaging to guide it internally. Cryoablation uses an extremely cold gas to freeze the tumor to kill it. This technique has been used for many years by urologists in the operating room, but in the last few years, the needles have become small enough to be used by interventional radiologists through a small incision in the skin without the need for an operation. The ice ball that is created around the needle grows in size and destroys the frozen tumor cells.

Thermal Ablation Treatments

The conventional treatment for kidney cancer without metastases is surgical removal by a urologist. However, some patients could benefit from minimally invasive, kidney-sparing treatment, such as those with high surgical risk, underlying illnesses, multiple recurrent tumors, borderline kidney function or only one kidney. For these patients, interventional radiologists may be able to treat the tumor with new, less invasive treatments using specially designed needles to eliminate the kidney cancer. The urologist and interventional radiologist work together in a multidisciplinary team to determine whether a less invasive percutaneous ablation can be done safely and effectively.

Radiofrequency Ablation

For inoperable kidney tumors, radiofrequency ablation (RFA) offers a nonsurgical, localized treatment that kills the tumor cells with heat, while sparing the healthy kidney tissue. This treatment is much easier on the patient and is more effective than systemic therapy. Radiofrequency energy can be given without affecting the patient’s overall health and most people can resume their usual activities in a few days.

In this procedure, the interventional radiologist guides a small needle through the skin into the tumor. From the tip of the needle, radiofrequency energy is transmitted into the tumor, where it produces heat and kills the tumor cells. The dead tumor tissue shrinks and slowly turns into a scar.

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Click on images to enlarge

Additional Facts About RFA

  • Is most effective when the kidney cancer is small in size (5cm or less)
  • May be performed under conscious sedation or general anesthesia
  • Is well tolerated-most patients can resume their normal routines the next day and may feel tired only for a few days
  • Can be repeated if necessary
  • May be combined with other treatment options

Efficacy

If the tumor is small, RFA can shrink and likely kill the tumor. Although early results are encouraging, long-term follow-up is necessary to determine the precise role of RFA in treating small kidney cancers. Current ongoing studies will determine long-term survival.

Because it is a local treatment that does not harm healthy tissue, the treatment can be repeated as often as needed. It is a very safe procedure, with low complication rates, and it has become more widely available over the last couple of years. The FDA has approved RFA for use in soft tissue tumors, of which renal cell carcinoma is one.

livertumorbeforerfa
BEFORE
livertumorafterrfa
AFTER

A LIVER TUMOR TREATED WITH RFA

Dead tissue appears larger and darker than the living tumor. Over time, the tumor shrinks as the body absorbs and excretes dead cells

Risks

The risks of RFA are similar to a biopsy, namely localized bleeding and some pain. Bleeding that requires action is uncommon partly because the heating from the radiofrequency energy cauterizes the tissue and minimizes the risk of hemorrhage. Heating of the tumor may cause heating of an adjacent structure, which can lead to some healthy tissue damage. This can be avoided by carefully reviewing the size and location of the tumor before the procedure. Tumors adjacent to structures such as bowel may not be candidates for RFA or may require special procedures (injection of fluid) to create safe distances between the tumor being treated and the adjacent bowel.

Cost/Insurance

Since RFA is new, many insurance companies may require preapproval prior to the procedure.

interventional_radiologist_treating_cancer
Interventional radiologists use special X-ray equipment to guide therapy directly to the site of tumors

Management of Advanced Renal Cell Carcinoma

Arterial Embolization

Advanced renal cell carcinoma tumors are often quite large and invade adjacent structures and veins. They may even extend through the veins into one of the heart chambers. Some patients with advanced tumors may not be surgical candidates. Arterial embolization is an invaluable treatment option for such patients.

During embolization, an interventional radiologist inserts a small tube (catheter) into an artery in the groin and directs it to the renal artery that supplies blood to the kidney and the tumor. The doctor injects small solid particles or special liquid agents into the artery to block the flow of blood into the kidney. The blockage prevents the tumor from getting oxygen and other substances it needs to grow, causing it to shrink.

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Click on images to enlarge

In some patients, arterial embolization may shrink the tumor substantially, rendering the patient a suitable surgical candidate. In others, arterial embolization effectively eliminates tumor-related symptoms and improves patients’ quality of life.

Arterial embolization has also been used to facilitate surgical resection of large tumors. Blocking the blood supply to the tumor decreases the risk of bleeding and minimizes the amount of blood transfusion during surgery. Similarly, arterial embolization can facilitate ablation of larger tumors. Reduction of blood supply to the tumor renders ablation procedures (RFA or cryoablation) safer and more effective.

Surgery

Radical Nephrectomy: Kidney cancer may be treated with radical nephrectomy, in which the entire kidney, along with the adrenal gland and some tissue around the kidney, is surgically removed. Some lymph nodes in the area also may be removed.

Simple Nephrectomy: Some patients with early kidney cancer may have a simple nephrectomy which involves removing only the kidney.

Partial Nephrectomy: A surgeon removes the section of the kidney with the tumor. This procedure may be used when the patient has only one kidney or the cancer affects both kidneys, and only in patients with small kidney tumors.

Biological Therapy and Immunotherapy

Biological therapy is a systemic therapy that uses substances injected into the bloodstream to reach and affect cells all over the body. Biological therapy utilizes the body’s natural ability, such as using the immune system, to fight cancer.2 Recent advances in immunotherapy have made a significant improvement in survival of patients with inoperable renal cancer.

Chemotherapy

Chemotherapy is a systemic therapy in which anticancer drugs enter the bloodstream and travel throughout the body. Anticancer drugs have shown limited effectiveness against kidney cancer.

New Cancer Treatments on the Horizon

Interventional radiology is playing a role in developing new techniques that may improve cancer treatment in the future, including the use of magnetic particles to draw cancer-killing agents into tumors; and the delivery of genetic material, called gene therapy, to fight or prevent cancers. These techniques are still investigational, but they offer new hope in the war against cancer.

Magnetic Chemotherapy

Interventional radiologists are currently investigating a new technique in which magnets are used to pull chemotherapy drugs into tumors. Microscopic magnetic particles are attached to the cancer-killing drugs and infused through a catheter into the blood vessel that feeds the tumor. A rare earth magnet is positioned over the patient’s body directly above the site of the tumor. The magnet pulls the drug-carrying particles out of the blood vessel so that they lodge in the tumor. Although the technique is still experimental, early research is promising. Physicians are hopeful that it will bolster the effects of chemotherapy while avoiding some of the drugs’ side effects, such as hair loss and nausea.

Gene Therapy

genetherapyresearch1In recent years, scientists have gained a new understanding about genes-the basic biological units of heredity-and the role they play in disease. This knowledge has set the stage for medical science to alter patients’ genetic material to fight or prevent cancer. Although the science of gene therapy is still in the early, experimental stages, researchers are hoping that in the future the therapy can be used to:

  • alter the cells of a patient’s natural immune system with cancer-fighting genes and returning them to the body, where they could more forcefully attack the cancer
  • remove cancer cells from the body and alter them genetically so that the patient’s own immune system will mount a strong defense against them. In this technique, the altered cancer cells would act as a cancer vaccine
  • replace a faulty gene responsible for the growth of cancer with a “good” gene
  • inject a tumor with genes that will make it more susceptible to chemotherapy or other cancer-fighting agents
  • make bone marrow and other organs resistant to chemotherapy, so that the drugs will destroy tumors without damaging healthy tissue

One of the challenges of gene therapy is finding safe and effective ways to deliver genes or genetically altered cells to the site of the tumor. Interventional radiologists, with their special expertise in using X-rays and other imaging techniques to guide catheters and other tools through the body are expected to play an important role in this new technology.

Treatments for Cancer Complications

There are also a number of interventional radiology techniques that are used to treat the complications of cancer, including pain, bleeding, obstruction of vital organs, blood clots and infection. Although these treatments do not cure cancer, they can make patients more comfortable, extend life by treating serious complications and improve the quality of life for cancer patients.

Treating Pain

Control of pain is one of the most important aspects of cancer care. Pain not only affects patients’ quality of life and ability to function, it may also lower their tolerance for needed cancer treatments.

In many cancer patients, pain results from the spread of the tumor into surrounding nerves and other tissues. For example, patients with cancer of the pancreas or stomach, sometimes experience pain from the spread of the tumor into a network of nerves and blood vessels in the abdomen called the celiac plexus. To treat the pain, interventional radiologists insert catheters or needles into the affected area and administer alcohol or other agents that destroy the nerves causing the pain.

A particularly painful complication of cancer is when the disease spreads (metastasizes) to bones. In a technique called transcatheter embolization, interventional radiologists inject tiny particles, the size of grains of sand, through a catheter and into the artery that supplies blood to the tumor. The particles cause clotting that decreases the tumor’s blood supply, reducing pain and decreasing the likelihood of bone fracture.

Controlling Bleeding

If a cancer spreads to the blood vessels it may cause hemorrhage or bleeding. An interventional radiology technique called transcatheter embolization can be used to clot the affected blood vessels and stop the bleeding.

Treating Organ Obstruction and Infection

stent1Cancers can obstruct the normal flow of urine or bile, causing these fluids to build up in the body. If left untreated, these conditions are not only painful but may also result in organ failure or infection. Under X-ray guidance, catheters can be inserted to drain the collection of fluids. Often, a small device called a stent is inserted into the organ to bypass the obstruction and allow fluids to drain internally.

Treating Blood Clots

One common side effect of cancer or cancer treatments is the development of blood clots, or emboli, that can be life-threatening if they travel to the brain, lungs or heart. There are two interventional radiology procedures that can reduce the risks posed by blood clots:

  • Intra-arterial thrombolysis. In this technique, the interventional radiologist guides a catheter through the blood vessels and to the site of a blood clot. Clot-busting drugs are infused through the catheter to break up the clot.
  • Filter placement. This technique is most often used when a blood clot is detected in the blood vessels of the leg (a condition called deep vein thrombosis). The interventional radiologist guides a small filter into the blood vessel that receives blood from the lower body (the vena cava) and carries it to the heart. If the blood clot dislodges from the vein in the leg, the filter will trap it before it can reach the heart.

Interventional Radiologists are Minimally Invasive Experts

Interventional radiologists work with other specialists on a multidisciplinary cancer team to determine the best treatment for each individual patient. Interventional radiology is a recognized medical specialty by the American Board of Medical Specialties. Interventional radiologists are board-certified physicians with extensive training in disease diagnosis, management and treatment. Their board certification includes both Vascular and Interventional Radiology and Diagnostic Radiology which are administered by the American Board of Radiology. This training marries state-of-the-art imaging and diagnostic expertise, coupled with clinical experience across all specialties and in-depth knowledge of the least invasive treatments. Interventional oncology is a growing area within interventional radiology.

Minimally Invasive Treatments Help Cancer Patients Extend and Improve Quality of Life

Surgical removal of liver tumors offers the best chance for a cure. Unfortunately, liver tumors are often inoperable because the tumor may be too large, or has grown into major blood vessels or other vital structures. Sometimes, many small tumors are spread throughout the liver, making surgery too risky or impractical. Surgical removal is not possible for more than two-thirds of primary liver cancer patients and 90 percent of patients with secondary liver cancer.

Historically, chemotherapy drugs have been generally ineffective at curing liver cancer. Interventional radiologists can treat liver cancer with SIRT, a radiation therapy that provides much better results.

Who gets liver cancer?

About 18,500 cases of primary liver cancer are diagnosed each year. The most common form is hepatocellular carcinoma (HCC). This is a tumor that begins in the main cells of the liver (hepatocytes). Primary liver cancer is twice as common in men as in women.

HCC most frequently occurs in those who have a form of liver disease called cirrhosis. Cirrhosis occurs when the liver becomes diseased and develops scarring, usually over a period of years. The liver attempts to repair, or regenerate itself. This process can lead to the formation of tumors. In the U.S., the most common causes of cirrhosis are alcohol abuse and chronic infection with the liver virus hepatitis B or C.

Metastatic liver cancer

Cancer may spread from any part of the body to the liver. There the cancer cells may grow for months or years before they are detected. One of the most common sources of metastatic liver cancer is from tumors of the colon and rectum. About 140,000 people in the United States are diagnosed with colon cancer each year, and roughly half of these patients will develop tumors in their liver at some time. About one in 10 of these patients will have a chance for a cure by having the liver tumors removed surgically.

Patients with other types of cancer also are at risk for liver cancer. The liver serves as a way-station for cancer cells that circulate through the bloodstream. These cells may grow and form tumors in the liver. It is estimated that as many as 70 percent of all people with uncontrolled cancer will eventually develop secondary liver tumors, or metastases (tumors formed by primary cancer cells that have spread from other cancer sites).

Liver Cancer Diagnosis

There are a number of tests that can help in the diagnosis of cancer, including blood tests, physical examination and a variety of imaging techniques including X-rays (e.g., chest X-rays and mammograms); computed tomography (CT); magnetic resonance (MR) and ultrasound. Usually, however, the final diagnosis cannot be made until a biopsy is performed. In a biopsy, a sample of tissue from the tumor or other abnormality is obtained and examined by a pathologist. By examining the biopsy sample, pathologists and other experts also can determine what kind of cancer is present and whether it is likely to be fast or slow growing. This information is important in deciding the best type of treatment. Open surgery is sometimes performed to obtain a tissue sample for biopsy. But in most cases, tissue samples can be obtained without open surgery with interventional radiology techniques.

Needle biopsy

Needle biopsy, also called image-guided biopsy, is usually performed using a moving X-ray technique (fluoroscopy) computed tomography (CT), ultrasound or magnetic resonance (MR) to guide the procedure. In many cases, needle biopsies are performed with the aid of equipment that creates a computer-generated image and allows radiologists to see an area inside the body from various angles. This stereotactic equipment helps them pinpoint the exact location of the abnormal tissue.

Needle biopsy is typically an outpatient procedure with very infrequent complications; less than 1 percent of patients develop bleeding or infection. In about 90 percent of patients, needle biopsy provides enough tissue for the pathologist to determine the cause of the abnormality.

Advantages of needle biopsy include:

  • With image guidance, the abnormality can be biopsied while important nearby structures such as blood vessels and vital organs can be seen and avoided.
  • The patient is spared the pain, scarring and complications associated with open surgery.
  • Recovery times are usually shorter and patients can more quickly resume normal activities.
x-ray_of_needle_biopsy
An X-ray of a needle inserted into the lung to obtain a sample for biopsy.

Large core needle biopsy. In this technique, a special needle is used that enables the radiologist to obtain a larger biopsy sample. This technique is often used to obtain tissue samples from lumps or other abnormalities in the breast that are detected by physical examination or on mammograms or other imaging scans. Because approximately 80 percent of all breast abnormalities turn out not to be cancer, this technique is often preferred by women and their physicians because it:

  • is less painful and requires less recovery time than open surgical biopsy
  • avoids the scarring and disfigurement that may result from open surgery

A similar technique called fine needle aspiration can be used to withdraw cells from a suspected cancer. It also can diagnose fluids that have collected in the body. Sometimes, these fluid collections also may be drained through a catheter, such as when pockets of infection are diagnosed.

Many interventional radiology procedures for the diagnosis and treatment of cancer can be performed on an outpatient basis or during a short hospital stay. In many cases, the procedures:

  • offer new cancer treatment options
  • are less painful and debilitating for patients
  • result in quicker recoveries
  • have fewer side effects and complications

Liver Cancer Treatments

As vascular experts, interventional radiologists are uniquely skilled in using the vascular system to deliver targeted treatments via catheter throughout the body. In treating cancer patients, interventional radiologists can attack the cancer tumor from inside the body without medicating or affecting other parts of the body.

Tumors need a blood supply, which they actively generate, to feed themselves and grow. As vascular experts, interventional radiologists are uniquely skilled in using the vascular system to deliver targeted treatments via catheter throughout the body. In treating cancer patients, interventional radiologists can attack the cancer tumor from inside the body without medicating or affecting other parts of the body by using embolization and radiofrequency heat.

Embolization is a well-established interventional radiology technique that is used to treat trauma victims with massive bleeding, to control hemorrhage after childbirth, to decrease blood loss prior to surgery and to treat tumors. In treating cancer patients, interventional radiologists use embolization to cut off the blood supply to the tumor (embolization), deliver radiation to a tumor (radioembolization), or combine this technique with chemotherapy to deliver the cancer drug directly to the tumor (chemoembolization).

Additionally, interventional radiologists can use imaging to guide them directly to the tumor through the skin to administer radiofrequency heat to cook and kill the cancer cells (radiofrequency ablation) or cyroablation to freeze the tumor.

Chemoembolization

Chemoembolization is a minimally invasive treatment for liver cancer that can be used when there is too much tumor to treat with radiofrequency ablation (RFA), when the tumor is in a location that cannot be treated with RFA, or in combination with RFA or other treatments.

Chemoembolization delivers a high dose of cancer-killing drug (chemotherapy) directly to the organ while depriving the tumor of its blood supply by blocking, or embolizing, the arteries feeding the tumor. Using imaging for guidance, the interventional radiologist threads a tiny catheter up the femoral artery in the groin into the blood vessels supplying the liver tumor. The embolic agents keep the chemotherapy drug in the tumor by blocking the flow to other areas of the body. This allows for a higher dose of chemotherapy drug to be used, because less of the drug is able to circulate to the healthy cells in the body. Chemoembolization usually involves a hospital stay of two to four days. Patients typically have lower than normal energy levels for about a month afterwards.

Chemoembolization is a palliative, not a curative, treatment. It can be extremely effective in treating primary liver cancers, especially when combined with other therapies. Chemoembolization has shown promising early results with some types of metastatic tumors. Although the individual materials used in this treatment are FDA approved, the treatment itself is not approved for intra-arterial therapy of liver tumors.

 

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Click on images to enlarge

Yttrium-90 Radioembolization

Radioembolization is very similar to chemoembolization but with the use of radioactive microspheres. This therapy is used to treat both primary and metastatic liver tumors.

This treatment incorporates the radioactive isotope Yttrium-90 into the embolic spheres to deliver radiation directly to the tumor. Each sphere is about the size of five red blood cells in width. These beads are injected through a catheter from the groin into the liver artery supplying the tumor. The beads become lodged within the tumor vessels where they exert their local radiation that causes cell death. This technique allows for a higher, local dose of radiation to be used, without subjecting healthy tissue in the body to the radiation. The Yttrium-90 radiates from within and, since it is administered in the hepatic artery, it can be viewed as internal radiation.
Radioembolization is a palliative, not a curative, treatment-but patients benefit by extending their lives and improving their quality of life. It is a relatively new therapy that has been effective in treating primary and metastatic liver cancers. It is performed as an outpatient treatment. There are fewer side effects from this treatment compared to standard cancer treatments, with the main one being fatigue for seven to 10 days.

Thermal Ablation Treatments

Radiofrequency Ablation

For inoperable liver tumors, radiofrequency ablation (RFA) offers a nonsurgical, localized treatment that kills the tumor cells with heat, while sparing the healthy liver tissue. Thus, this treatment is much easier on the patient than systemic therapy. Radiofrequency energy can be given without affecting the patient’s overall health and most people can resume their usual activities in a few days.

In this procedure, the interventional radiologist guides a small needle through the skin into the tumor. From the tip of the needle, radiofrequency energy (similar to microwaves) is transmitted to the tip of the needle, where it produces heat in the tissues. The dead tumor tissue shrinks and slowly forms a scar. The FDA has approved RFA for the treatment of liver tumors.

radio1 radio2 radio3
Click on images to enlarge

Efficacy

In a small number of cases, RFA can extend patients’ lives, but it is generally palliative. Depending on the size of the tumor, RFA can shrink or kill the tumor, extending the patient’s survival time and greatly improving their quality of life while living with cancer.

Because it is a local treatment that does not harm healthy tissue, the treatment can be repeated as often as needed to keep patients comfortable. It is a very safe procedure, with complication rates on the order of two to three percent, and has been available since the late 1990s.

By decreasing the size of a large mass, or treating new tumors in the liver as they arise, the pain and other debilitating symptoms caused by the tumors are relieved. While the tumors themselves may not be painful, when they press against nerves or interfere with vital organs, they can cause pain. RFA is effective for small to medium-sized tumors and emerging new technologies should allow the treatment of larger cancers in the future.

livertumorbeforerfa
BEFORE
livertumorafterrfa
AFTER

A LIVER TUMOR TREATED WITH RFA

Dead tissue appears larger and darker than the living tumor. Over time, the tumor shrinks as the body absorbs and excretes dead cells

Benefits

  • Is most effective when all the cancer is localized in the liver
  • Can be used to treat primary liver cancer and tumors that have metastasized (spread) from other areas in the body to the liver
  • Usually does not require general anesthesia
  • Is well tolerated-most patients can resume their normal routine the next day and may feel tired for a few days
  • Can be repeated if necessary
  • May be combined with other treatment options
  • Can relieve pain and suffering for many cancer patients
interventional_radiologist_treating_cancer
Interventional radiologists use special X-ray equipment to guide therapy directly to the site of tumors

Cryoablation

Cryoablation is similar to RFA in that the energy is delivered directly into the tumor by a probe that is inserted through the skin. But rather than killing the tumor with heat, cryoablation uses an extremely cold gas to freeze it. This technique has been used for many years by surgeons in the operating room, but in the last few years, the needles have become small enough to be used by interventional radiologists through a small nick in the skin, without the need for an operation. The ice ball that is created around the needle grows in size and destroys the frozen tumor cells.

New Cancer Treatments on the Horizon
Interventional radiology is playing a role in developing new techniques that may improve cancer treatment in the future, including the use of magnetic particles to draw cancer-killing agents into tumors; and the delivery of genetic material, called gene therapy, to fight or prevent cancers. These techniques are still investigational, but they offer new hope in the war against cancer.

Magnetic Chemotherapy

Interventional radiologists are currently investigating a new technique in which magnets are used to pull chemotherapy drugs into tumors. Microscopic magnetic particles are attached to the cancer-killing drugs and infused through a catheter into the blood vessel that feeds the tumor. A rare earth magnet is positioned over the patient’s body directly above the site of the tumor. The magnet pulls the drug-carrying particles out of the blood vessel so that they lodge in the tumor. Although the technique is still experimental, early research is promising. Physicians are hopeful that it will bolster the effects of chemotherapy while avoiding some of the drugs’ side effects, such as hair loss and nausea.

Gene Therapy

genetherapyresearch1In recent years, scientists have gained a new understanding about genes-the basic biological units of heredity-and the role they play in disease. This knowledge has set the stage for medical science to alter patients’ genetic material to fight or prevent cancer. Although the science of gene therapy is still in the early, experimental stages, researchers are hoping that in the future the therapy can be used to:

  • alter the cells of a patient’s natural immune system with cancer-fighting genes and returning them to the body, where they could more forcefully attack the cancer
  • remove cancer cells from the body and alter them genetically so that the patient’s own immune system will mount a strong defense against them. In this technique, the altered cancer cells would act as a cancer vaccine
  • replace a faulty gene responsible for the growth of cancer with a “good” gene
  • inject a tumor with genes that will make it more susceptible to chemotherapy or other cancer-fighting agents
  • make bone marrow and other organs resistant to chemotherapy, so that the drugs will destroy tumors without damaging healthy tissue

One of the challenges of gene therapy is finding safe and effective ways to deliver genes or genetically altered cells to the site of the tumor. Interventional radiologists, with their special expertise in using X-rays and other imaging techniques to guide catheters and other tools through the body are expected to play an important role in this new technology.

Treatments for Cancer Complications

There are also a number of interventional radiology techniques that are used to treat the complications of cancer, including pain, bleeding, obstruction of vital organs, blood clots and infection. Although these treatments do not cure cancer, they can make patients more comfortable, extend life by treating serious complications and improve the quality of life for cancer patients.

Treating Pain

Control of pain is one of the most important aspects of cancer care. Pain not only affects patients’ quality of life and ability to function, it may also lower their tolerance for needed cancer treatments.

In many cancer patients, pain results from the spread of the tumor into surrounding nerves and other tissues. For example, patients with cancer of the pancreas or stomach, sometimes experience pain from the spread of the tumor into a network of nerves and blood vessels in the abdomen called the celiac plexus. To treat the pain, interventional radiologists insert catheters or needles into the affected area and administer alcohol or other agents that destroy the nerves causing the pain.

A particularly painful complication of cancer is when the disease spreads (metastasizes) to bones. In a technique called transcatheter embolization, interventional radiologists inject tiny particles, the size of grains of sand, through a catheter and into the artery that supplies blood to the tumor. The particles cause clotting that decreases the tumor’s blood supply, reducing pain and decreasing the likelihood of bone fracture.

Controlling Bleeding

If a cancer spreads to the blood vessels it may cause hemorrhage or bleeding. An interventional radiology technique called transcatheter embolization can be used to clot the affected blood vessels and stop the bleeding.

Treating Organ Obstruction and Infection

stent1Cancers can obstruct the normal flow of urine or bile, causing these fluids to build up in the body. If left untreated, these conditions are not only painful but may also result in organ failure or infection. Under X-ray guidance, catheters can be inserted to drain the collection of fluids. Often, a small device called a stent is inserted into the organ to bypass the obstruction and allow fluids to drain internally.

Treating Blood Clots

One common side effect of cancer or cancer treatments is the development of blood clots, or emboli, that can be life-threatening if they travel to the brain, lungs or heart. There are two interventional radiology procedures that can reduce the risks posed by blood clots:

  • Intra-arterial thrombolysis. In this technique, the interventional radiologist guides a catheter through the blood vessels and to the site of a blood clot. Clot-busting drugs are infused through the catheter to break up the clot.
  • Filter placement. This technique is most often used when a blood clot is detected in the blood vessels of the leg (a condition called deep vein thrombosis). The interventional radiologist guides a small filter into the blood vessel that receives blood from the lower body (the vena cava) and carries it to the heart. If the blood clot dislodges from the vein in the leg, the filter will trap it before it can reach the heart.

Interventional Radiologists are Minimally Invasive Experts

Interventional radiologists work with other specialists on a multidisciplinary cancer team to determine the best treatment for each individual patient. Interventional radiology is a recognized medical specialty by the American Board of Medical Specialties. Interventional radiologists are board-certified physicians with extensive training in disease diagnosis, management and treatment. Their board certification includes both Vascular and Interventional Radiology and Diagnostic Radiology which are administered by the American Board of Radiology. This training marries state-of-the-art imaging and diagnostic expertise, coupled with clinical experience across all specialties and in-depth knowledge of the least invasive treatments. Interventional oncology is a growing area within interventional radiology.

Minimally Invasive Treatments Help Cancer Patients Extend life and Improve Quality of Life

Normally, cells grow and divide to form new cells as the body needs them. When cells grow old, they die and new cells take their place. Sometimes this orderly process goes awry-that is, new cells form when the body does not need them, and old cells do not die when they should. These extra cells can form a mass of tissue, or tumor. Cancerous tumors are abnormal and divide without control or order.

The lung is the most common site for primary cancer worldwide, and smoking tobacco is the leading risk factor. The lung is also a common site of metastases for various malignancies. Metastases occur when a single tumor cell or clump of cells gain access to the blood stream or lymphatic system, travel to a new organ such as the lung, begin to multiply, and then regrow their vascular structure to obtain food.

Interventional radiologists can deliver treatments for lung cancer directly to the cancer without significant side effects or damage to nearby normal tissue. There are two main methods by which interventional radiologists can treat cancer. The first is to use the vascular system to deliver chemotherapy medicine directly to the cancer’s vascular supply. This limits damage and toxicity to the rest of the body while delivering the highest dose of the chemotherapy to the cancer. The second method interventional radiologists use to treat cancer is to cook or freeze the cancer by sticking a small, energy-delivering needle directly into the cancer that heats or freezes the cancer without significant damage to nearby normal tissue. Since these techniques are delivered at the cancer specifically, patients have fewer overall side effects making this especially useful in patients with other significant medical problems. According to the National Cancer Institute, “targeted cancer therapies will give doctors a better way to tailor cancer treatment.”

Prevalence

  • Approximately 173,770 new cases of lung cancer will be diagnosed in 2004, accounting for 13 percent of all new cancer cases.
  • An estimated 160,440 Americans will die in 2004 from lung cancer, accounting for 28 percent of all cancer deaths.
  • 85-95 percent of lung cancers are smoking related
  • More Americans die each year from lung cancer than from breast, prostate and colorectal cancers combined.
  • Lung cancer kills more men than prostate cancer and more women than breast cancer
  • Between 1960 and 1990, deaths from lung cancer among women increased by more than 400 percent.
  • African American men are at least 40 percent more likely to develop lung cancer than white males.

Symptoms

  • Coughing that doesn’t go away
  • Persistent chest pain
  • Shortness of breath, wheezing
  • Coughing up blood
  • Hoarseness
  • Swelling of the face and neck
  • Loss of appetite and weight
  • Fatigue

Lung Cancer Diagnosis

There are a number of tests that can help in the diagnosis of cancer, including blood tests, physical examination and a variety of imaging techniques including X- rays (e.g., chest X-rays and mammograms); computed tomography (CT); magnetic resonance (MR) and ultrasound. Usually, however, the final diagnosis cannot be made until a biopsy is performed. In a biopsy, a sample of tissue from the tumor or other abnormality is obtained and examined by a pathologist. By examining the biopsy sample, pathologists and other experts also can determine what kind of cancer is present and whether it is likely to be fast or slow growing. This information is important in deciding the best type of treatment. Open surgery is sometimes performed to obtain a tissue sample for biopsy. But in most cases, tissue samples can be obtained without open surgery with interventional radiology techniques.

Needle biopsy

Needle biopsy, also called image-guided biopsy, is usually performed using a moving X-ray technique (fluoroscopy) computed tomography (CT), ultrasound or magnetic resonance (MR) to guide the procedure. In many cases, needle biopsies are performed with the aid of equipment that creates a computer-generated image and allows radiologists to see an area inside the body from various angles. This stereotactic equipment helps them pinpoint the exact location of the abnormal tissue.

Needle biopsy is typically an outpatient procedure with very infrequent complications; less than 1 percent of patients develop bleeding or infection. In about 90 percent of patients, needle biopsy provides enough tissue for the pathologist to determine the cause of the abnormality.

Advantages of needle biopsy include:

  • With image guidance, the abnormality can be biopsied while important nearby structures such as blood vessels and vital organs can be seen and avoided.
  • The patient is spared the pain, scarring and complications associated with open surgery.
  • Recovery times are usually shorter and patients can more quickly resume normal activities.
x-ray_of_needle_biopsy
An X-ray of a needle inserted into the lung to obtain a sample for biopsy.

Large core needle biopsy. In this technique, a special needle is used that enables the radiologist to obtain a larger biopsy sample. This technique is often used to obtain tissue samples from lumps or other abnormalities in the breast that are detected by physical examination or on mammograms or other imaging scans. Because approximately 80 percent of all breast abnormalities turn out not to be cancer, this technique is often preferred by women and their physicians because it:

  • is less painful and requires less recovery time than open surgical biopsy
  • avoids the scarring and disfigurement that may result from open surgery

A similar technique called fine needle aspiration can be used to withdraw cells from a suspected cancer. It also can diagnose fluids that have collected in the body. Sometimes, these fluid collections also may be drained through a catheter, such as when pockets of infection are diagnosed.

Many interventional radiology procedures for the diagnosis and treatment of cancer can be performed on an outpatient basis or during a short hospital stay. In many cases, the procedures:

  • offer new cancer treatment options
  • are less painful and debilitating for patients
  • result in quicker recoveries
  • have fewer side effects and complications.

Lung Cancer Treatments

Tumors need a blood supply, which they actively generate, to feed themselves and grow. As vascular experts, interventional radiologists are uniquely skilled in using the vascular system to deliver targeted treatments via catheter throughout the body. In treating cancer patients, interventional radiologists can attack the cancer tumor from inside the body without medicating or affecting other parts of the body by using embolization and radiofrequency heat.

Thermal Ablation Treatments

By the time lung cancer becomes symptomatic, 85 percent of patients are incurable, often due to serious coexisting health conditions or poor respiratory function. Most patients who are diagnosed with non-small cell lung cancer are not surgically resectable at the time of diagnosis. For these patients, minimally invasive interventional radiology procedures can help reduce pain and improve quality of life.

Radiofrequency Ablation

Radiofrequency ablation (RFA) offers a nonsurgical, localized treatment that kills the tumor cells with heat, while sparing nearby healthy lung tissue. Thus, this treatment is much easier on the patient than systemic therapy. Radiofrequency energy can be given without affecting the patient’s overall health and most people can resume their usual activities in a few days. It is a safe, minimally invasive tool for local pulmonary tumor control with negligible mortality, little morbidity, short hospital stay, and positive gain in quality of life.

In this procedure, the interventional radiologist guides a small needle through the skin into the tumor. From the tip of the needle, radiofrequency energy (similar to microwaves) is transmitted to the tip of the needle, where it produces heat in the tissues. The dead tumor tissue shrinks and slowly forms a scar. It is ideal for nonsurgical candidates and those with smaller tumors. The FDA has approved RFA for the treatment of tumors in soft tissue that includes the lung.

radio1 radio2 radio3
Click on images to enlarge

Efficacy of RFA

Depending on the size of the tumor, RFA can shrink or kill the tumor. Because it is a local treatment that does not harm much healthy tissue, the treatment can be repeated as often as needed to keep patients comfortable. It is a relatively safe procedure, with low complication rates.

By decreasing the size of a large mass, or treating new tumors in the lung as they arise, the pain and other debilitating symptoms caused by the tumors are often relieved. While the tumors themselves may not be painful, when they press against nerves or interfere with vital organs, they can cause pain. RFA is effective for small to medium-sized tumors and emerging new technologies should allow the treatment of larger cancers in the future. RFA is a new treatment that has shown early, promising results, but long-term studies have not yet been completed.

livertumorbeforerfa
BEFORE
livertumorbeforerfa
AFTER
A LIVER TUMOR TREATED WITH RFA
Dead tissue appears larger and darker than the living tumor. Over time, the tumor shrinks as the body absorbs and excretes dead cells

Benefits

  • Is most effective when all the cancer is localized in the lung
  • Can be used to treat primary lung cancer and tumors that have metastasized (spread) from other areas in the body to the lung
  • Usually does not require general anesthesia
  • Relatively low cost
  • Is well tolerated. Most patients can resume their normal routine the next day and may feel tired for a few days.
  • It can be repeated if necessary
  • It may be combined with other treatment options
  • It can relieve pain and suffering for many cancer patients
  • It has a short hospital stay
  • It has few complications
interventional_radiologist_treating_cancer
Interventional radiologists use special X-ray equipment to guide therapy directly to the site of tumors

Click here to watch an interview discussing radiofrequency ablation on Discovery Channel’s Living with Cancer special.

Cryoablation

Cryoablation is similar to RFA in that the energy is delivered directly into the tumor by a probe that is inserted through the skin. But rather than killing the tumor with heat, cryoablation uses an extremely cold gas to freeze it. This technique has been used for many years by surgeons in the operating room, but in the last few years, the needles have become small enough to be used by interventional radiologists through a small nick in the skin without the need for an operation. The ice ball that is created around the needle grows in size and destroys the frozen tumor cells.

Chemoembolization

Chemoembolization is a minimally invasive treatment for lung cancer that can be used when there is too much tumor to treat with radiofrequency ablation (RFA), when the tumor is in a location that cannot be treated with RFA, or in combination with RFA or other treatments.

Chemoembolization delivers a high dose of cancer-killing drug (chemotherapy) directly to the organ while depriving the tumor of its blood supply by blocking, or embolizing, the arteries feeding the tumor. Using imaging for guidance, the interventional radiologist threads a tiny catheter up the femoral artery in the groin into the blood vessels supplying the lung tumor. The embolic agents keep the chemotherapy drug in the tumor by blocking the flow to other areas of the body. This allows for a higher dose of chemotherapy drug to be used, because less of the drug is able to circulate to the healthy cells in the body. Chemoembolization usually involves a hospital stay of two to four days. Patients typically have lower than normal energy levels for about a month afterward.

chemo1 chemo2 chemo3
Click on images to enlarge

Chemoembolization is a palliative, not a curative, treatment. Chemoembolization has shown promising early results with some types of metastatic tumors. Although the individual materials used in this treatment are FDA approved, the treatment itself is not approved specifically for intra-arterial therapy of lung tumors.

New Cancer Treatments on the Horizon

Interventional radiology is playing a role in developing new techniques that may improve cancer treatment in the future, including the use of magnetic particles to draw cancer-killing agents into tumors; and the delivery of genetic material, called gene therapy, to fight or prevent cancers. These techniques are still investigational, but they offer new hope in the war against cancer.

Magnetic Chemotherapy

Interventional radiologists are currently investigating a new technique in which magnets are used to pull chemotherapy drugs into tumors. Microscopic magnetic particles are attached to the cancer-killing drugs and infused through a catheter into the blood vessel that feeds the tumor. A rare earth magnet is positioned over the patient’s body directly above the site of the tumor. The magnet pulls the drug-carrying particles out of the blood vessel so that they lodge in the tumor. Although the technique is still experimental, early research is promising. Physicians are hopeful that it will bolster the effects of chemotherapy while avoiding some of the drugs’ side effects, such as hair loss and nausea.

Gene Therapy

genetherapyresearch1In recent years, scientists have gained a new understanding about genes-the basic biological units of heredity-and the role they play in disease. This knowledge has set the stage for medical science to alter patients’ genetic material to fight or prevent cancer. Although the science of gene therapy is still in the early, experimental stages, researchers are hoping that in the future the therapy can be used to:

  • alter the cells of a patient’s natural immune system with cancer-fighting genes and returning them to the body, where they could more forcefully attack the cancer
  • remove cancer cells from the body and alter them genetically so that the patient’s own immune system will mount a strong defense against them. In this technique, the altered cancer cells would act as a cancer vaccine
  • replace a faulty gene responsible for the growth of cancer with a “good” gene
  • inject a tumor with genes that will make it more susceptible to chemotherapy or other cancer-fighting agents
  • make bone marrow and other organs resistant to chemotherapy, so that the drugs will destroy tumors without damaging healthy tissue

One of the challenges of gene therapy is finding safe and effective ways to deliver genes or genetically altered cells to the site of the tumor. Interventional radiologists, with their special expertise in using X-rays and other imaging techniques to guide catheters and other tools through the body are expected to play an important role in this new technology.

Treatments for Cancer Complications

There are also a number of interventional radiology techniques that are used to treat the complications of cancer, including pain, bleeding, obstruction of vital organs, blood clots and infection. Although these treatments do not cure cancer, they can make patients more comfortable, extend life by treating serious complications and improve the quality of life for cancer patients.

Treating Pain

Control of pain is one of the most important aspects of cancer care. Pain not only affects patients’ quality of life and ability to function, it may also lower their tolerance for needed cancer treatments.

In many cancer patients, pain results from the spread of the tumor into surrounding nerves and other tissues. For example, patients with cancer of the pancreas or stomach, sometimes experience pain from the spread of the tumor into a network of nerves and blood vessels in the abdomen called the celiac plexus. To treat the pain, interventional radiologists insert catheters or needles into the affected area and administer alcohol or other agents that destroy the nerves causing the pain.

A particularly painful complication of cancer is when the disease spreads (metastasizes) to bones. In a technique called transcatheter embolization, interventional radiologists inject tiny particles, the size of grains of sand, through a catheter and into the artery that supplies blood to the tumor. The particles cause clotting that decreases the tumor’s blood supply, reducing pain and decreasing the likelihood of bone fracture.

Controlling Bleeding

If a cancer spreads to the blood vessels it may cause hemorrhage or bleeding. An interventional radiology technique called transcatheter embolization can be used to clot the affected blood vessels and stop the bleeding.

Treating Organ Obstruction and Infection

stent1Cancers can obstruct the normal flow of urine or bile, causing these fluids to build up in the body. If left untreated, these conditions are not only painful but may also result in organ failure or infection. Under X-ray guidance, catheters can be inserted to drain the collection of fluids. Often, a small device called a stent is inserted into the organ to bypass the obstruction and allow fluids to drain internally.

Treating Blood Clots

One common side effect of cancer or cancer treatments is the development of blood clots, or emboli, that can be life-threatening if they travel to the brain, lungs or heart. There are two interventional radiology procedures that can reduce the risks posed by blood clots:

  • Intra-arterial thrombolysis. In this technique, the interventional radiologist guides a catheter through the blood vessels and to the site of a blood clot. Clot-busting drugs are infused through the catheter to break up the clot.
  • Filter placement. This technique is most often used when a blood clot is detected in the blood vessels of the leg (a condition called deep vein thrombosis). The interventional radiologist guides a small filter into the blood vessel that receives blood from the lower body (the vena cava) and carries it to the heart. If the blood clot dislodges from the vein in the leg, the filter will trap it before it can reach the heart.

Interventional Radiologists are Minimally Invasive Experts

Interventional radiologists work with other specialists on a multidisciplinary cancer team to determine the best treatment for each individual patient. Interventional radiology is a recognized medical specialty by the American Board of Medical Specialties. Interventional radiologists are board-certified physicians with extensive training in disease diagnosis, management and treatment. Their board certification includes both Vascular and Interventional Radiology and Diagnostic Radiology which are administered by the American Board of Radiology. This training marries state-of-the-art imaging and diagnostic expertise, coupled with clinical experience across all specialties and in-depth knowledge of the least invasive treatments. Interventional oncology is a growing area within interventional radiology.

Non-Surgical Procedure Effective for Painful Ovarian Varicose Veins

It is estimated that one-third of all women will experience chronic pelvic pain in their lifetime. Many of these women are told the problem is all in their head but recent advancements now show the pain may be due to hard to detect varicose veins in the pelvis, known as pelvic congestion syndrome.

The causes of chronic pelvic pain are varied, but are often associated with the presence of ovarian and pelvic varicose veins. Pelvic congestion syndrome is similar to varicose veins in the legs. In both cases, the valves in the veins that help return blood to the heart against gravity become weakened and don’t close properly, this allows blood to flow backwards and pool in the vein causing pressure and bulging veins. In the pelvis, varicose veins can cause pain and affect the uterus, ovaries and vulva. Up to 15 percent of women, generally between the ages of 20 and 50, have varicose veins in the pelvis, although not all experience symptoms.

The diagnosis if often missed because women lie down for a pelvic exam, relieving pressure from the ovarian veins, so that the veins no longer bulge with blood as they do while a woman is standing.

Many women with pelvic congestion syndrome, spend many years trying to get an answer to why they have this chronic pelvic pain. Living with chronic pelvic pain is difficult and affects not only the woman directly, but also her interactions with her family, friends, and her general outlook on life. Because the cause of the pelvic pain is not diagnosed, no therapy is provided even though there is therapy available.

If you have pelvic pain that worsens throughout the day when standing, you may want to seek a second opinion with an interventional radiologist, who can work with your gynecologist. You can ask your doctor to send a referral form or contact the radiology department, and ask for interventional radiology.

Prevalence

  • Women with pelvic congestion syndrome are typically less than 45 years old and in their child bearing years
  • Ovarian veins increase in size related to previous pregnancies. Pelvic congestion syndrome is unusual in women who have not been pregnant.
  • Chronic pelvic pain accounts for 15% of outpatient gynecologic visits
  • Studies show 30% of patients with chronic pelvic pain have pelvic congestion syndrome (PCS) as a sole cause of their pain and an additional 15% have PCS along with another pelvic pathology

Risk Factors

  • Two or more pregnancies and hormonal increases
  • Fullness of leg veins
  • Polycystic ovaries
  • Hormonal dysfunction

Symptoms

The chronic pain that is associated with this disease is usually dull and aching. The pain is usually felt in the lower abdomen and lower back. The pain often increases during the following times:

  • Following intercourse
  • Menstrual periods
  • When tired or when standing (worse at end of day)
  • Pregnancy

Other symptoms include:

  • Irritable bladder
  • Abnormal menstrual bleeding
  • Vaginal discharge
  • Varicose veins on vulva, buttocks or thigh.

Diagnosis and Assessment

Once other abnormalities or inflammation has been ruled out by a thorough pelvic exam, pelvic congestion syndrome can be diagnosed through several minimally invasive methods. An interventional radiologist, a doctor specially trained in performing minimally invasive treatments using imaging for guidance, will use the following imaging techniques to confirm pelvic varicose veins that could be causing chronic pain.

Pelvic venography: Thought to be the most accurate method for diagnosis, a venogram is performed by injecting contract dye in the veins of the pelvic organs to make them visible during an X-ray. To help accuracy of diagnosis, interventional radiologists examine patients on an incline, because the veins decrease in size when a woman is lying flat.

MRI: May be the best non-invasive way of diagnosing pelvic congestion syndrome. The exam needs to be done in a way that is specifically adapted for looking at the pelvic blood vessels. A standard MRI may not show the abnormality.

Pelvic ultrasound: Usually not very helpful in diagnosing pelvic congestion syndrome unless done is an very specific manner with the patient standing while the study is being done. Ultrasound may be used to exclude other problems that might be causing pelvic pain.

Transvaginal ultrasound: This technique is used to see better inside the pelvic cavity. As with a pelvic ultrasound it is not very good at visualizing the pelvic veins unless the woman is standing. However it may be used to exclude other problems.

Treatment Options

Once a diagnosis is made, if the patient is symptomatic, an embolization should be done. Embolization is a minimally invasive procedure performed by interventional radiologists using imaging for guidance. During the outpatient procedure, the interventional radiologist inserts a thin catheter, about the size of a strand of spaghetti, into the femoral vein in the groin and guides it to the affected vein using X-ray guidance. To seal the faulty, enlarged vein and relieve painful pressure, an interventional radiologist inserts tiny coils often with a sclerosing agent (the same type of material used to treat varicose veins) to close the vein. After treatment, patients can return to normal activities immediately.

Additional treatments are available depending on the severity of the woman’s symptoms. Analgesics may be prescribed to reduce the pain. Hormones such birth control pills decrease a woman’s hormone level causing menstruation to stop may be helpful in controlling her symptoms. Surgical options include a hysterectomy with removal of ovaries, and tying off or removing the veins.

Efficacy

In addition to being less expensive to surgery and much less invasive, embolization offers a safe, effective, minimally invasive treatment option that restores patients to normal. The procedure is very commonly successful in blocking the abnormal blood flow. It is successfully performed in 95-100 percent of cases. A large percentage of women have improvement in their symptoms, between 85-95 percent of women are improved after the procedure. Although women are usually improved, the veins are never normal and in some cases other pelvic veins are also affected which may require further treatment.

Heart disease is the #1 killer of women in the United States. Peripheral arterial disease (PAD)-clogged or narrowed arteries in the legs-is a red flag that the same process may be going on elsewhere because PAD is associated with other life-threatening vascular diseases. Through early detection, interventional radiologists can save women from future stroke, heart attack, and early death. To combat this major public health issue, the Society of Interventional Radiology recommends greater screening efforts by the medical community through the use of the ankle brachial index (ABI) test.

PAD Under-recognized in Women

Like heart disease, peripheral arterial disease is under-recognized in women. According to a survey of primary care physicians conducted in 2002, nearly all recognized that older people are more susceptible to PAD, and identified men as being susceptible to PAD. However, they mostly excluded women as likely to have PAD, which is incorrect. The prevalence is actually equal on the diagnostic ABI test. As vascular experts, interventional radiologists are partnering with primary care physicians to increase early screening.

Twelve to 20 percent of Americans older than 65 suffer from peripheral arterial disease but only one-third are symptomatic. Symptoms can include pain when walking that subsides at rest, leg cramps, pain at rest, numbness and skin discoloration, sores or other symptoms of skin breakdown. Women may be more likely than men to have PAD without experiencing symptoms; 50 to 90 percent are asymptomatic or have unrecognized symptoms of the disease, which could put them at greater risk of developing serious disease before it is diagnosed and treated. Specifically, women are also less likely to have intermittent claudication symptoms, i.e., pain when walking that subsides at rest.

Catching the Asymptomatic Warning Sign Early When Treatment is Most Effective

However, identifying PAD while asymptomatic may be life-saving for women, since it allows the easy, cheap identification of a systemic disease that may be treated. Treatment may greatly influence the woman’s outcome. These treatments may include further investigation into the state of disease in the coronaries, which could lead to heart disease, and carotids, which could lead to stroke, as well as the legs, and treating the significant areas of blockage that are found. Treatment with lifestyle modification and medication may slow the natural advancement of the disease.

Risk for Heart Attack, Stroke and Death

The ABI, a comparative blood pressure reading in the arm and ankle, is used to screen for peripheral arterial disease. It is a direct measure of fatty plaque buildup in leg arteries and an indirect gauge of plaque accumulations throughout the entire cardiovascular system. Because atherosclerosis is a systemic disease, women developing plaque in their legs are likely to have plaque building up in the carotid arteries, which can lead to stroke, or the coronary arteries, which can lead to heart attack. Early detection of PAD is important because these women are at significantly increased risk, and preventive measures can be taken.

  • Women with PAD have four times the risk of heart attack and stroke.
  • A person with an ABI of 0.3 (high risk) has a two- to three-fold increased risk of five-year cardiovascular death compared to a patient with an ABI of 0.95 (normal or low risk).

Legs for Life® Data and Gender Differences

The influence of gender on PAD has not been studied and is not defined in the medical literature. However, there is some data collected by the Society of Interventional Radiology Foundation through its Legs For Life national PAD screening program. From 1999 to 2002, 3,762 people were screened: 2,786 (74%) women and 976 (26%) men. Of the women screened, 1,067 (38%) were at moderate to high risk for PAD compared to 284 (29%) of men screened. Neither smoking nor diabetes was an independent risk factor for PAD by gender, i.e., the risk of having PAD for smokers and diabetics was similar, in both males and females.

Legs For Life has been successful at attracting women to free screenings and is identifying previously under-diagnosed women who are at moderate to high risk for PAD. This SIR Foundation program provides the opportunity to identify asymptomatic and symptomatic women earlier, allowing women to benefit from the same aggressive approach to risk reduction and treatment as men.

Providing a list of risk factors for PAD to women may enable them to be more active in their health care and seek an ABI test and consult with an interventional radiologist to be assessed for vascular disease.

Get Tested for PAD If You

  • Are over age 50
  • Have a family history of vascular disease, such as PAD, aneurysm, heart attack or stroke
  • Have high cholesterol and/or high lipid blood test
  • Have diabetes
  • Have ever smoked or smoke now
  • Have an inactive lifestyle
  • Have a personal history of high blood pressure, heart disease, or other vascular disease
  • Have trouble walking that involves cramping or tiredness in the muscle with walking or exercising, which is relieved by resting
  • Have pain in the legs or feet that awaken you at night

About Peripheral Arterial Disease

PAD is a common circulation problem in which the arteries that carry blood to the legs or arms become narrowed or clogged. This interferes with the normal flow of blood, sometimes causing pain, but often causing no symptoms at all. The most common cause of PAD is atherosclerosis, often called hardening of the arteries. Atherosclerosis is a gradual process in which cholesterol and scar tissue build up, forming a substance called plaque that clogs the blood vessels. In some cases, PAD may be caused by blood clots that lodge in the arteries and restrict blood flow. Left untreated, this insufficient blood flow will lead to limb amputation in some patients.

In atherosclerosis, the blood flow channel narrows from the buildup of plaque, preventing blood from passing through as needed, restricting oxygen and other nutrients from getting to normal tissue. The arteries also become rigid and less elastic, and are less able to react to tissue demands for changes in blood flow. Many of the risk factors-high cholesterol, high blood pressure, smoking and diabetes-may also damage the blood vessel wall, making the blood vessel prone to diffuse plaque deposits.

PAD Symptoms

  • The most common symptom of PAD is called claudication, which is leg pain that occurs when walking or exercising and disappears when the person stops the activity.
  • Other symptoms of PAD include: numbness and tingling in the lower legs and feet, coldness in the lower legs and feet, and ulcers or sores on the legs or feet that don’t heal.

Many people simply live with their pain, assuming it is a normal part of aging, rather than reporting it to their doctor.

Prevalence

  • PAD is a disease of the arteries that affects ten million Americans.
  • PAD can happen to anyone, regardless of age, but it is most common in men and women over age 50.
  • PAD affects 12-20 percent of Americans age 65 and older.

PAD Treatments

Lifestyle

Often PAD can be treated with lifestyle changes. Smoking cessation and a structured exercise program are often all that is needed to alleviate symptoms and prevent further progression of the disease.

Angioplasty and Stenting

Interventional radiologists pioneered angioplasty and stenting, which was first performed to treat peripheral arterial disease. Using imaging for guidance, the interventional radiologist threads a catheter through the femoral artery in the groin to the blocked artery in the legs. Then he or she inflates a balloon to open the blood vessel where it is narrowed or blocked. In some cases this is then held open with a stent, a tiny metal cylinder. This is a minimally invasive treatment that does not require surgery, just a nick in the skin the size of a pencil tip.

Pulmonary Embolism

human_circulatory_systemLeft untreated, a deep vein thrombosis (DVT) can break off and travel in the circulation, getting trapped in the lung, where it blocks t he oxygen supply, causing heart failure. This is known as a pulmonary embolism, which can be fatal. With early treatment, people with DVT can reduce their chances of developing a life threatening pulmonary embolism to less than one percent. Blood thinners like heparin and coumadin are effective in preventing further clotting and can prevent a pulmonary embolism from occurring.

  • It is estimated that each year more than 600,000 patients suffer a pulmonary embolism.
  • PE causes or contributes to up to 200,000 deaths annually in the United States.
  • One in every 100 patients who develop DVT die due to pulmonary embolism.
  • A majority of pulmonary embolism are caused by DVT.
  • If pulmonary embolism can be diagnosed and appropriate therapy started, the mortality can be reduced from approximately 30 percent to less than ten percent.

Symptoms of Pulmonary Embolism

The symptoms are frequently nonspecific and can mimic many other cardiopulmonary events.

  • Shortness of breath
  • Rapid pulse
  • Sweating
  • Sharp chest pain
  • Bloody sputum (coughing up blood)
  • Fainting

pulmonary_embolism_illustration

Treatments

Early Treatment With Blood Thinners Is Important to Prevent a Life-threatening Pulmonary Embolism, but Does Not Treat the Existing Clot

Blood Thinners

Early in treatment, blood thinners are given to keep the clot from growing or breaking off and traveling to the lung and causing a life-threatening pulmonary embolism by blocking the oxygen supply causing heart failure. Contrary to popular belief, blood thinners (anticoagulants) do not actively dissolve the clot, but instead prevents new clots from forming. Over time, the body will dissolve the clot, but often the vein becomes damaged in the meantime.

Catheter-directed Thrombolysis (Clot-Busting) Treatment

Catheter-directed thrombolysis is performed under imaging guidance by interventional radiologists. This procedure, performed in a hospital’s interventional radiology suite, is designed to rapidly break up the clot, restore blood flow within the vein, and potentially preserve valve function to minimize the risk of post-thrombotic syndrome. The interventional radiologist inserts a catheter into the popliteal (located behind the knee) or other leg vein and threads it into the vein containing the clot using imaging guidance. The catheter tip is placed into the clot and a clot busting drug is infused directly to the thrombus (clot). The fresher the clot, the faster it dissolves – one to two days. Any narrowing in the vein that might lead to future clot formation can be identified by venography, an imaging study of the veins, and treated by the interventional radiologist with a balloon angioplasty or stent placement.

In patients in whom this is not appropriate and blood thinners are not medically appropriate, an interventional radiologist can insert a vena cava filter, a small device that functions like a catcher’s mitt to capture blood clots but allow normal liquid blood to pass.

Efficacy

Clinical resolution of pain and swelling and restoration of blood flow in the vein is greater than 85 percent with the catheter-directed technique.

Information can also be found on the SIR Foundation Web site.

Uterine fibroid embolization (UFE) is a minimally invasive interventional radiology treatment for uterine fibroids and is a safe and effective option for women to consider. Most women with fibroids are candidates for UFE and should consult with an interventional radiologist to determine whether UFE is a treatment option for them.

WVU Health Report: Uterine Fibroids

Uterine fibroid embolization is an less invasive alternative to hysterectomy whose benefits include less pain and a shorter recovery time.

Minimally Invasive Treatment Options

Interventional radiologists use MRIs

  • to determine if fibroids can be embolized
  • to detect alternate causes for symptoms and rule out misdiagnosis
  • to identify which treatments are best for each patient

Women typically undergo an ultrasound at their gynecologist’s office as part of the evaluation process to determine the presence of uterine fibroids. An MRI is a much better imaging tool for uterine fibroids than ultrasound because it can show underlying diseases and reveal all of the fibroids.

UFE Often Replaces Hysterectomy

fibroid_lady Uterine fibroids are common, non-cancerous (benign) growths that develop in the muscular wall of the uterus. They can range in size from very tiny (a quarter of an inch) to larger than a cantaloupe.

Occasionally, they can cause the uterus to grow to the size of a five-month pregnancy. In most cases, there is more than one fibroid in the uterus. While fibroids do not always cause symptoms, their size and location can lead to problems for some women, including pain and heavy bleeding.

Fibroids can dramatically increase in size during pregnancy. This is thought to occur because of the increase in estrogen levels during pregnancy. After pregnancy, the fibroids usually shrink back to their pre-pregnancy size. They typically improve after menopause when the level of estrogen, the female hormone that circulates in the blood, decreases dramatically. However, menopausal women who are taking supplemental estrogen (hormone replacement therapy) may not experience relief of symptoms.
fibroid_types Uterine fibroids are the most common tumors of the female genital tract. You might hear them referred to as fibroids or by several other names, including leiomyoma, leiomyomata, myoma and fibromyoma.

Fibroid tumors of the uterus are very common, but for most women, they either do not cause symptoms or cause only minor symptoms.

Subserosal Fibroids

These develop under the outside covering of the uterus and expand outward through the wall, giving the uterus a knobby appearance. They typically do not affect a woman’s menstrual flow, but can cause pelvic pain, back pain, and generalized pressure. The subserosal fibroid can develop a stalk or stem-like base, making it difficult to distinguish from an ovarian mass. The correct diagnosis can be made with either an ultrasound or magnetic resonance (MR) exam.

Intramural Fibroids

These develop within the lining of the uterus and expand inward, increasing the size of the uterus, and making it feel larger than normal in a gynecologic internal exam. These are the most common fibroids. Intramural fibroids can result in heavier menstrual bleeding and pelvic pain, back pain, or the generalized pressure that many women experience.

Submucosal Fibroids

These are just under the lining of the uterus. These are the least common fibroids, but they tend to cause the most problems. Even a very small submucosal fibroid can cause heavy bleeding – gushing, very heavy, and prolonged periods.

Prevalence of Uterine Fibroids

Twenty to 40% of women age 35 and older have uterine fibroids of a significant size. African American women are at a higher risk for fibroids: as many as 50% have fibroids of a significant size. Uterine fibroids are the most frequent indication for hysterectomy in premenopausal women and, therefore, are a major public health issue. Of the 600,000 hysterectomies performed annually in the United States, one-third are due to fibroids.

Uterine Fibroid Symptoms

Most fibroids don’t cause symptoms-only 10 to 20% of women who have fibroids require treatment. Depending on size, location, and number of fibroids, they may cause:

  • Heavy, prolonged menstrual periods and unusual monthly bleeding, sometimes with clots. This can lead to anemia.
  • Pelvic pain and pressure
  • Pain in the back and legs
  • Pain during sexual intercourse
  • Bladder pressure leading to a frequent urge to urinate
  • Pressure on the bowel, leading to constipation and bloating
  • Abnormally enlarged abdomen

Better Diagnosis and Nonsurgical Treatment Options

Women typically undergo an ultrasound at their gynecologist’s office as part of the evaluation process to determine the presence of uterine fibroids. An ultrasound often does not show other underlying diseases or all the existing fibroids. For this reason, MRI is the standard imaging tool used by interventional radiologists.

By working with a patient’s gynecologist, interventional radiologists can use MRIs to enhance the level of patient care through better diagnosis, better education, better treatment options, and better outcomes.

Second Opinion Prior to Hysterectomy

For true informed consent before surgery, patients should be aware of all of their treatment options. Patients considering surgical treatment should also get a second opinion from an interventional radiologist who is most qualified to interpret the MRI and determine if they are candidates for the interventional procedure. You can ask your doctor to send a referral form or contact the radiology department, and ask for interventional radiology.

Uterine Fibroid Treatments

Nonsurgical Uterine Fibroid Embolization – A Major Advance in Women’s Health

uterine_fibroid_embolization_overview Uterine fibroid embolization (UFE), also known as uterine artery embolization, is performed by an interventional radiologist, a physician who is trained to perform this and other types of embolization and minimally invasive procedures. It is performed while the patient is conscious, but sedated, and feeling no pain. It does not require general anesthesia.
uterine_fibroid_embolization_closeup The interventional radiologist makes a tiny nick in the skin in the groin and inserts a catheter into the femoral artery. Using real-time imaging, the physician guides the catheter through the artery and then releases tiny particles, the size of grains of sand, into the uterine arteries that supply blood to the fibroid tumor. This blocks the blood flow to the fibroid tumor and causes it to shrink and die.

UFE Recovery Time

Fibroid embolization usually requires a hospital stay of one night. Pain-killing medications and drugs that control swelling typically are prescribed following the procedure to treat cramping and pain. Many women resume light activities in a few days and the majority of women are able to return to normal activities within seven to 10 days.

UFE Efficacy

  • On average, 85-90% of women who have had the procedure experience significant or total relief of heavy bleeding, pain, and/or bulk-related symptoms.
  • The procedure is effective for multiple fibroids and large fibroids.
  • Recurrence of treated fibroids is very rare. Short and mid-term data show UFE to be very effective with a very low rate of recurrence. Long-term (10-year) data are not yet available, but in one study in which patients were followed for six years, no fibroid that had been embolized regrew.

Additional UFE Facts

  • In 2007, the first gorilla was treated with UFE for her fibroids
  • An estimated 13,000 -14,000 UFE procedures are performed annually in the U.S. (as of 2004)
  • Embolization of the uterine arteries is not new. It has been used successfully by interventional radiologists for more than 20 years to treat heavy bleeding after childbirth.
  • Embolization has been used to treat tumors since 1966. Embolization to treat uterine fibroids has been performed since 1995 and the embolic particles are approved by the FDA specifically to treat uterine fibroid tumors, based on comparative trials showing similar efficacy with less serious complications compared to hysterectomy and myomectomy (the surgical removal of fibroids).
  • Embolization of fibroids was first used as an adjunct to help decrease blood loss during myomectomy. To the surprise of the initial users of this method, many patients had spontaneous resolution of their symptoms after only the embolization and no longer needed the surgery.
  • UFE is covered by most major insurance companies and is widely available across the country.
  • Most women with symptomatic fibroids are candidates for UFE and should obtain a consult with an interventional radiologist to determine whether UFE is a treatment option for them. An ultrasound or MRI diagnostic test will help the interventional radiologist to determine if the woman is a candidate for this treatment.
  • Many women wonder about the safety of leaving particles in the body. The embolic particles most commonly used in UFE have been available with FDA approval for use in people for more than 20 years. During that time, they have been used in thousands of patients without long-term complications.

Effect on Fertility

There have been numerous reports of pregnancies following uterine fibroid embolization, however prospective studies are needed to determine the effects of UFE on the ability of a woman to have children. One study comparing the fertility of women who had UFE with those who had myomectomy showed similar numbers of successful pregnancies. However, this study has not yet been confirmed by other investigators.

Less than 2% of patients have entered menopause as a result of UFE. This is more likely to occur if the woman is in her mid-40’s or older and is already nearing menopause.

Risks

UFE is a very safe method and, like other minimally invasive procedures, has significant advantages over conventional open surgery. However, there are some associated risks, as there are with any medical procedure. A small number of patients have experienced infection, which usually can be controlled by antibiotics. There also is a less than 1% chance of injury to the uterus, potentially leading to a hysterectomy. These complication rates are lower than those of hysterectomy and myomectomy.

Magnetic Resonance Guided Focused Ultrasound

Magnetic resonance guided focused ultrasound (MRGFU) is a non-invasive outpatient, procedure that uses high intensity focused ultrasound waves to ablate (destroy) the fibroid tissue. During the procedure, an interventional radiologist uses magnetic resonance imaging (MRI) to see inside the body to deliver the treatment directly to the fibroid. The procedure is FDA approved for treating uterine fibroids.

focused_ultrasound_illustration_1

MRI scans identify the tissue in the body to treat and are used to plan each patient’s procedure. MRI’s provide a three-dimensional view of the targeted tissue, allowing for precise focusing and delivery of the ultrasound energy. MRI also enables the physician to monitor tissue temperature in real-time to ensure adequate but safe heating of the target. Immediate imaging of the treated area following MRGFU helps the physician determine if the treatment was successful.

focused_ultrasound_illustration_2

The ultrasound energy used in MRGFU can pass through skin, muscle, fat, and other soft tissues. High-intensity ultrasound energy that is directed to the fibroid heats up the tissue and destroys it. This method of tissue destruction is called thermal ablation.

Surgical Treatments for Fibroids

Gynecologists perform hysterectomy and myomectomy surgery. Hysterectomy is the removal of the uterus and is considered major abdominal surgery. It requires three to four days of hospitalization and the average recovery period is six weeks.

Depending on the size and placement of the fibroids, myomectomy can be an outpatient surgery or require two to three days in the hospital. However, myomectomy is usually major surgery that involves cutting out the biggest fibroid or collection of fibroids and then stitching the uterus back together. Most women have multiple fibroids, and it is not physically possible to remove all of them because it would remove too much of the uterus. While myomectomy is frequently successful in controlling symptoms, the more fibroids the patient has, generally, the less successful the surgery. In addition, fibroids may grow back several years later.

Myomectomy, like UFE, leaves the uterus in place and may, therefore, preserve the woman’s ability to have children.

Highly Effective, Widely Available Treatment

A varicocele is a varicose vein of the testicle and scrotum that may cause pain, testicular atrophy (shrinkage) or fertility problems. Veins contain one-way valves that work to allow blood to flow from the testicles and scrotum back to the heart. When these valves fail, the blood pools and enlarges the veins around the testicle in the scrotum to cause a varicocele. Open surgical ligation, performed by a urologist, is the most common treatment for symptomatic varicoceles. Varicocele embolization, a nonsurgical treatment performed by an interventional radiologist, is as effective as surgery with less risk, less pain and less recovery time. Patients considering surgical treatment should also get a second opinion from an interventional radiologist to ensure they know all of their treatment options. You can ask your doctor to send a referral form or contact the radiology department, and ask for interventional radiology..

varicoceles_in_the_scrotum

Prevalence

  • Approximately 10 percent of all men have varicoceles – among infertile couples, the incidence of varicoceles increases to 30 percent
  • Highest occurrence in men aged 15-35
  • As many as 70-80,000 men in America may undergo surgical correction of varicocele annually

Symptoms

Pain – aching pain when an individual has been standing or sitting for long periods of time and pressure builds up on the affected veins. Typically, painful varicoceles are prominent in size.

Fertility Problems – There is an association between varicoceles and infertility. The incidence of varicocele increases to 30 percent in infertile couples. Decreased sperm count, decreased motility of sperm, and an increase in the number of deformed sperm are related to varicoceles. Some experts believe that blocked and enlarged veins around the testes, called varicoceles, cause infertility by raising the temperature in the scrotum and decreasing sperm production.

Testicular Atrophy – Shrinking of the testicles is another sign of varicoceles. Often, once the testicle is repaired it will return to normal size.

Varicocele Diagnosis

Diagnosis is fairly simple through either physical or diagnostic examination.

  • Typical on left side of scrotum
  • Visual physical exam-scrotum looks like a bag of worms
  • Testicle can shrink in size/atrophy
  • When varicoceles are not clearly present, the abnormal blood flow can often be detected with a noninvasive imaging exam called color flow ultrasound or through a venogram-an X-ray in which a special dye is injected into the veins to highlight blood vessel abnormalities

Varicocele Treatments

Currently there are two treatment options for men with varicoceles: Catheter-directed embolization or surgical ligation.

Catheter-directed Embolization

Catheter directed embolization is a non-surgical, outpatient treatment performed by an interventional radiologist using imaging to guide catheters or other instruments inside the body. Through mild IV sedation and local anesthesia, patients are relaxed and pain-free during the approximately two-hour procedure.

For the procedure, an interventional radiologist makes a tiny nick in the skin at the groin using local anesthesia, through which a thin catheter (much like a piece of spaghetti) is passed into the femoral vein, directly to the testicular vein. The physician then injects contrast dye to provide direct visualization of the veins so s/he can map out exactly where the problem is and where to embolize, or block, the vein. By using coils, balloons, or particles, the interventional radiologist blocks the blood flow in the vein which reduces pressure on the varicocele. By embolizing the vein, blood flow is re-directed to other healthy pathways. Essentially, the incompetent vein is shut off internally by preventing blood flow, accomplishing what the urologist does, but without surgery.

Efficacy of Embolization for Varicoceles

Embolization is equally effective in improving male infertility and costs about the same as surgical ligation. Pregnancy rates and recurrence rates are comparable to those following surgical varicocelectomy. In one study, sixty percent conceived who were treated for infertility.

In another study, sperm concentration improved in 83 percent of patients undergoing embolization compared to 63 percent of those surgically ligated. Patients who underwent both procedures expressed a strong preference for embolization.

varicocele_embolization

Recovery Time

  • Average of one to two days for complete recovery for embolization, compared to two to three weeks for surgery
  • 24 percent of surgical ligation patients required overnight hospital stay, compared to none for embolization

Benefits of Interventional Radiology Procedure

  • No surgical incision in the scrotal area
  • Effective as surgery, as measured by improvement in semen analysis and pregnancy rates
  • Less recovery time-patients are able to return to normal daily activities immediately and without hospital admittance
  • A patient with varicoceles on both sides can have them fixed simultaneously through one vein puncture site, compared to surgery, which requires two separate open incisions
  • No general anesthesia
  • No sutures
  • No infections
  • Cost-effective

Surgical Treatment of Varicocele

After the patient receives anesthesia, an incision is made in the skin above the scrotum, cutting down to the testicular veins, and tying them off with sutures. Although patients leave the hospital the same day, there is a two- to three-week recovery period.

Get dramatic results without surgery

Are painful varicose veins getting you down? Don’t suffer any longer. WVU Medicine offers a minimally invasive laser procedure, VenaCureTM, for varicose veins.

Varicose veins develop as a result of weakened vein walls plus faulty one-way valves in the veins. Ordinarily, the valves stop blood from flowing backward while on its way up to the heart. When these valves don’t work correctly, the veins become twisted, enlarged, and painful. VenaCureTM laser treatment closes off the veins so they shrink and the pain and pressure is relieved.

The benefits of VenaCureTM laser treatment include:

  • No need for general anesthesia or hospitalization, a local anesthetic is all you need.
  • The procedure generally takes only 45 minutes.
  • You can return immediately to your normal routine.
  • The procedure is covered by most insurance.

Patients are seen at the WVU Heart Institute, 600 Suncrest Towne Centre in Morgantown. For appointments, call 304-598-4478 or toll-free 877-988-4478.