Interventional Oncology | Dallas Fort Worth Carrollton TX | Precision VIR

Interventional Oncology

Introduction

Precision Vascular & Interventional offers new and expanded opportunities to investigate cancer therapies that use imaging technology to diagnose and treat localized cancers in ways that are precisely targeted and minimally or non-invasive. By use of advanced imaging technologies located at the Clinical Center, including cutting-edge magnetic resonance imaging (MRI), positron emission tomography (PET), and computed tomography (CT) – combined with the capability to use all three technologies simultaneously to navigate a therapeutic device through the body, the new center’s goal is localized treatment and drug delivery.

Treatments

Interventional oncology, practiced by interventional radiologists, is one of four parts of a multidisciplinary team approach in the treatment of cancer and cancer-related disorders. The others include medical oncology, surgical oncology, and radiation oncology. Interventional oncology procedures provide minimally invasive, targeted treatment of cancer. Image guidance is used in combination with the most current innovations available to treat cancerous tumors while minimizing possible injury to other body organs. Most patients having these procedures are outpatients or require a one night stay in the hospital.

  • Some of these therapies are regional, as when treating cancers involving several areas of the liver with chemoembolization or radioembolization.
  • Others are better classified as local, as when treating focal lesions in the kidney, liver, lung and bone with cryoablation (freezing), or microwave or radiofrequency ablation (heating).

In general, these techniques are reserved for patients whose cancer cannot be surgically removed or effectively treated with systemic chemotherapy. These procedures are also frequently used in combination with other therapies provided by other members of the cancer team.

Epidemiology

The overall incidence of colorectal cancer is higher in men than in women. Incidence and death rates for colorectal cancer increase with age, with over 90% of new cases and deaths occur in individuals 50 and older. Colorectal cancer is mainly a disease of developed countries with a Western culture (Boyle 2000). However elsewhere the incidence is increasing rapidly, particularly in countries with a high-income economy that have recently made the transition from a relatively low-income economy, such as Japan, Singapore, and Eastern European countries (Haggar 2009).
Oncology - epidemiology
Oncology

Five-year survival rates for patients with colorectal cancer have improved in recent years. This fact may be due to wider surgical resections, modern anesthetic techniques, and improved supportive care. In addition, better preoperative staging and abdominal exploration reveal clinically occult disease and allow treatment to be delivered more accurately. Survival also has improved through the use of adjuvant chemotherapy for colon cancer and neoadjuvant chemoradiation therapy for rectal cancer. Nonetheless, 5-year survival rates for patients with distant metastases are only 10%.

Colorectal Cancer

Colorectal cancer, or colon cancer, occurs in the colon or rectum. As the graphic below shows, the colon is the large intestine or large bowel. The rectum is the passageway that connects the colon to the anus.Colon cancer, when discovered early, is highly treatable. Even if it spreads into nearby lymph nodes, surgical treatment followed by chemotherapy is highly successful. In the most difficult cases — when the cancer has metastasized to the liver, lungs or other sites — treatment can prolong and add to one’s quality of life.

Symptoms
Colon cancer affects men and women of all racial and ethnic groups, and is most often found in people 50 years or older. It is the third most common cancer in the United States, behind only lung and prostate cancers in men and lung and breast cancers in women, and the second leading cause of cancer death.In fact, it is estimated that in 2013, 50,830 people will die of colon cancer. But the truth is: it doesn’t have to be this way. If everyone 50 years or older had a regular screening test, as many as 80% of deaths from colon cancer could be prevented.
Screening for colon cancer saves lives.
Screening detects precancerous polyps and allows them to be removed before turning into cancer. Screening also helps find colon cancer at an early stage, when treatment often leads to a cure. So please, take control of your life and your health – if you’re turning 50 or are experiencing abnormal symptoms, GET SCREENED and urge those you love to do the same.

Liver (Hepatocellular) Cancer

Hepatocellular cancer (HCC) is the fourth most common cancer in the world.  Age-standardized incidence rates vary from 2.1 per 100,000 in North America to 80 per 100,000 in China.  In the United States, it is estimated that there will be 35,660 new cases diagnosed in 2015 and 24,550 deaths due to this disease.  There is a distinct male preponderance among all ethnic groups in the United States, although this trend is most marked among Chinese Americans, in whom the annualized rate of HCC among men is 21.6 per 100,000 and among women is 8.1 per 100,000 population

When the valves do not perform their function, blood can flow backwards or reflux. This reflux results in what is known as venous insufficiency, a very common condition that results in the pooling of blood in the veins

Risks
Chronic hepatitis B and C are recognized as the major factors worldwide increasing the risk of HCC, with risk being greater in the presence of coinfection with hepatitis B virus and hepatitis C virus.  The incidence of HCC in individuals with chronic hepatitis is as high as 0.46% per year. In the United States, chronic hepatitis B and C account for about 30% to 40% of HCC. Chronic hepatitis G infection is not associated with HCC in either hepatitis B surface antigen–positive carriers or noncarriers.

Cirrhosis is also a risk factor for HCC, irrespective of the etiology of the cirrhosis. The annual risk of developing HCC among persons with cirrhosis is between 1% and 6%. Other risk factors include alcoholic cirrhosis, hemochromatosis, alpha-l-antitrypsin deficiency, glycogen storage disease, porphyria cutanea tarda, tyrosinemia, and Wilson disease, but rarely biliary cirrhosis.  A retrospective case-control study found that features suggestive of nonalcoholic steatohepatitis, including obesity, type 2 diabetes, dyslipidemia, and insulin resistance, were more frequently observed in patients with HCC associated with cryptogenic cirrhosis than in those with HCC of viral or alcohol etiology.  Aflatoxins, which are mycotoxins formed by certain Aspergillus species, are a frequent contaminant of improperly stored grains and nuts. In parts of Africa, the high incidence of HCC in humans may by related to ingestion of foods contaminated with aflatoxins.

Likely Etiology of HCC
Causative Agents (Dominant Geographical Area)

  • Hepatitis B virus ( Asia and Africa)
  • Hepatitis C virus (Europe, United States, and Japan)
  • Alcohol (Europe and United States)
  • Aflatoxins (East Asia and Africa)

Percutaneous Minimally Invasive Biopsy

Percutaneous biopsy is minimally invasive, causes little pain and requires usually a tiny incision. Most percutaneous needle biopsy procedures are performed with image guidance, with x-rays, ultrasound or CT.  Patients undergo percutaneous biopsy procedures while awake or with moderate sedation. Many patients resume their normal lifestyle and routine the same day of the procedure.

Services

We perform the following image guided biopsies:

  • Lung biopsy
  • Liver biopsy
  • Thyroid biopsy
  • Abdominal mass biopsy
  • Kidney (Native or transplant) biopsy
  • Bone biopsy
  • Lymph node biopsy
What to expect
The skin above the region to be biopsied is cleansed. In some cases, the region of the biopsy needle insertion will be anesthetized with a small hypodermic needle before the sampling needle is placed. In addition, a general sedative is sometimes used to further reduce discomfort. During the needle biopsy, patients may experience a slight pressure but should not experience any pain. Typically, several samples are removed. The samples will be sent to the pathology laboratory for diagnosis. The length of the exam can vary up to an hour, depending on the type of biopsy being performed. During the procedure, the patient will be informed of what is occurring and what he or she will need to do to assist in the exam. Typically the patient needs to cooperate and remain still. For biopsy of the lung or upper abdomen or liver, patients may be required to hold their breath during the imaging portion of the biopsy and during the needle placement. There will be some minor bleeding when the needle is placed. For biopsy that involves passing the needle near a rib, patient discomfort may be greater because of the sensitivity of the rib bone. This should not be cause for alarm. In general, patients should try to relax and remain calm and still during a biopsy.

Mediports

Interventional Oncology - MediportsA mediport is a small medical device implanted beneath the skin, to give chemotherapy, to receive blood transfusions or draw blood, and to receive IV fluids or IV medications. The port consists of a reservoir which attaches to a catheter, a thin, soft plastic tube. The catheter connects the port through a vein in the neck. It is inserted in the upper chest and appears as a bump on the skin.

The mediport requires no special maintenance on your part and is completely internal, so swimming and bathing are not a problem.

Secondary Hepatic Malignancies

Many recent advances in medicine and surgery have made it possible to successfully treat, and sometimes cure, cancers that were previously considered incurable. At Precision Vascular & Interventional, these advances have been incorporated into a multidisciplinary approach that can offer treatment for most patients who have developed metastatic liver lesions from malignant tumors such as colon cancer or breast cancer. Our team of specialists will work with you to provide a comprehensive treatment plan that includes the latest technology in diagnosis and treatment.

What Are Metastatic Liver Lesions
Cancer can develop in any organ and each cancer acts differently in its tendency to spread to other organs. When a cancer has spread to the liver, it is referred to as a metastatic liver lesion. Sometimes the metastatic lesion is identified at the same time as the original cancer (synchronous) and sometimes the metastatic lesion is discovered later, after the original cancer has been treated or surgically removed (metachronous). The liver has two separate sources of blood supply: the hepatic artery (provides oxygenated blood) and the portal vein (carries blood from the intestines back to the liver for extraction of nutrients). For this reason, the liver is the most common site for metastasis from gastrointestinal cancers, such as colon cancer or pancreatic cancer.
Detecting and Staging Metastases
When cancer has spread to the liver, it typically does not cause any symptoms. As a result, most patients do not notice any change in their health. Blood tests and imaging, such as CT scan or ultrasound, are important tools to detect metastatic liver lesions at an early stage, when they are most effectively treated. These tests can also be helpful in determining if the cancer has spread to areas in addition to the liver. In some patients additional testing, such as a positron emission tomography (PET) and MRI scan may be required to determine the extent of the liver metastases.

Treatment Options for Metastatic Liver Lesions

Once a metastatic liver lesion is detected, patients should undergo a rapid medical, oncologic and surgical evaluation to determine the most appropriate treatment. The treatment may vary between patients, and will be tailored to best fit each individual’s specific needs. Frequently, combinations of treatments, rather than a single type of treatment will be required, and you will meet with a team of specialists to discuss these different options during your evaluation.

Systemic Chemotherapy
The most common treatment used for metastatic liver lesions is systemic chemotherapy. In this treatment, anti-cancer medications may be delivered intravenously, or by ingestion of an oral preparation containing the anti-cancer drug. Cancer cells vary widely in their response to systemic chemotherapy, and some cancers respond well to chemotherapy, while others may be unaffected. This type of treatment is commonly offered for patients who have large malignant tumors that cannot be removed surgically, or patients who have cancer spread to other organs in addition to the liver.
Transarterial Chemoembolization (TACE)
Some patients may be more appropriate for a specialized form of chemotherapy, TACE, which uses special catheters to deliver chemotherapeutic drugs directly into the artery supplying the liver. This procedure focuses the anti-cancer effect on the metastatic lesions in the liver, and tends to have fewer side effects commonly seen with systemic chemotherapy. TACE has the added advantage of being able to partially block the blood supply to the area of the cancer, depriving the blood supply needed by the cancer cells for nutrients and oxygen. For most individuals TACE is well-tolerated, with few side-effects, and can frequently be performed as an outpatient procedure.
Radiofrequency Ablation

Interventional Oncology - Radiofrequency Ablation

Patients with small metastatic tumors may be best treated with radiofrequency ablation (RFA). With this procedure, a specially designed probe is radiographically guided into the liver tumor, and radiofrequency energy is used to destroy tumor cells. During the procedure, tumor cells are heated to more than 50° C. Most commonly, this procedure is done using laparoscopic surgery (small incisions on the abdomen), or performed in the radiology suite, using CT guidance. In some instances, open surgery may be required to perform this procedure. RFA may be used for patients who have unresectable metastatic liver lesions, or are too ill to undergo surgical resection, and may be used in combination with other forms of treatment.

Urologic Interventions

The kidneys produce urine, which is drained through the ureters into the bladder, before passing through the urethra and leaving the body. Sometimes cancer in the lower abdomen can block one or both of the ureters. When this happens, urine can’t leave the kidney, causing damage.

A nephrostomy allows urine to be drained through a tube inserted through the skin on your back and into the kidney. Using an X-ray or ultrasound, your doctor will find the best place within the kidney to place the tube. The doctor numbs your back with a local anaesthetic and inserts a fine guidewire into the kidney. The guidewire helps the doctor place the nephrostomy tube correctly. Stitches hold the tube securely in place, and it’s connected to a urine collection bag which can be worn under your clothing. Your nurses will give you advice and support on looking after your nephrostomy outside of hospital.

Some people will need the nephrostomy for only a short time, while others may need to keep it permanently. Schedule your free consultation with us today to receive more information.

Symptoms
People with cancer may need a nephrostomy if the cancer is blocking one or both ureters. If a ureter becomes blocked, urine can’t flow through from the kidney to the bladder, which causes urine to build up in the kidney. When this happens the kidneys can’t work properly and they may gradually stop working. This can make you feel very unwell unless it’s treated immediately. You may need one nephrostomy tube or two depending on whether one or both ureters are blocked.

Your ureters are more likely to become blocked if you have a cancer that started in the lower tummy (pelvis) and has spread within that area. For example, in women this may be a cancer of the bladder, cervix, womb or ovaries. In men, it may be a cancer of the prostate or bladder. In both men and women, it may be a cancer of the colon or rectum. Occasionally, a cancer that started in another part of the body spreads to the pelvis and blocks one or both ureters. You’ll usually have a scan to find out exactly where the blockage is.

Before you have a nephrostomy, your doctor will explain its aims to you and the possible side effects or complications. You’ll be asked to sign a form giving your permission (consent) to have the procedure. Make sure you ask any questions you have and if there’s anything you don’t understand let the staff know so that they can explain. You may also want to talk things over with family or friends.

Treatments
A nephrostomy tube is usually put in under local anesthetic during a short stay in the hospital. The procedure is done by a radiologist – a doctor who specializes in diagnosing and treating disease using x-rays and scans. It’s usually done in the x-ray (radiology) department as the doctor will use x-ray or an ultrasound scanning to guide them as they place the nephrostomy tube in the kidney. It can take up to 30-60 minutes.

Before the procedure, a fine tube (cannula) may be put into a vein in your arm. Sometimes a drip (infusion) is attached to the cannula to give you fluids. Through the cannula, you may be given intravenous antibiotics to reduce the risk of getting an infection. You may also be given a sedative to help you relax.

You’ll usually be asked to lie flat on your stomach on an x-ray table. When you’re comfortably positioned, the doctor will inject some local anesthetic into the skin on the side of your back. Once the area is numb the doctor gently inserts a fine needle into the kidney and then puts a guidewire through the needle. The doctor uses the guidewire to place the nephrostomy tube in the correct position in the kidney. The tube is kept securely in place with stitches so it won’t come out and is connected to a bag outside the body that collects the urine.

When the nephrostomy tube is being put into the kidney it may hurt a little for a short time. You may be given a painkiller through the cannula in your arm. Remember to let the doctor or nurse know if you’re in any pain or feeling anxious.