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Percutaneous Abscess Drainage in Gynecologic Cancer Patients
GYNECOLOGIC ONCOLOGY ARTICLE NO.
62, 366–369 (1996)
0250
Percutaneous Abscess Drainage in Gynecologic Cancer Patients LOIS M. RAMONDETTA, M.D.,* CHARLES J. DUNTON, M.D.,* MARCELLE J. SHAPIRO, M.D.,† JOHN A. CARLSON JR., M.D.,* AND JORGE ARSUAGA, M.D.† Departments of *Obstetrics and Gynecology and †Cardiovascular Interventional Radiology, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania 19107 Received January 17, 1996
CASE REPORT Percutaneous abscess drainage (PAD) is regarded as an alternative treatment for the care of the gynecologic cancer patient with a pelvic infection. Four female patients with infected pelvic malignancies were evaluated and treated with PAD at Thomas Jefferson University Hospital over a 4-year period. Abscesses in three of the four patients were drained successfully and the catheters were ultimately removed. Successful drainage was defined as a good clinical response and avoidance of surgical debridement. For the patient with an infected pelvic malignancy, PAD offers an alternative to surgery without associated morbidity. Our experience indicates PAD is associated with expedient clinical recovery and preservation of quality of life for most patients. q 1996 Academic Press, Inc.
INTRODUCTION
The development of a pelvic abscess in a gynecologic oncology patient can pose a management dilemma. An abscess in a patient without cancer (e.g., tubo-ovarian, colorectal, postoperative) can usually be cured with drainage and antibiotics. The infection and its source can usually be eliminated. However, a cancer patient may have reduced healing capacity because of previous treatment or may not be a surgical candidate. In addition, a tumor mass with decreased oxygen penetration may readily allow for the growth of anaerobic bacteria and development of abscess formation [1]. Drainage of pelvic abscesses may be accomplished by laparotomy or percutaneous abscess drainage (PAD). Placement of the catheter for PAD can be guided either by ultrasound or computed tomography (CT) combined with fluoroscopy. Percutaneous abscess drainage may be a method particularly suited to cancer patients. In addition, PAD can be useful preoperatively to help obtain better outcomes in difficult surgical debridements or as a temporizing procedure until the patient is able to undergo surgical debridement. Previously published studies only peripherally address the success of PAD in patients with infected tumors [1, 8–11]. We have treated all four patients presenting with secondarily infected pelvic malignancies at Thomas Jefferson University Hospital by percutaneous abscess drainage. This paper is a review of our experience with these four patients.
366
0090-8258/96 $18.00 Copyright q 1996 by Academic Press, Inc. All rights of reproduction in any form reserved.
AID
Gyn 4392
/
6d0f$$$241
Case 1. This patient was admitted on May 26, 1994 and discharged on June 4, 1994. She was a 45-year-old black female with Stage IIIc ovarian cancer diagnosed and optimally resected in 1975. Pathology was consistent with cancer of low malignant potential with invasive implants. She received multiple chemotherapy courses in addition to whole abdominal and pelvic radiation. Progression of the disease was noted in May 1994 and she was started on a course of Taxol. After completing the first treatment, she presented with fever, diarrhea, increasing lower quadrant pain, abdominal distention, and neutropenia. An obstruction series and CT confirmed the presence of a 17 1 14 1 10-cm abscess (Fig. 1a). CT further revealed lymphadenopathy, peritoneal implants, and pleural metastasis. On the second hospital day, the patient underwent a combined CT/fluoroscopically guided percutaneous drainage of the mass with placement of a 12 French Cope Loop catheter. Approximately 600 cc of purulent fluid was initially obtained and cultures were positive for gram-negative gastrointestinal flora. The patient was started on appropriate antibiotics and defervesced 5 days following percutaneous drainage. She was discharged home with the catheter in place and was followed with biweekly catheter checks. The catheter was manipulated (either repositioned or downsized) according to the amount of drainage and the size of the remaining cavity was noted on crosssectional imaging. The catheter was removed following complete resolution of the cavity which occurred 2.5 months following initial drainage (Fig. 1b). The patient had no further recurrence of the abscess at 19.5 months and continues with palliative chemotherapy. Case 2. This patient was admitted on June 15, 1994 and discharged on July 15, 1994. She was a 64-year-old white female with a history of endometrial cancer diagnosed in October 1991. She was initially treated with whole pelvic radiation and chemotherapy (cisplatin, Adriamycin). Her past medical history is significant only for non-insulin-dependent diabetes mellitus (NIDDM). During her treatment, she developed an enterocutaneous fistula and underwent lap-
08-19-96 20:13:14
goal
AP: Gyn Onc
PAD FOR GYNECOLOGIC CANCER PATIENT
367
FIG. 1. (a) Left lower quadrant septated, cystic collection with mural nodularity in a patient with known ovarian carcinoma (Case 1). (b) Followup CT scan after drainage and catheter removal shows complete resolution of the collection.
arotomy and small bowel resection. Pathologic examination revealed adenocarcinoma within the fistula. On the eighth postoperative day, she became febrile and was placed on broad spectrum antibiotics. A CT scan performed that evening revealed a previously noted left lower quadrant necrotic tumor mass and a new 6- 1 10-cm right lower quadrant abscess. Combined US/fluoroscopically guided transabdominal drainage was performed the next day with drainage producing 1100 cc of purulent fluid through a 12 French Cope Loop catheter. Cultures revealed Streptococcus, Candida,
AID
Gyn 4392
/
6d0f$$$242
08-19-96 20:13:14
Klebsiella, and Pseudomonas growth. The patient defervesced but subsequently developed Candida albicans fungemia on Day 13. Despite optimal catheter position, she succumbed 17 days following drainage with the catheter in place. Her immediate cause of death was fungal septicemia. Case 3. This patient was admitted on November 20, 1992 and discharged on January 8, 1993. She was a 74-yearold female, admitted for suspected urosepsis after a 3-week history of weakness, confusion, and decreased oral intake. Her past medical history was significant for NIDDM. Gyne-
goal
AP: Gyn Onc
368
RAMONDETTA ET AL.
TABLE 1 Methods of Approach and Details of Drainage
Approach Catheter Guidance Defervescence Fistula Cultures Cancer Drainage Complications Diabetes Antibiotics Discharge status
Case 1
Case 2
Case 3
Case 4
Transabdominal 12 Fr Cope Loop US/fluoroscopy 5 days Gastrointestinal Klebsiella, E. coli Rec. ovarian 8 days None No Periprocedure Catheter in
Transabdominal 12 Fr Cope Loop US/fluoroscopy 2 days Gastrointestinal Klebsiella, E. coli Rec. endometrial 30 days None NIDDM Periprocedure Expired/catheter in
Transvaginal 10 Fr Cope Loop US/fluoroscopy AF Genitourinary Mixed gram/ Primary cervical 48 days None NIDDM Periprocedure Catheter out
Transabdominal 12 Fr Cope Loop US/fluoroscopy 2 days None B. fragilli Rec. ovarian 21 days None No Periprocedure Catheter in
cological exam then revealed advanced cervical cancer. A CT scan revealed a 9 1 5 1 9-cm complex fluid collection posterior to the bladder, probable bowel involvement as well as multiple hepatic lesions. A combined US/fluoroscopic transvaginal drainage was performed with placement of a 10 French Cope Loop catheter. Drainage initially produced 260 cc of purulent fluid. No fistula was noted on the radiographic studies. The patient deferred further treatment and was transferred for hospice care. The catheter was maintained with thrice weekly flushing. Removal of the catheter was performed 48 days after placement when resolution of the infection was documented by collapse of the abscess cavity on cross-sectional imaging studies. The patient died 5 months after transfer. Case 4. This patient was admitted on February 15, 1991 and was discharged on March 3, 1991. She was a 61-year-old female with Stage IIIc papillary serous ovarian carcinoma diagnosed and optimally resected in 1988. She initially received Cytoxan and cisplatin followed by 6 courses of ip platinum after a positive second-look operation. She had since undergone whole abdominal radiation therapy for persistent disease. In December 1990 she received 5-fluorouracil. Three months later she was admitted with fever, nausea, vomiting, and severe right lower-quadrant pain. CT scan revealed a right lower-quadrant 10 1 7.5 1 7-cm tumor mass adherent to bowel and suspicious for an abscess. Because no improvement followed a course of intravenous antibiotics, a percutaneous transabdominal approach with combined ultrasound and fluoroscopic guidance was used to place a 12 French Cope Loop catheter within the infected tumor. The patient’s pain resolved and she promptly defervesced 1 day following drainage. No small bowel or colonic fistula was demonstrated on radiographic studies. She was discharged with the drainage catheter in place and was instructed to flush the catheter thrice weekly. CT scan 2 months later demonstrated resolution of the abscess. The catheter was successfully removed with no further recurrence of infection (Table 1).
AID
Gyn 4392
/
6d0f$$$242
08-19-96 20:13:14
DISCUSSION
Infected pelvic malignancies can pose a management dilemma for physicians. The published reports that compare PAD with surgical drainage in patients with infected tumors is limited. The safety, cost-effectiveness, and successful drainage of benign lesions such as tubo-ovarian abscesses (TOAs) is well documented [3–5, 7, 8]. Choice of the guidance method depends on the radiologists’ comfort level and the abscess size and its location. The two methods presently used are ultrasound or CT with fluoroscopic guidance. Ultrasound has the disadvantage of comparatively poor bowel visibility, although the transvaginal approach may eliminate this disadvantage [7]. Ultrasound with fluoroscopic guidance was used successfully in the four procedures performed on patients with pelvic malignancies at Thomas Jefferson University Hospital. The transvaginal or transabdominal approach was individualized based on abscess location. Regardless of approach, complications reported following PAD include septicemia, hemorrhage, bowel laceration, and one reported case of necrotizing fasciitis. The complication rate reported varies from 2 to 10% [5, 6]. No complications of placement or drainage occurred in our four patients. A success rate between 77 and 93% has been reported for ultrasound-guided percutaneous drainage of TOAs. Successful drainage was based on avoidance of surgery and clinical improvement. Long-term avoidance of surgery has been approximately 80% [4, 7]. Success rates are higher for unilocular abscesses than for complex abscesses [5]. Successful drainage in patients with pelvic malignancies is difficult to define. Although success is typically defined as avoidance of surgery after drainage, existing malignancies make longterm avoidance of surgery less likely. Our experience suggests that successful drainage in patients with pelvic malignancies be defined by the resolution and avoidance of surgery for the acute infection. Mueller et al. [1] evaluated 16 patients undergoing percutaneous drainage of infected
goal
AP: Gyn Onc
369
PAD FOR GYNECOLOGIC CANCER PATIENT
abdominal tumors; 12 patients improved clinically post-catheter placement and four patients had no response. Of those four with no response, most required surgery, improved initially, but expired secondary to complications of the infection. Twelve of the 16 patients showing significant improvement had differing long-term results. Three patients ultimately required surgery for staging or debulking unrelated to the infection and six patients had catheter placement with resolution of the abscess. Catheter duration lasted from 5 weeks to 1 year. Three patients died with their catheters in place [1]. Typically, catheters for TOA drainage remain in place 1– 20 days, with an average of 6 days [7]. Removal is determined by clinical improvement and drainage volume. Maximum daily drainage prior to removal is approximately 10– 20 cc/day [3]. Malignancies present a complicated management picture. Significant necrotic tumor tissue exists as a nidus for recurrent infection. The preferred management for the four patients with gynecologic malignancy who underwent drainage at Thomas Jefferson University Hospital was an individualized evaluation of clinical improvement by members of the Cardiovascular Interventional Radiology Division correlated with radiologic evaluation. Patient selection for PAD, regardless of the presence of a malignancy, should depend upon hemodynamic stability. Septicemia and the risk of hemodynamic instability should be addressed quickly with broad spectrum antibiotics and surgical debridement [2]. Contraindications to PAD are severe uncorrected coagulopathy and abscess inaccessibility most often due to surrounding bowel [3, 5]. Preevaluation for a gastrointestinal fistula is not necessary and does not preclude successful PAD. However, drainage in the presence of a fistula may be prolonged and may necessitate intravenous hyperalimentation for successful closure. In addition, resolution of the infection is necessary for closure of the fistula [3]. Surgical debridement has been the principle treatment for abscesses in oncologic patients. However, surgery in cancer patients is often associated with a higher postoperative morbidity because of poor tissue healing capacity. Patients with terminal illnesses may benefit most from nonoperative therapy, early discharge, avoidance of general anesthesia, or early return to chemotherapy treatment. Percutaneous drainage of infected malignancies offers an alternative to surgical drainage and debridement. We have found no specific contraindications for PAD in patients with pelvic malignancies. Although one of the patients we are reporting died with the catheter in place, we do not feel this was a direct result of the choice of PAD for treatment.
AID
Gyn 4392
/
6d0f$$$242
08-19-96 20:13:14
Patients with infected pelvic malignancies should be managed individually. Treatment may be based on the understanding that patients with newly diagnosed malignancies have healthy tissue and good healing potential, and may best benefit from surgical debridement, debulking, and staging. Patients with recurrent and resistant cancers may be best treated with minimal invasive interventions. Case 2 was a patient who presented with advanced disease and metastatic complications. Although she died with the catheter in place, minimizing invasive intervention is often important in order to preserve the quality of remaining life. The method of catheter placement, duration of drainage, and the need for surgical treatment appear to be equally applicable to treatment of pelvic infections in patients with benign or malignant disease. Our experience with percutaneous abscess drainage has been without complications directly resulting from the procedure and has offered the gynecologic cancer patient an opportunity for a successful and expedient clinical response. REFERENCES 1. Mueller, P. R., White, E. M., and Glass-Royal, M. Infected abdominal tumors: Percutaneous catheter drainage, Radiology 173, 627–629 (1989). 2. Longo, W. E., Milsom, J. W., and Lavery, I. C. Pelvic abscess after colon and rectal surgery—What is optimal management? Dis. Colon Rectum 36, 936–941 (1993). 3. Gazelle, G. S., and Mueller, P. R. Abdominal abscess: Imaging and intervention, Radiol. Clin. N. Am. 32, 913–932 (1994). 4. Feld, R., Eschelman, D. J., Sagerman, J. E., and Segal, S. Treatment of pelvic abscesses and other fluid collections: Efficacy of transvaginal sonographically guided aspiration and drainage, Am. J. Roentgenol. 163, 1141–1145 (1994). 5. Fabiszewski, N. L., Sumkin, J. H., and Johns, C. M. Contemporary radiologic percutaneous abscess drainage in the pelvis, Clin. Obstet. Gynecol. 36, 445–456 (1993). 6. Holly, D. T., McGrath, P. C., and Sloan, D. A. Necrotizing fasciitis as a complication of percutaneous catheter drainage of an intra-abdominal abscess, Am. Surg. 60, 197–199 (1994). 7. Casola, G., vanSonnenberg, E., D’Agostino, H. B., Harker, C. P., Varney, R. R., and Smith, D. Percutaneous drainage of tubo-ovarian abscesses, Radiology 182, 399–402 (1992). 8. vanSonnenberg, E., D’Agostino, H. B., Casola, G., Goodacre, B. W., Sanchez, R. B., and Taylor, B. US-guided transvaginal drainage of pelvic abscesses and fluid collections, Radiology 181, 53–56 (1991). 9. Marcus, S. G., Walsh, T. J., Pizzo, P. A., and Danforth, D. N. Hepatic abscess in cancer patients, Arch. Surg. 128, 1358–1364 (1993). 10. Mann, W. J., Calayag, P. T., Muffoletto, J. P., Ross, F., Chalas, E., and Deitch, J. Management of gastric outlet obstruction caused by ovarian cancer, Gynecol. Oncol. 40, 277–279 (1991). 11. Segreti, E. M., Munkarah, A., and Levenback, C. Successful percutaneous drainage of gluteal pyomyositis occurring after intra-arterial chemotherapy and pelvic irradiation, Gynecol. Oncol. 53, 376–379 (1994).
goal
AP: Gyn Onc
62, 366–369 (1996)
0250
Percutaneous Abscess Drainage in Gynecologic Cancer Patients LOIS M. RAMONDETTA, M.D.,* CHARLES J. DUNTON, M.D.,* MARCELLE J. SHAPIRO, M.D.,† JOHN A. CARLSON JR., M.D.,* AND JORGE ARSUAGA, M.D.† Departments of *Obstetrics and Gynecology and †Cardiovascular Interventional Radiology, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania 19107 Received January 17, 1996
CASE REPORT Percutaneous abscess drainage (PAD) is regarded as an alternative treatment for the care of the gynecologic cancer patient with a pelvic infection. Four female patients with infected pelvic malignancies were evaluated and treated with PAD at Thomas Jefferson University Hospital over a 4-year period. Abscesses in three of the four patients were drained successfully and the catheters were ultimately removed. Successful drainage was defined as a good clinical response and avoidance of surgical debridement. For the patient with an infected pelvic malignancy, PAD offers an alternative to surgery without associated morbidity. Our experience indicates PAD is associated with expedient clinical recovery and preservation of quality of life for most patients. q 1996 Academic Press, Inc.
INTRODUCTION
The development of a pelvic abscess in a gynecologic oncology patient can pose a management dilemma. An abscess in a patient without cancer (e.g., tubo-ovarian, colorectal, postoperative) can usually be cured with drainage and antibiotics. The infection and its source can usually be eliminated. However, a cancer patient may have reduced healing capacity because of previous treatment or may not be a surgical candidate. In addition, a tumor mass with decreased oxygen penetration may readily allow for the growth of anaerobic bacteria and development of abscess formation [1]. Drainage of pelvic abscesses may be accomplished by laparotomy or percutaneous abscess drainage (PAD). Placement of the catheter for PAD can be guided either by ultrasound or computed tomography (CT) combined with fluoroscopy. Percutaneous abscess drainage may be a method particularly suited to cancer patients. In addition, PAD can be useful preoperatively to help obtain better outcomes in difficult surgical debridements or as a temporizing procedure until the patient is able to undergo surgical debridement. Previously published studies only peripherally address the success of PAD in patients with infected tumors [1, 8–11]. We have treated all four patients presenting with secondarily infected pelvic malignancies at Thomas Jefferson University Hospital by percutaneous abscess drainage. This paper is a review of our experience with these four patients.
366
0090-8258/96 $18.00 Copyright q 1996 by Academic Press, Inc. All rights of reproduction in any form reserved.
AID
Gyn 4392
/
6d0f$$$241
Case 1. This patient was admitted on May 26, 1994 and discharged on June 4, 1994. She was a 45-year-old black female with Stage IIIc ovarian cancer diagnosed and optimally resected in 1975. Pathology was consistent with cancer of low malignant potential with invasive implants. She received multiple chemotherapy courses in addition to whole abdominal and pelvic radiation. Progression of the disease was noted in May 1994 and she was started on a course of Taxol. After completing the first treatment, she presented with fever, diarrhea, increasing lower quadrant pain, abdominal distention, and neutropenia. An obstruction series and CT confirmed the presence of a 17 1 14 1 10-cm abscess (Fig. 1a). CT further revealed lymphadenopathy, peritoneal implants, and pleural metastasis. On the second hospital day, the patient underwent a combined CT/fluoroscopically guided percutaneous drainage of the mass with placement of a 12 French Cope Loop catheter. Approximately 600 cc of purulent fluid was initially obtained and cultures were positive for gram-negative gastrointestinal flora. The patient was started on appropriate antibiotics and defervesced 5 days following percutaneous drainage. She was discharged home with the catheter in place and was followed with biweekly catheter checks. The catheter was manipulated (either repositioned or downsized) according to the amount of drainage and the size of the remaining cavity was noted on crosssectional imaging. The catheter was removed following complete resolution of the cavity which occurred 2.5 months following initial drainage (Fig. 1b). The patient had no further recurrence of the abscess at 19.5 months and continues with palliative chemotherapy. Case 2. This patient was admitted on June 15, 1994 and discharged on July 15, 1994. She was a 64-year-old white female with a history of endometrial cancer diagnosed in October 1991. She was initially treated with whole pelvic radiation and chemotherapy (cisplatin, Adriamycin). Her past medical history is significant only for non-insulin-dependent diabetes mellitus (NIDDM). During her treatment, she developed an enterocutaneous fistula and underwent lap-
08-19-96 20:13:14
goal
AP: Gyn Onc
PAD FOR GYNECOLOGIC CANCER PATIENT
367
FIG. 1. (a) Left lower quadrant septated, cystic collection with mural nodularity in a patient with known ovarian carcinoma (Case 1). (b) Followup CT scan after drainage and catheter removal shows complete resolution of the collection.
arotomy and small bowel resection. Pathologic examination revealed adenocarcinoma within the fistula. On the eighth postoperative day, she became febrile and was placed on broad spectrum antibiotics. A CT scan performed that evening revealed a previously noted left lower quadrant necrotic tumor mass and a new 6- 1 10-cm right lower quadrant abscess. Combined US/fluoroscopically guided transabdominal drainage was performed the next day with drainage producing 1100 cc of purulent fluid through a 12 French Cope Loop catheter. Cultures revealed Streptococcus, Candida,
AID
Gyn 4392
/
6d0f$$$242
08-19-96 20:13:14
Klebsiella, and Pseudomonas growth. The patient defervesced but subsequently developed Candida albicans fungemia on Day 13. Despite optimal catheter position, she succumbed 17 days following drainage with the catheter in place. Her immediate cause of death was fungal septicemia. Case 3. This patient was admitted on November 20, 1992 and discharged on January 8, 1993. She was a 74-yearold female, admitted for suspected urosepsis after a 3-week history of weakness, confusion, and decreased oral intake. Her past medical history was significant for NIDDM. Gyne-
goal
AP: Gyn Onc
368
RAMONDETTA ET AL.
TABLE 1 Methods of Approach and Details of Drainage
Approach Catheter Guidance Defervescence Fistula Cultures Cancer Drainage Complications Diabetes Antibiotics Discharge status
Case 1
Case 2
Case 3
Case 4
Transabdominal 12 Fr Cope Loop US/fluoroscopy 5 days Gastrointestinal Klebsiella, E. coli Rec. ovarian 8 days None No Periprocedure Catheter in
Transabdominal 12 Fr Cope Loop US/fluoroscopy 2 days Gastrointestinal Klebsiella, E. coli Rec. endometrial 30 days None NIDDM Periprocedure Expired/catheter in
Transvaginal 10 Fr Cope Loop US/fluoroscopy AF Genitourinary Mixed gram/ Primary cervical 48 days None NIDDM Periprocedure Catheter out
Transabdominal 12 Fr Cope Loop US/fluoroscopy 2 days None B. fragilli Rec. ovarian 21 days None No Periprocedure Catheter in
cological exam then revealed advanced cervical cancer. A CT scan revealed a 9 1 5 1 9-cm complex fluid collection posterior to the bladder, probable bowel involvement as well as multiple hepatic lesions. A combined US/fluoroscopic transvaginal drainage was performed with placement of a 10 French Cope Loop catheter. Drainage initially produced 260 cc of purulent fluid. No fistula was noted on the radiographic studies. The patient deferred further treatment and was transferred for hospice care. The catheter was maintained with thrice weekly flushing. Removal of the catheter was performed 48 days after placement when resolution of the infection was documented by collapse of the abscess cavity on cross-sectional imaging studies. The patient died 5 months after transfer. Case 4. This patient was admitted on February 15, 1991 and was discharged on March 3, 1991. She was a 61-year-old female with Stage IIIc papillary serous ovarian carcinoma diagnosed and optimally resected in 1988. She initially received Cytoxan and cisplatin followed by 6 courses of ip platinum after a positive second-look operation. She had since undergone whole abdominal radiation therapy for persistent disease. In December 1990 she received 5-fluorouracil. Three months later she was admitted with fever, nausea, vomiting, and severe right lower-quadrant pain. CT scan revealed a right lower-quadrant 10 1 7.5 1 7-cm tumor mass adherent to bowel and suspicious for an abscess. Because no improvement followed a course of intravenous antibiotics, a percutaneous transabdominal approach with combined ultrasound and fluoroscopic guidance was used to place a 12 French Cope Loop catheter within the infected tumor. The patient’s pain resolved and she promptly defervesced 1 day following drainage. No small bowel or colonic fistula was demonstrated on radiographic studies. She was discharged with the drainage catheter in place and was instructed to flush the catheter thrice weekly. CT scan 2 months later demonstrated resolution of the abscess. The catheter was successfully removed with no further recurrence of infection (Table 1).
AID
Gyn 4392
/
6d0f$$$242
08-19-96 20:13:14
DISCUSSION
Infected pelvic malignancies can pose a management dilemma for physicians. The published reports that compare PAD with surgical drainage in patients with infected tumors is limited. The safety, cost-effectiveness, and successful drainage of benign lesions such as tubo-ovarian abscesses (TOAs) is well documented [3–5, 7, 8]. Choice of the guidance method depends on the radiologists’ comfort level and the abscess size and its location. The two methods presently used are ultrasound or CT with fluoroscopic guidance. Ultrasound has the disadvantage of comparatively poor bowel visibility, although the transvaginal approach may eliminate this disadvantage [7]. Ultrasound with fluoroscopic guidance was used successfully in the four procedures performed on patients with pelvic malignancies at Thomas Jefferson University Hospital. The transvaginal or transabdominal approach was individualized based on abscess location. Regardless of approach, complications reported following PAD include septicemia, hemorrhage, bowel laceration, and one reported case of necrotizing fasciitis. The complication rate reported varies from 2 to 10% [5, 6]. No complications of placement or drainage occurred in our four patients. A success rate between 77 and 93% has been reported for ultrasound-guided percutaneous drainage of TOAs. Successful drainage was based on avoidance of surgery and clinical improvement. Long-term avoidance of surgery has been approximately 80% [4, 7]. Success rates are higher for unilocular abscesses than for complex abscesses [5]. Successful drainage in patients with pelvic malignancies is difficult to define. Although success is typically defined as avoidance of surgery after drainage, existing malignancies make longterm avoidance of surgery less likely. Our experience suggests that successful drainage in patients with pelvic malignancies be defined by the resolution and avoidance of surgery for the acute infection. Mueller et al. [1] evaluated 16 patients undergoing percutaneous drainage of infected
goal
AP: Gyn Onc
369
PAD FOR GYNECOLOGIC CANCER PATIENT
abdominal tumors; 12 patients improved clinically post-catheter placement and four patients had no response. Of those four with no response, most required surgery, improved initially, but expired secondary to complications of the infection. Twelve of the 16 patients showing significant improvement had differing long-term results. Three patients ultimately required surgery for staging or debulking unrelated to the infection and six patients had catheter placement with resolution of the abscess. Catheter duration lasted from 5 weeks to 1 year. Three patients died with their catheters in place [1]. Typically, catheters for TOA drainage remain in place 1– 20 days, with an average of 6 days [7]. Removal is determined by clinical improvement and drainage volume. Maximum daily drainage prior to removal is approximately 10– 20 cc/day [3]. Malignancies present a complicated management picture. Significant necrotic tumor tissue exists as a nidus for recurrent infection. The preferred management for the four patients with gynecologic malignancy who underwent drainage at Thomas Jefferson University Hospital was an individualized evaluation of clinical improvement by members of the Cardiovascular Interventional Radiology Division correlated with radiologic evaluation. Patient selection for PAD, regardless of the presence of a malignancy, should depend upon hemodynamic stability. Septicemia and the risk of hemodynamic instability should be addressed quickly with broad spectrum antibiotics and surgical debridement [2]. Contraindications to PAD are severe uncorrected coagulopathy and abscess inaccessibility most often due to surrounding bowel [3, 5]. Preevaluation for a gastrointestinal fistula is not necessary and does not preclude successful PAD. However, drainage in the presence of a fistula may be prolonged and may necessitate intravenous hyperalimentation for successful closure. In addition, resolution of the infection is necessary for closure of the fistula [3]. Surgical debridement has been the principle treatment for abscesses in oncologic patients. However, surgery in cancer patients is often associated with a higher postoperative morbidity because of poor tissue healing capacity. Patients with terminal illnesses may benefit most from nonoperative therapy, early discharge, avoidance of general anesthesia, or early return to chemotherapy treatment. Percutaneous drainage of infected malignancies offers an alternative to surgical drainage and debridement. We have found no specific contraindications for PAD in patients with pelvic malignancies. Although one of the patients we are reporting died with the catheter in place, we do not feel this was a direct result of the choice of PAD for treatment.
AID
Gyn 4392
/
6d0f$$$242
08-19-96 20:13:14
Patients with infected pelvic malignancies should be managed individually. Treatment may be based on the understanding that patients with newly diagnosed malignancies have healthy tissue and good healing potential, and may best benefit from surgical debridement, debulking, and staging. Patients with recurrent and resistant cancers may be best treated with minimal invasive interventions. Case 2 was a patient who presented with advanced disease and metastatic complications. Although she died with the catheter in place, minimizing invasive intervention is often important in order to preserve the quality of remaining life. The method of catheter placement, duration of drainage, and the need for surgical treatment appear to be equally applicable to treatment of pelvic infections in patients with benign or malignant disease. Our experience with percutaneous abscess drainage has been without complications directly resulting from the procedure and has offered the gynecologic cancer patient an opportunity for a successful and expedient clinical response. REFERENCES 1. Mueller, P. R., White, E. M., and Glass-Royal, M. Infected abdominal tumors: Percutaneous catheter drainage, Radiology 173, 627–629 (1989). 2. Longo, W. E., Milsom, J. W., and Lavery, I. C. Pelvic abscess after colon and rectal surgery—What is optimal management? Dis. Colon Rectum 36, 936–941 (1993). 3. Gazelle, G. S., and Mueller, P. R. Abdominal abscess: Imaging and intervention, Radiol. Clin. N. Am. 32, 913–932 (1994). 4. Feld, R., Eschelman, D. J., Sagerman, J. E., and Segal, S. Treatment of pelvic abscesses and other fluid collections: Efficacy of transvaginal sonographically guided aspiration and drainage, Am. J. Roentgenol. 163, 1141–1145 (1994). 5. Fabiszewski, N. L., Sumkin, J. H., and Johns, C. M. Contemporary radiologic percutaneous abscess drainage in the pelvis, Clin. Obstet. Gynecol. 36, 445–456 (1993). 6. Holly, D. T., McGrath, P. C., and Sloan, D. A. Necrotizing fasciitis as a complication of percutaneous catheter drainage of an intra-abdominal abscess, Am. Surg. 60, 197–199 (1994). 7. Casola, G., vanSonnenberg, E., D’Agostino, H. B., Harker, C. P., Varney, R. R., and Smith, D. Percutaneous drainage of tubo-ovarian abscesses, Radiology 182, 399–402 (1992). 8. vanSonnenberg, E., D’Agostino, H. B., Casola, G., Goodacre, B. W., Sanchez, R. B., and Taylor, B. US-guided transvaginal drainage of pelvic abscesses and fluid collections, Radiology 181, 53–56 (1991). 9. Marcus, S. G., Walsh, T. J., Pizzo, P. A., and Danforth, D. N. Hepatic abscess in cancer patients, Arch. Surg. 128, 1358–1364 (1993). 10. Mann, W. J., Calayag, P. T., Muffoletto, J. P., Ross, F., Chalas, E., and Deitch, J. Management of gastric outlet obstruction caused by ovarian cancer, Gynecol. Oncol. 40, 277–279 (1991). 11. Segreti, E. M., Munkarah, A., and Levenback, C. Successful percutaneous drainage of gluteal pyomyositis occurring after intra-arterial chemotherapy and pelvic irradiation, Gynecol. Oncol. 53, 376–379 (1994).
goal
AP: Gyn Onc