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The role of invasive radiology in cancer management: Vascular approaches to the management of cancer
ABSTRACTS successful than barium. Some authors quote lower screening times with air, a n d maintain that dose to the patient must therefore be lower. In order to evaluate any difference in dose between the two agents, a retrospective, comparative study of 75 intussusception reductions, using air (44 patients) and barium (31 patients) was undertaken. This confirmed all of the anticipated advantages of air. In 61 of these patients, doses were recorded. Although a reduction of 18% in screening time and 34% in dose was measured when using air, these differences were not significant. The reasons for this are discussed. The study illustrated the importance of overall dose reduction techniques in paediatric radiology. It does not find any significant decrease in dose when using air as the reduction agent. Employing a 4point plan could result in dose reduction of up to 60%, regardless o f the choice of reduction agent.
421
such as, for example, flushing and diarrhoea in patients with carcinoid hepatic metastases, or to treat complications of the neoplasm such as haemorrhage; (ii) The administration of local chemotherapy into, for example, the hepatic artery or portal vein i n patients with hepatocellular carcinoma; or (iii) A combination of (i) a n d (ii). The above techniques and their use in the m a n a g e m e n t of particular tumours will be discussed.
BALLOON DILATATION OF THE PHARYNX AND NEOPHARYNX C. D. G E O R G E , J. ROWE-JONES*, V. M O O R E - G I L L O N * and A. G R U N D Y
T H E R O L E O F I N T E R V E N T I O N A L R A D I O L O G Y IN HEPATOBILIARY MALIGNANCY A. A D A M
Departments of Radiology and *ENT Surgery, St George~ Hospital and Medical School, London
Department of Radiological Sciences, UMDS of Guy's and St Thomas's Schools, Guy's Hospital, London
Balloon dilatation is widely used in the management of oesophageal strictures but has not been evaluated in the management of strictures of the pharynx and neopharynx. This study describes the technique of balloon dilatation in the pharynx and neopharynx and assesses its role in the management of strictures of this region. Over 6 years 13 patients, with a m e a n age of 65.5 years, had balloon dilatation of pharyngeal or neopharyngeal strictures. In three the primary pathology was benign and in 10 it was malignant. A total of 57 dilatations were performed with two complications: a perforation and an aspiration. In three patients all symptoms were abolished after one dilatation. Seven patients were successfully managed on regular dilatations, many being elderly and unfit for the general anaesthetic necessary for rigid oesophagoscopy and bouginage. Two patients had a good initial response to dilatation but rapidly failed to respond and both required surgical excision of their strictures. One patient had no relief of symptoms following dilatation. Pharyngeal and neopharyngeal strictures are difficult to manage especially in the elderly and in patients with concurrent medical problems which preclude general anaesthesia. In such cases balloon dilatation is a valuable therapeutic option which can rapidly restore normal swallowing and m a y be repeated if symptoms recur.
Interventional radiological techniques can make a significant contribution to the management of unresectable hepatobiliary neoplasms. Imaging guided biopsies are often useful in the planning of treatment. In patients with uncorrectable coagulation abnormalities it m a y be possible to perform a transjugular biopsy or a percutaneous biopsy followed by embolization of the tract. Occasionally, when t u m o u r s invade the inferior vena cava, the mass can be biopsied using a transfemoral vein approach. Small hepatocellular carcinomas m a y be treated by direct percutaneous injection of alcohol into the tumour. When treating patients with malignant obstructive jaundice indwelling stents are preferable to permanent internal/external drainage. In recent years plastic stents have been replaced by large-calibre, selfexpandable metallic endoprostheses. These can be delivered over small catheters, minimizing trauma to the liver, but expand to achieve a large lumen which provides excellent drainage and minimizes the rate of occlusion due to bile encrustation. In patients with intractable pain due to malignant invasion o f the retroperitoneum by carcinoma of the pancreas it m a y be possible to provide excellent palliation by ablating the coeliac plexus with alcohol using a CT-guided method.
CAN I N T E R V E N T I O N A L R A D I O L O G Y H E L P US IN T H E M A N A G E M E N T O F C A N C E R PATIENTS: R E N A L AND URINARY TRACT R. D. E D W A R D S
Department of Radiology, Western Infirmary, Glasgow Interventional radiology has a considerable role to play in the management of renal and urinary tract malignancy. Obstructive uropathy is the commonest clinical problem and the role of percutaneous nephrostomy and ureteric stenting, in the context of malignant disease, will be discussed. Technical advances in catheter and stent materials, such as hydrophilic coatings m a y facilitate insertion and reduce encrustation, but stent replacement is usually necessary within 6 months. This can be performed radiologically on an outpatient basis using local anaesthesia. The role of percutaneous ureteric occlusion, in the m a n a g e m e n t of urinary fistulae, will be discussed and the technique described. The indications and limitations of palliative embolization of renal and bladder tumours, will also be reviewed. T H E R O L E OF INVASIVE R A D I O L O G Y IN C A N C E R MANAGEMENT: VASCULAR APPROACHES TO THE MANAGEMENT OF CANCER J. E. J A C K S O N
Department of Diagnostic Radiology, Hammersmith Hospital, London Angiographic intervention in the m a n a g e m e n t of the patient with cancer can be broadly divided into two categories: firstly it m a y be used for diagnosis and defining the extent of disease. Secondly it m a y be used for therapy, either alone or as an adjunct to other medical or surgical treatment. Therapeutic angiographic techniques m a y involve: (i) The deliberate occlusion of an abdominal vascular bed-embolization in order to reduce t u m o u r bulk and relieve symptoms
INITIAL CLINICAL E X P E R I E N C E W I T H G A D O L I N I U M BOPTA/DIMEG: A NEW HEPATOBILIARY SPECIFIC CONTRAST AGENT FOR MAGNETIC RESONANCE IMAGING (MRI) O F T H E LIVER M. W. B O U R N E , C. E. W I L L I A M S , P. C. R O W L A N D S and G. H. W H I T E H O U S E
Department of Radiodiagnosis, University of Liverpool, Royal Liverpool University Hospital, Liverpool Extra-cellular agents such as Gadolinium D T P A (Magnevist, Schering AG), are initially distributed throughout the intra-vascular compartment and then rapidly diffuse throughout the interstitial extravascular space in a manner analogous to iodinated contrast agents. As a result, lesion-to-liver contrast is reduced. Paramagnetic contrast agents that are taken up preferentially by hepatocytes, thus improving lesion to liver contrast, are therefore likely to prove useful in the detection of hepatic mass lesions. This is achieved in the case of Gadolinium BOPTA/ D I M E G by selective hepato-cellular uptake and by concentration and secretion in the bile. Twenty patients (aged 18-65 years) who required magnetic resonance imaging of the liver for either diagnostic purposes or pre-operative evaluation were entered into an open label Phase 2 trial to establish safety and efficacy. Ischaemic heart disease, renal impairment, severe hepatic dysfunction and the routine M R I contra-indications were applied as exclusion criteria. Patients were randomized to receive either 0.05 mmol/kg or 0.1 mmol/kg body weight of Gadolinium B O P T A / D I M E G as an intra-venous infusion at 10 ml per min. Precontrast T 1 W (TR 300-400, T E 12 20, 4NEX, 256 by 192 Matrix) and T 2 W (TR 2000, TE 30/80, 2NEX, 256 by 128 Matrix) acquisitions were obtained. Post-contrast T 1 W acquisitions were obtained at 0, 10, 20, 30, 40, 60 and 120 min and a single post-contrast T 2 W acquisition was obtained at 120 min. All post-contrast acquisitions were acquired using identical parameters and spatial locations to the pre-contrast acquisitions. Clinical adverse events were monitored by history, examination, pulse BP and ECG. Biochemical adverse events were monitored by exhaustive haematological, biochemical and urine analyses. A quantitative and qualitative assessment of the images and safety profile of this agent will be presented, based on the results of this 20 patient Phase 2 trial.
421
such as, for example, flushing and diarrhoea in patients with carcinoid hepatic metastases, or to treat complications of the neoplasm such as haemorrhage; (ii) The administration of local chemotherapy into, for example, the hepatic artery or portal vein i n patients with hepatocellular carcinoma; or (iii) A combination of (i) a n d (ii). The above techniques and their use in the m a n a g e m e n t of particular tumours will be discussed.
BALLOON DILATATION OF THE PHARYNX AND NEOPHARYNX C. D. G E O R G E , J. ROWE-JONES*, V. M O O R E - G I L L O N * and A. G R U N D Y
T H E R O L E O F I N T E R V E N T I O N A L R A D I O L O G Y IN HEPATOBILIARY MALIGNANCY A. A D A M
Departments of Radiology and *ENT Surgery, St George~ Hospital and Medical School, London
Department of Radiological Sciences, UMDS of Guy's and St Thomas's Schools, Guy's Hospital, London
Balloon dilatation is widely used in the management of oesophageal strictures but has not been evaluated in the management of strictures of the pharynx and neopharynx. This study describes the technique of balloon dilatation in the pharynx and neopharynx and assesses its role in the management of strictures of this region. Over 6 years 13 patients, with a m e a n age of 65.5 years, had balloon dilatation of pharyngeal or neopharyngeal strictures. In three the primary pathology was benign and in 10 it was malignant. A total of 57 dilatations were performed with two complications: a perforation and an aspiration. In three patients all symptoms were abolished after one dilatation. Seven patients were successfully managed on regular dilatations, many being elderly and unfit for the general anaesthetic necessary for rigid oesophagoscopy and bouginage. Two patients had a good initial response to dilatation but rapidly failed to respond and both required surgical excision of their strictures. One patient had no relief of symptoms following dilatation. Pharyngeal and neopharyngeal strictures are difficult to manage especially in the elderly and in patients with concurrent medical problems which preclude general anaesthesia. In such cases balloon dilatation is a valuable therapeutic option which can rapidly restore normal swallowing and m a y be repeated if symptoms recur.
Interventional radiological techniques can make a significant contribution to the management of unresectable hepatobiliary neoplasms. Imaging guided biopsies are often useful in the planning of treatment. In patients with uncorrectable coagulation abnormalities it m a y be possible to perform a transjugular biopsy or a percutaneous biopsy followed by embolization of the tract. Occasionally, when t u m o u r s invade the inferior vena cava, the mass can be biopsied using a transfemoral vein approach. Small hepatocellular carcinomas m a y be treated by direct percutaneous injection of alcohol into the tumour. When treating patients with malignant obstructive jaundice indwelling stents are preferable to permanent internal/external drainage. In recent years plastic stents have been replaced by large-calibre, selfexpandable metallic endoprostheses. These can be delivered over small catheters, minimizing trauma to the liver, but expand to achieve a large lumen which provides excellent drainage and minimizes the rate of occlusion due to bile encrustation. In patients with intractable pain due to malignant invasion o f the retroperitoneum by carcinoma of the pancreas it m a y be possible to provide excellent palliation by ablating the coeliac plexus with alcohol using a CT-guided method.
CAN I N T E R V E N T I O N A L R A D I O L O G Y H E L P US IN T H E M A N A G E M E N T O F C A N C E R PATIENTS: R E N A L AND URINARY TRACT R. D. E D W A R D S
Department of Radiology, Western Infirmary, Glasgow Interventional radiology has a considerable role to play in the management of renal and urinary tract malignancy. Obstructive uropathy is the commonest clinical problem and the role of percutaneous nephrostomy and ureteric stenting, in the context of malignant disease, will be discussed. Technical advances in catheter and stent materials, such as hydrophilic coatings m a y facilitate insertion and reduce encrustation, but stent replacement is usually necessary within 6 months. This can be performed radiologically on an outpatient basis using local anaesthesia. The role of percutaneous ureteric occlusion, in the m a n a g e m e n t of urinary fistulae, will be discussed and the technique described. The indications and limitations of palliative embolization of renal and bladder tumours, will also be reviewed. T H E R O L E OF INVASIVE R A D I O L O G Y IN C A N C E R MANAGEMENT: VASCULAR APPROACHES TO THE MANAGEMENT OF CANCER J. E. J A C K S O N
Department of Diagnostic Radiology, Hammersmith Hospital, London Angiographic intervention in the m a n a g e m e n t of the patient with cancer can be broadly divided into two categories: firstly it m a y be used for diagnosis and defining the extent of disease. Secondly it m a y be used for therapy, either alone or as an adjunct to other medical or surgical treatment. Therapeutic angiographic techniques m a y involve: (i) The deliberate occlusion of an abdominal vascular bed-embolization in order to reduce t u m o u r bulk and relieve symptoms
INITIAL CLINICAL E X P E R I E N C E W I T H G A D O L I N I U M BOPTA/DIMEG: A NEW HEPATOBILIARY SPECIFIC CONTRAST AGENT FOR MAGNETIC RESONANCE IMAGING (MRI) O F T H E LIVER M. W. B O U R N E , C. E. W I L L I A M S , P. C. R O W L A N D S and G. H. W H I T E H O U S E
Department of Radiodiagnosis, University of Liverpool, Royal Liverpool University Hospital, Liverpool Extra-cellular agents such as Gadolinium D T P A (Magnevist, Schering AG), are initially distributed throughout the intra-vascular compartment and then rapidly diffuse throughout the interstitial extravascular space in a manner analogous to iodinated contrast agents. As a result, lesion-to-liver contrast is reduced. Paramagnetic contrast agents that are taken up preferentially by hepatocytes, thus improving lesion to liver contrast, are therefore likely to prove useful in the detection of hepatic mass lesions. This is achieved in the case of Gadolinium BOPTA/ D I M E G by selective hepato-cellular uptake and by concentration and secretion in the bile. Twenty patients (aged 18-65 years) who required magnetic resonance imaging of the liver for either diagnostic purposes or pre-operative evaluation were entered into an open label Phase 2 trial to establish safety and efficacy. Ischaemic heart disease, renal impairment, severe hepatic dysfunction and the routine M R I contra-indications were applied as exclusion criteria. Patients were randomized to receive either 0.05 mmol/kg or 0.1 mmol/kg body weight of Gadolinium B O P T A / D I M E G as an intra-venous infusion at 10 ml per min. Precontrast T 1 W (TR 300-400, T E 12 20, 4NEX, 256 by 192 Matrix) and T 2 W (TR 2000, TE 30/80, 2NEX, 256 by 128 Matrix) acquisitions were obtained. Post-contrast T 1 W acquisitions were obtained at 0, 10, 20, 30, 40, 60 and 120 min and a single post-contrast T 2 W acquisition was obtained at 120 min. All post-contrast acquisitions were acquired using identical parameters and spatial locations to the pre-contrast acquisitions. Clinical adverse events were monitored by history, examination, pulse BP and ECG. Biochemical adverse events were monitored by exhaustive haematological, biochemical and urine analyses. A quantitative and qualitative assessment of the images and safety profile of this agent will be presented, based on the results of this 20 patient Phase 2 trial.