| Article Access Statistics|
| Viewed||442 |
| Printed||13 |
| Emailed||0 |
| PDF Downloaded||25 |
| Comments ||[Add] |
Click on image for details.
|Year : 2019 | Volume
| Issue : 3 | Page : 462-467
Complementary role of intervention radiology in palliative care in oncology setting
Ekta Dhamija1, Ashwin Deshmukh1, Pankaj Meena1, Mukesh Kumar1, Sushma Bhatnagar2, Sanjay Thulkar1
1 Department of Radiodiagnosis, All India Institute of Medical Sciences, New Delhi, India
2 Department of Onco-Anaesthesia and Palliative Medicine, All India Institute of Medical Sciences, New Delhi, India
|Date of Web Publication||17-Jul-2019|
Dr. Ekta Dhamija
Room Number 137, First Floor, Department of Radiodiagnosis, Dr. BR Ambedkar Institute Rotary Cancer Hospital, All India Institute of Medical Sciences, New Delhi - 110 029
Source of Support: None, Conflict of Interest: None
Owing to advances in treatment of cancer, there has been increase in life expectancy. Palliative care aims at improving quality of life of patients suffering from malignancy and is now recognized as a separate subspecialty. Management of cancer patients needs a multidisciplinary approach, and radiology has a key role to play at every step of it. Interventional radiology has broadened its scope immensely over the last decade with development of newer and less invasive applications useful in oncology and palliative care. The role of interventional radiologists begins from obtaining tissue for histopathological examination and extends to controlling disease spread with ablation or chemoembolization, to managing the tumor-related complications and relieving stressful symptoms such as dyspnea and pain. This article aims to review the interventional radiologist's arsenal in managing patients with malignancies with a special emphasis on palliative care, providing a more holistic approach in improving the quality of life of cancer patients.
Keywords: Fluid drainage, intervention radiology, neurolytic blocks, palliative care
|How to cite this article:|
Dhamija E, Deshmukh A, Meena P, Kumar M, Bhatnagar S, Thulkar S. Complementary role of intervention radiology in palliative care in oncology setting. Indian J Palliat Care 2019;25:462-7
|How to cite this URL:|
Dhamija E, Deshmukh A, Meena P, Kumar M, Bhatnagar S, Thulkar S. Complementary role of intervention radiology in palliative care in oncology setting. Indian J Palliat Care [serial online] 2019 [cited 2019 Oct 22];25:462-7. Available from: http://www.jpalliativecare.com/text.asp?2019/25/3/462/262851
| » Introduction|| |
Imaging is an integral and indispensible part of workup of any cancer patient. It encompasses diagnosis, staging, tissue sampling, treatment strategies, and follow-up for response assessment. A component of imaging which extends beyond routine cross-sectional imaging done for staging and response assessment is interventional radiology (IR). The role of latter is crucial and much needed at multiple stages of patient management starting from image guide tissue sampling to executing interventional procedures with curative or palliative intent. Likewise, palliative care is another important front in oncology. It aims at improving quality of life of patients not only physically but also spiritually and emotionally. Both intervention radiology and palliative care work hand-in-hand in more fronts than looked upon commonly.
This article aims at elaborating the scope of IR in oncology and palliative care [Table 1].
| » Management of Malignancy or Metastases|| |
IR-mediated tumor ablation causes tumor necrosis by deposition of energy in the tissue by means of radiofrequency ablation (RFA), microwave, ultrasound, laser-induced thermotherapy, cryotherapy, and irreversible electroporation. RFA is considered to be safe, with a mortality rate of 0.3% and a major complication rate of 2.2%. In RFA, electromagnetic energy is administered in a radiofrequency range to the target tissue causing tissue temperature to rise above 60°C with resultant thermal damage and cell death. RFA has gained popularity and is now considered the treatment modality of choice in appropriate liver tumors (hepatocellular carcinoma [HCC]). Few authors have suggested RFA as first treatment option in single liver lesions that are 2 cm or smaller in size., RFA has also been successfully used in unresectable and potentially resectable liver metastases from colorectal cancer, [Figure 1]. In palliative care, RFA is used for treatment of painful bone metastases refractory to palliative radiotherapy.
|Figure 1: Radiofrequency ablation of metastatic lesion in liver from colorectal cancer: (a) Axial CT and volume rendered coronal reformatted image (b) showing the course of radiofrequency ablation probe and its expanded prongs in situ|
Click here to view
Transarterial chemoembolization (TACE) is used in the treatment of HCCs, where selective hepatic artery cannulation is done and a chemotherapy agent is directly infused in tumor bed followed by an embolic agent that occludes the flow through the catheterized artery. Ischemia produced by the embolic agent makes the tumor cells susceptible to damage by the cytotoxic agents. The advantage of TACE over systemic chemotherapy is that delivery of the chemotherapeutic agent is targeted at the lesion allowing a higher local concentration of the agent and lower systemic doses. The liver tolerates TACE procedure due to its dual blood supply. TACE is the standard treatment in Barcelona clinic liver cancer stage B (intermediate HCC) tumors and is performed with palliative intent in larger unresectable tumors. Overall survival rates for the combination therapy (ablation and chemoembolization) are found to be higher.
| » Management of Complications|| |
Drainage of fluid
Fluid accumulation in pleural, peritoneal, or pericardial cavity can lead to significant deterioration in patient's general condition. Malignancies are the third most common cause of pleural effusion and the second most common cause of ascites after cirrhosis., These are among the most debilitating complications of malignancy leading to worsening of quality of life. Drainage of these fluid collections hence becomes important whether it is one-time aspiration or placement of percutaneous catheter.
Malignant pleural effusions are significant cause of morbidity in the oncology patient, presenting with dyspnea, cough, and chest pain. Prevention of recurrent pleural effusions can be achieved by chemical pleurodesis. Before pleurodesis, large effusions require drainage to optimize success rates of pleurodesis and to prevent accumulation of therapeutic agents within the pleural space. Compared to pleurodesis, placement of tunneled pleural catheters has been shown to be feasible and shown to have lower morbidity, lower rates of hospital stay, reduced rates of repeat intervention, and reduction in dyspnea in patients with failed pleurodesis [Figure 2].
|Figure 2: Drainage of pleural effusion: (a) Ultrasound screen and convex probe wrapped and duly covered using aseptic precautions. (b) Ultrasonography image showing echogenic needle within the pleural fluid (arrow). Subsequently deployed pigtail catheter is see in situ as it forms loop (arrow in c). The patient sits comfortably after pigtail insertion till the catheter is sutured to skin (d)|
Click here to view
Tunneled peritoneal catheters for patients with peritoneal carcinomatosis and refractory ascites have been shown to be safe, cost-effective, and well-tolerated with close to 100% technical success rate. These catheters may also be used to instill chemotherapy without an increase in the rate of infections.
Peritoneovenous shunt (PVS) transfers fluid from the peritoneal cavity into the central venous system through the subclavian or the jugular vein. PVS placement offers several advantages over tunneled catheters. There is no loss of nutrients through drainage of the fluid. Patients may experience a better quality of life as there is no external tube extending out of the patient. It is especially beneficial in chylous ascites following retroperitoneal lymph node dissection, as it may provide complete resolution of ascites.,
Percutaneous interventions in malignant pericardial infusions include pericardiocentesis and catheter drainage, pericardial instillation of sclerosing agents, and placement of a pericardial balloon catheter.
Management of obstructions (hepatobiliary, gastrointestinal, and urinary)
Majority of the patients presenting with malignant biliary obstruction have an underlying carcinoma of the pancreas or gallbladder. Metastatic nodes at hepatic hilar or peripancreatic location may also cause extrinsic compression of proximal part of common bile duct with resultant biliary obstruction. Patients suffer from primary malignancy as well as the severe pruritus caused due to obstruction of the route of biliary drainage. This can be relieved with percutaneous biliary interventions which are preferred in high biliary obstruction whereas endoscopic techniques are preferred in lower biliary duct obstructions. Percutaneous techniques may be indicated in low biliary obstruction when the patient has undergone pancreaticoduodenectomy and in whom endoscopic interventions may be technically challenging. Percutaneous transhepatic biliary drainage involves selective cannulation of the biliary tree with catheter manipulation followed by placement of a catheter or stent to facilitate internal or external drainage of bile and cause slow biliary decompression [Figure 3]. Complications of biliary drainage include cholangitis, hemorrhage, and pericatheter leakage. The likelihood of developing an infection increases with increasing duration of external drain. The ultimate goal of biliary interventions is to provide an internal drainage by stenting, for which self-expandable metallic stents are used.
|Figure 3: Percutaneous transhepatic biliary drainage: (a) Fluoroscopic image showing dilated biliary ducts (black arrow) opacified by iodinated contrast injected through the catheter in situ(white arrow). (b) Ring biliary catheter (white arrow) placed with tip in duodenum (black arrow) enabling internal drainage of the bile|
Click here to view
Patients with head, neck, or esophageal malignant lesions are frequently unable to tolerate adequate oral intake due to luminal obstruction or swallow impairment and require nutritional support, often by gastrostomy or gastrojejunostomy. Percutaneous image-guided placement of feeding tubes has demonstrated higher technical success rates and is considered safer than endoscopic or surgical placement. Early complications of gastrostomy insertion are infection and mild discomfort on feeding. Tube dislodgement is relatively uncommon; however, if the tract is established for more than 2 weeks, it is frequently possible to access the tract and reinsert the tube without the need for repuncture of the stomach. Nasojejunal tubes can be placed under fluoroscopic guidance and have shown to have an advantage over nasogastric tubes in ill patients.
Decompressive cecostomy can be done under fluoroscopic guidance in cancer patients with large bowel obstruction. It prevents perforation and also provides symptomatic relief. They may also be used as a bridge to more definitive treatment. Colonic stent placement may be done under fluoroscopic guidance alone in patients with unresectable colonic carcinoma or as a bridge to elective surgery with favorable results.
The urinary tract obstruction occurs most commonly at the level of ureters due to pelvic or retroperitoneal malignancies. Image-guided urinary decompression, by means of percutaneous nephrostomy (PCN), is indicated in cases of deteriorating renal function or electrolyte disturbances such as hyperkalemia and metabolic acidosis, pyonephrosis. Image guidance may be provided with fluoroscopy, ultrasound, or often a combination of both modalities. In a study by Wong et al., with malignant ureteral obstruction (bilateral in 68% cases), initial management with PCN achieved successful decompression of the system in 94% of cases. Degree of dilatation of collecting system and the patient's body habitus was the main determinant of the rate of successful completion of PCN in oncology.
Embolization to achieve hemostasis
Approximately 10% patients with lung cancer may have massive hemoptysis. Bronchial artery embolization can be beneficial in these patients. Similarly, embolization can be successfully used in ruptured HCCs, retroperitoneal tumors such as angiomyolipomas and renal cell carcinomas, and severe hemorrhagic cystitis (cyclophosphamide, RT induced) refractory to conservative management.,
Pain is a significant source of cancer-related morbidity, particularly in advanced cancer, in which inadequately controlled pain can have a profound impact on the quality of life. Strong analgesics like opiates with considerable side effect profile remain the mainstay of treatment and are used to manage pain in majority of the cancer patients according to the principles of the World Health Organization analgesic ladder.,, Neuropathic pain associated with upper abdominal visceral tumors is frequently poorly responsive to analgesic therapy. Celiac ganglion neurolysis and nerve block can achieve successful palliation of pain in the majority of patients, who are refractory to analgesics with pancreatic, gastric, esophageal, and biliary malignancies. It can be performed using fluoroscopic guidance, ultrasonography (USG), or computed tomography (CT) guidance depending on operator's experience. Where fluoroscopy is based on anatomical landmarks, USG provides real-time visualization of needle and CT confirms the location of needle tip in relation to surrounding structures [Figure 4]. Reported minor complications include transient diarrhea in 73% and orthostatic hypotension in 12%. Similarly, peripheral nerve blocks can be used to provide pain relief in various other malignancies.,,,,
|Figure 4: Computed tomography-guided celiac plexus neurolysis: Needle is placed at the level of celiac axis (arrow) under computed tomography guidance. Uniform spread of contrast-mixed neurolytic agent is seen (arrowheads)|
Click here to view
Analgesics, bisphosphonates, chemotherapy, and radiation have been traditionally used to manage metastatic bone pain. Radiotherapy provides partial pain relief in 70% patients while complete pain relief may be seen in up to one-third of patients., Up to one-third of patients may have refractory pain. According to the latest NCCN guidelines concerning adult cancer pain (v2, 2016), percutaneous ablation for metastatic bone pain may be considered when pharmacologic therapy is inadequate and radiation therapy is contraindicated or not desired by the patient in cases without an oncologic emergency (e.g., pathologic fracture or epidural disease).
Percutaneous cementoplasty provides not only stability but also analgesic effect in painful lytic or mixed bone metastases. It has been reported to provide palliation in extraspinal lytic bone metastases. High-intensity focused ultrasound has been shown to be safe and effective for primary pain palliation and local tumor control.
| » Miscellaneous|| |
Central venous access and other venous interventions
Cancer patients often require long-term venous access for administration of drugs as well as repeated blood sampling. Permanent venous access is most commonly obtained through the internal jugular vein. “Landmark method” is used to be employed traditionally to locate and puncture the venous sites. Blind or surface marking-guided central venous catheter (CVC) insertions are associated with number of potential complications including pneumothorax, inadvertent injury to arteries, and nerves. USG-guided CVC access has been proven to not only reduce the number of attempts but also reduce arterial puncture and bloodstream infections. There is 4–6 times increased risk of thrombosis in oncology patients as compared with the general population, which is further increased by placement of a CVC., Peripherally inserted central catheters (PICC) were introduced with the presumed benefit in terms of decreasing these complications. Typically, the cephalic or basilic vein is used as the access site, and the PICC line is advanced into the central veins with its tip lying in the superior vena cava (SVC) or at the cavoatrial junction under US and fluoroscopic guidance [Figure 5].
|Figure 5: Peripherally inserted central venous catheter: (a) Venous puncture under ultrasonography guidance is performed followed by establishing access using guidewire (arrow in b). (c) Central venous catheter is placed over the guidewire and position confirmed on radiograph or fluoroscopy spot image (arrows, d)|
Click here to view
Malignancy accounts for up to 70% cases of SVC syndrome. Other causes include thrombosis from CVCs and pacemaker leads., Although no scientific evidence exists, endovascular treatment has been proposed as a first-line treatment for malignant SVC obstruction., Similarly, obstruction of inferior vena cava (IVC) may result in pedal edema, venous ulcers, renal vein thrombosis, and/or renal insufficiency (when IVC obstruction is at or above the level of renal veins) and Budd–Chiari syndrome (when IVC obstruction is at the level of hepatic veins)., IVC occlusion can be treated successfully using endovascular techniques, and a study by Razavi et al. has reported to have a primary patency rate of 80% at 19 months.,, The generally accepted indications of IVC filter placement include failure, contraindication, and complications of anticoagulation. Cancer patients are at an increased risk of venous thrombosis as well as bleeding when on anticoagulation. Placement of IVC filters is an option in these patients for preventing pulmonary embolism.
| » Conclusion|| |
With the expanding application of minimally invasive techniques to the investigation and management of malignancies, the interventional radiologist is assuming a more prominent role in the multidisciplinary team that cares for the patient with cancer. The use of IR techniques in oncology patients should be evidence based to ensure optimal outcome and minimize potential complications.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| » References|| |
Livraghi T, Solbiati L, Meloni MF, Gazelle GS, Halpern EF, Goldberg SN. Treatment of focal liver tumors with percutaneous radio-frequency ablation: Complications encountered in a multicenter study. Radiology 2003;226:441-51.
de Meijer VE, Verhoef C, Kuiper JW, Alwayn IP, Kazemier G, Ijzermans JN, et al.
Radiofrequency ablation in patients with primary and secondary hepatic malignancies. J Gastrointest Surg 2006;10:960-73.
Choi D, Lim HK, Rhim H, Kim YS, Lee WJ, Paik SW, et al.
Percutaneous radiofrequency ablation for early-stage hepatocellular carcinoma as a first-line treatment: Long-term results and prognostic factors in a large single-institution series. Eur Radiol 2007;17:684-92.
Livraghi T, Meloni F, Di Stasi M, Rolle E, Solbiati L, Tinelli C, et al.
Sustained complete response and complications rates after radiofrequency ablation of very early hepatocellular carcinoma in cirrhosis: Is resection still the treatment of choice? Hepatology 2008;47:82-9.
Vogl TJ, Farshid P, Naguib NN, Darvishi A, Bazrafshan B, Mbalisike E, et al.
Thermal ablation of liver metastases from colorectal cancer: Radiofrequency, microwave and laser ablation therapies. Radiol Med 2014;119:451-61.
Worni M, Shah KN, Clary BM. Colorectal cancer with potentially resectable hepatic metastases: Optimizing treatment. Curr Oncol Rep 2014;16:407.
Thanos L, Mylona S, Galani P, Tzavoulis D, Kalioras V, Tanteles S, et al.
Radiofrequency ablation of osseous metastases for the palliation of pain. Skeletal Radiol 2008;37:189-94.
Tanaka M, Ando E, Simose S, Hori M, Kuraoka K, Ohno M, et al.
Radiofrequency ablation combined with transarterial chemoembolization for intermediate hepatocellular carcinoma. Hepatol Res 2014;44:194-200.
Light RW. Clinical practice. Pleural effusion. N
Engl J Med 2002;346:1971-7.
Runyon BA. Care of patients with ascites. N
Engl J Med 1994;330:337-42.
Dhamija E, Thulkar S, Bhatnagar S. Utility and potential of bedside ultrasound in palliative care. Indian J Palliat Care 2015;21:132-6.
] [Full text]
Freeman RK, Ascioti AJ, Mahidhara RS. A propensity-matched comparison of pleurodesis or tunneled pleural catheter in patients undergoing diagnostic thoracoscopy for malignancy. Ann Thorac Surg 2013;96:259-63: discussion 263-4.
Hunt BM, Farivar AS, Vallières E, Louie BE, Aye RW, Flores EE, et al.
Thoracoscopic talc versus tunneled pleural catheters for palliation of malignant pleural effusions. Ann Thorac Surg 2012;94:1053-7.
Thornton RH, Miller Z, Covey AM, Brody L, Sofocleous CT, Solomon SB, et al.
Tunneled pleural catheters for treatment of recurrent malignant pleural effusion following failed pleurodesis. J Vasc Interv Radiol 2010;21:696-700.
Bohn KA, Ray CE Jr. Repeat large-volume paracentesis versus tunneled peritoneal catheter placement for malignant ascites: A cost-minimization study. AJR Am J Roentgenol 2015;205:1126-34.
Maleux G, Indesteege I, Laenen A, Verslype C, Vergote I, Prenen H. Tenckhoff tunneled peritoneal catheter placement in the palliative treatment of malignant ascites: Technical results and overall clinical outcome. Radiol Oncol 2016;50:197-203.
Yarmohammadi H, Brody LA, Erinjeri JP, Covey AM, Boas FE, Ziv E, et al.
Therapeutic application of percutaneous peritoneovenous (Denver) shunt in treating chylous ascites in cancer patients. J Vasc Interv Radiol 2016;27:665-73.
Yarmohammadi H, Getrajdman GI. Symptomatic fluid drainage: Peritoneovenous shunt placement. Semin Intervent Radiol 2017;34:343-8.
Virk SA, Chandrakumar D, Villanueva C, Wolfenden H, Liou K, Cao C. Systematic review of percutaneous interventions for malignant pericardial effusion. Heart 2015;101:1619-26.
Covey AM, Brown KT. Palliative percutaneous drainage in malignant biliary obstruction. Part 2: Mechanisms and postprocedure management. J Support Oncol 2006;4:329-35.
Rossi P, Bezzi M, Rossi M, Adam A, Chetty N, Roddie ME, et al.
Metallic stents in malignant biliary obstruction: Results of a multicenter European study of 240 patients. J Vasc Interv Radiol 1994;5:279-85.
Nomura T, Shirai Y, Hatakeyama K. Bacteribilia and cholangitis after percutaneous transhepatic biliary drainage for malignant biliary obstruction. Dig Dis Sci 1999;44:542-6.
Chan SC, Ko SF, Ng SH, Cheung YC, Chang JT, Liao CT, et al.
Fluoroscopically guided percutaneous gastrostomy with modified gastropexy and a large-bore balloon-retained catheter in patients with head and neck tumors. Acta Radiol 2004;45:130-5.
Wollman B, D'Agostino HB, Walus-Wigle JR, Easter DW, Beale A. Radiologic, endoscopic, and surgical gastrostomy: An institutional evaluation and meta-analysis of the literature. Radiology 1995;197:699-704.
Silas AM, Pearce LF, Lestina LS, Grove MR, Tosteson A, Manganiello WD, et al.
Percutaneous radiologic gastrostomy versus percutaneous endoscopic gastrostomy: A comparison of indications, complications and outcomes in 370 patients. Eur J Radiol 2005;56:84-90.
Davies AR, Froomes PR, French CJ, Bellomo R, Gutteridge GA, Nyulasi I, et al.
Randomized comparison of nasojejunal and nasogastric feeding in critically ill patients. Crit Care Med 2002;30:586-90.
Holm AN, Baron TH. Palliative use of percutaneous endoscopic gastrostomy and percutaneous endoscopic cecostomy tubes. Gastrointest Endosc Clin N
Tewari SO, Getrajdman GI, Petre EN, Sofocleous CT, Siegelbaum RH, Erinjeri JP, et al.
Safety and efficacy of percutaneous cecostomy/colostomy for treatment of large bowel obstruction in adults with cancer. J Vasc Interv Radiol 2015;26:182-8.
de Gregorio MA, Mainar A, Rodriguez J, Alfonso ER, Tejero E, Herrera M, et al.
Colon stenting: A review. Semin Intervent Radiol 2004;21:205-16.
O'Connor OJ, Buckley JM, Maher MM. Interventional radiology in oncology. Cancer Treat Res 2008;143:493-511.
Kalogeropoulou C, Kallidonis P, Liatsikos EN. Imaging in percutaneous nephrolithotomy. J Endourol 2009;23:1571-7.
Wong LM, Cleeve LK, Milner AD, Pitman AG. Malignant ureteral obstruction: Outcomes after intervention. Have things changed? J Urol 2007;178:178-83.
Lang EK, Price ET. Redefinitions of indications for percutaneous nephrostomy. Radiology 1983;147:419-26.
Revel-Mouroz P, Mokrane FZ, Collot S, Chabbert V, Rousseau H, Meyrignac O, et al.
Hemostastic embolization in oncology. Diagn Interv Imaging 2015;96:807-21.
Loffroy R, Pottecher P, Cherblanc V, Favelier S, Estivalet L, Koutlidis N, et al.
Current role of transcatheter arterial embolization for bladder and prostate hemorrhage. Diagn Interv Imaging 2014;95:1027-34.
O'Neill B, Fallon M. ABC of palliative care. Principles of palliative care and pain control. BMJ 1997;315:801-4.
Cleeland CS, Gonin R, Hatfield AK, Edmonson JH, Blum RH, Stewart JA, et al.
Pain and its treatment in outpatients with metastatic cancer. N
Engl J Med 1994;330:592-6.
Enting RH, Oldenmenger WH, van der Rijt CC, Wilms EB, Elfrink EJ, Elswijk I, et al.
Aprospective study evaluating the response of patients with unrelieved cancer pain to parenteral opioids. Cancer 2002;94:3049-56.
Titton RL, Lucey BC, Gervais DA, Boland GW, Mueller PR. Celiac plexus block: A palliative tool underused by radiologists. AJR Am J Roentgenol 2002;179:633-6.
Akhan O, Ozmen MN, Basgun N, Akinci D, Oguz O, Koroglu M, et al.
Long-term results of celiac ganglia block: Correlation of grade of tumoral invasion and pain relief. AJR Am J Roentgenol 2004;182:891-6.
Mishra S, Bhatnagar S, Rana SP, Khurana D, Thulkar S. Efficacy of the anterior ultrasound-guided superior hypogastric plexus neurolysis in pelvic cancer pain in advanced gynecological cancer patients. Pain Med 2013;14:837-42.
Ahmed DG, Mohamed MF, Mohamed SA. Superior hypogastric plexus combined with ganglion impar neurolytic blocks for pelvic and/or perineal cancer pain relief. Pain Physician 2015;18:E49-56.
Scott-Warren JT, Hill V, Rajasekaran A. Ganglion impar blockade: A review. Curr Pain Headache Rep 2013;17:306.
Pacenta HL, Kaddoum RN, Pereiras LA, Chidiac EJ, Burgoyne LL. Continuous tunnelled femoral nerve block for palliative care of a patient with metastatic osteosarcoma. Anaesth Intensive Care 2010;38:563-5.
Vranken JH, Zuurmond WW, de Lange JJ. Continuous brachial plexus block as treatment for the Pancoast syndrome. Clin J Pain 2000;16:327-33.
Frassica DA. General principles of external beam radiation therapy for skeletal metastases. Clin Orthop Relat Res 2003;(415 Suppl): S158-64.
Lutz S, Chow E. A review of recently published radiotherapy treatment guidelines for bone metastases: Contrasts or convergence? J Bone Oncol 2012;1:18-23.
Vayne-Bossert P, Afsharimani B, Good P, Gray P, Hardy J. Interventional options for the management of refractory cancer pain – What is the evidence? Support Care Cancer 2016;24:1429-38.
Deschamps F, de Baere T. Cementoplasty of bone metastases. Diagn Interv Imaging 2012;93:685-9.
Iannessi A, Amoretti N, Marcy PY, Sedat J. Percutaneous cementoplasty for the treatment of extraspinal painful bone lesion, a prospective study. Diagn Interv Imaging 2012;93:859-70.
Napoli A, Anzidei M, Marincola BC, Brachetti G, Ciolina F, Cartocci G, et al.
Primary pain palliation and local tumor control in bone metastases treated with magnetic resonance-guided focused ultrasound. Invest Radiol 2013;48:351-8.
Schmidt GA, Maizel J, Slama M. Ultrasound-guided central venous access: What's new? Intensive Care Med 2015;41:705-7.
Heit JA, Silverstein MD, Mohr DN, Petterson TM, O'Fallon WM, Melton LJ 3rd
. Risk factors for deep vein thrombosis and pulmonary embolism: A population-based case-control study. Arch Intern Med 2000;160:809-15.
Blom JW, Doggen CJ, Osanto S, Rosendaal FR. Malignancies, prothrombotic mutations, and the risk of venous thrombosis. JAMA 2005;293:715-22.
Stevens DC, Butty S, Johnson MS. Superior vena cava rupture and cardiac tamponade complicating the endovascular treatment of malignant superior vena cava syndrome: A case report and literature review. Semin Intervent Radiol 2015;32:439-44.
Rice TW, Rodriguez RM, Light RW. The superior vena cava syndrome: Clinical characteristics and evolving etiology. Medicine (Baltimore) 2006;85:37-42.
Lanciego C, Pangua C, Chacón JI, Velasco J, Boy RC, Viana A, et al.
Endovascular stenting as the first step in the overall management of malignant superior vena cava syndrome. AJR Am J Roentgenol 2009;193:549-58.
Lee-Elliott CE, Abubacker MZ, Lopez AJ. Fast-track management of malignant superior vena cava syndrome. Cardiovasc Intervent Radiol 2004;27:470-3.
Fletcher WS, Lakin PC, Pommier RF, Wilmarth T. Results of treatment of inferior vena cava syndrome with expandable metallic stents. Arch Surg 1998;133:935-8.
Shin N, Kim YH, Xu H, Shi HB, Zhang QQ, Colon Pons JP, et al.
Redefining Budd-Chiari syndrome: A systematic review. World J Hepatol 2016;8:691-702.
Razavi MK, Hansch EC, Kee ST, Sze DY, Semba CP, Dake MD. Chronically occluded inferior venae cavae: Endovascular treatment. Radiology 2000;214:133-8.
Brountzos EN, Binkert CA, Panagiotou IE, Petersen BD, Timmermans H, Lakin PC. Clinical outcome after intrahepatic venous stent placement for malignant inferior vena cava syndrome. Cardiovasc Intervent Radiol 2004;27:129-36.
Kaufman JA, Kinney TB, Streiff MB, Sing RF, Proctor MC, Becker D, et al.
Guidelines for the use of retrievable and convertible vena cava filters: Report from the society of interventional radiology multidisciplinary consensus conference. J Vasc Interv Radiol 2006;17:449-59.
Prandoni P, Lensing AW, Piccioli A, Bernardi E, Simioni P, Girolami B, et al.
Recurrent venous thromboembolism and bleeding complications during anticoagulant treatment in patients with cancer and venous thrombosis. Blood 2002;100:3484-8.
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]