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Complication of interventional oncology procedures

With careful patient selection and attention to detail, most IR oncologic interventions are well tolerated.  It is important to be aware of the most common complications and their management to provide the best outcomes.

 

Complications of Thermal ablation of pulmonary and chest wall tumors

Fever and a small pleural effusion may be present.  These are usually self limited and may be accompanied by a productive cough.  Pneumonia/abscess and significant hemoptysis are rare.  We typically prescribe peri and postprocedural prophylactic antibiotics for all pulmonary ablations.  Pneumothorax is relatively common, occurring in up to 40% of cases, however, only a small percentage of all patients (10%) require needle aspiration or chest tube placement.  More severe complications are rare but include bronchopleural fistula, tract seeding, brachial nerve injury, and skin burns.  Hemothorax, respiratory failure, pulmonary embolism, and death have been reported.  In 2007, the FDA issued a public health notification pertaining to deaths reported following RFA of lung tumors.

Complications of Thermal ablation of hepatic tumors

RFA of hepatic tumors has a long track record of safety.  Major complications have been reported to develop in up to 11% of cases with procedural mortality reported between 0.3 to 0.8% (most commonly attributed to hepatic failure and portal vein thrombosis).  Hepatic abscess occurs in up to 2% of patients.  A higher rate of abscess development is seen in patients with biliary obstruction or a bilioenteric anastomosis.  We routinely prescribe antibiotics for all of our thermal ablations.  Hemorrhage is usually self limited though hemoperitoneum and subcapsular hematoma can occur.   Microwave ablation may be associated with a lower rate of hemorrhage.  We typically ablate the needle tract (in both RFA and microwave ablation) to mitigate tract seeding or bleeding. Care must be exercised to avoid thermal injury to surrounding structures such as bowel loops and the diaphragm.  In select cases, hydrodissection or balloon interposition can be considered.  A self limited postablation syndrome with fever, pain, nausea, and transaminitis occurs in a minority of patients.

Complications of hepatic chemoembolization

Care must be taken to properly select patients for chemoembolization in order to avoid adverse outcomes.  Patients with portal vein thrombosis, encephalopathy, biliary obstruction, and/or poor hepatic function (Child Class C cirrhosis) are at increased risk for complications.  The majority of patients will experience a self limited postembolization syndrome consisting of pain, fatigue, fever and transient LFT abnormalities.  This usually lasts a few days.  Systemic effects of the individual chemotherapy agents are rare since most of the chemotherapy is retained in the liver. More serious complications include hepatic decompensation, hepatic abscess, bile duct injury and chemical cholecystitis.  While less of a concern than with radioembolization, gastroduodenal ulceration may occur.  Care must be taken to evaluate preprocedure renal function, intraprocedural contrast load, and post procedure hydration status as renal dysfunction can occur in up to 2% of patients.  Paradoxical embolization of lipiodol or particles is exceedingly rare but potentially grave.  Overall treatment related mortality rates from TACE have been reported to be roughly 2-3%.

Complications of Radioembolization Y90 procedures

Complications of radioembolization are similar to chemoembolization.  Following radioembolization, there is small risk of radiation induced liver disease (<4%), ipsilateral lobar volume decrease (“radiation lobectomy”), or liver fibrosis.  Radiation pneumonitis is largely avoidable with appropriate pre infusion mapping.  Similarly, prophylactic embolization of vessels which may supply the GI tract (typically the gastroduodenal and right gastric artery) lessen the incidence of gastric or duodenal injury.

 

Complications of cryoablation

In contrast to heat based ablation, cryoablation does not cauterize blood vessels which may result in higher bleeding risk.  Cryoablation is most commonly used to treat renal cell carcinoma, and in this application, damage to the collecting system (especially with central lesions) may occur.  Surrounding bowel or nerves (genitofemoral) may also be damaged.  Cryoshock, a severe systemic response due to rapid destruction of cell membranes and lack of protein denaturation, can result in disseminated intravascular coagulation and multisystem organ failure, though is exceedingly rare.

 

Complications of Portal Vein Embolization

Complications of percutaneous portal vein embolization are usually related to the transhepatic access and include subcapsular hematoma, hemobilia, hemoperitoneum, and cholangitis.  Since many of these occur more frequently in the punctured lobe, some advocate an ipsilateral approach (puncture the right lobe).  Nontarget embolization, incomplete embolization or recanalization of embolized segments, and complete portal vein thrombosis can occur.

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