Interventional radiologists at Temple University Hospital
now are able to treat many patients with minimally invasive procedures not available only a few years ago. “Conditions that used to require extensive surgery now take an hour or less, and patients leave with a bandaid and walk home,” says Gary Cohen, M.D., Section Chief of Interventional Radiology and Vice Chairman of Radiology. “How can you beat that?”
Dr. Cohen was recently recognized by his peers as a “top doc” in Philadelphia Magazine. While he was modest about the recognition, Cohen is more effusive when discussing recent advances in interventional radiology, including uterine artery embolization, varicose vein ablation, chemotherapy embolization and tumor radiofrequency ablation.
“We are thought of as a part of radiology, and it is true that we always use imaging to guide our procedures,“ says Cohen. “But I think of myself as a surgeon first — a minimally invasive surgeon. And we are doing many exciting minimally invasive procedures at Temple.”
Uterine Artery Embolization
Before the advent of uterine artery embolization about seven years ago, the only available treatments for painful benign uterine fibroid tumors were hysterectomy or myomectomy. Both procedures were extremely invasive and the fibroids so vascular that extensive bleeding was common. When surgeons asked interventional radiologists to embolize the tumors in advance of surgery to minimize bleeding, they quickly found that the fibroids shrank and pain decreased dramatically.
Since that time, interventional radiologists at Temple have done approximately 400 uterine artery embolizations. During the procedure, a catheter is placed in an artery in the groin and fed with guidance from imaging into one or both of the uterine arteries. Small particles of polyvinyl alcohol (PVA) are then injected to permanently stop blood flow to the tumor. Without blood flow, the tumor is choked off and dies.
“For patients with severe pain, bleeding, dyspareunia, and infertility, uterine artery embolization offers a minimally invasive option with a 90 percent success rate and very small risk of complications,” says Dr. Cohen. “Additionally, the uterus stays very much alive and viable.”
Varicose Vein Ablation
Eighty million people in the U.S. have venous insufficiency. Approximately 27 million of them are symptomatic. Until recently, the only treatment was saphenous vein stripping. Now, varicose vein ablation offers a minimally invasive treatment option.
“Under ultrasound guidance, we place a small catheter percutaneously at the level of the knee and ablate the vein with a small laser,” says Dr. Cohen.” It scars down and the varicose veins go away. It is a very elegant procedure.”
Varicose vein ablation is done on an outpatient basis and there is often no need for sedation. Patients walk out of the procedure with supportive leg stockings, which they wear for one week. The procedure is ideal for symptomatic patients who suffer from severe leg swelling, discoloration and incapacitating pain. It is also appropriate for patients who are bothered by the unsightly appearance of varicose veins.
“I believe that in the future we will be able to replace the faulty valves in the saphenous vein by percutaneous valve transplantation,” says Cohen. “Rather than ablating the vein, we will one day insert porcine valves into the saphenous vein making it competent once again.”
Patients who suffer from tumors that do not respond to systemic or IV chemotherapy may be candidates for chemotherapy embolization — a procedure that provides venous access for targeted chemotherapy insertion. Most often these patients suffer from primary or secondary hepatic cellular carcinoma.
During chemotherapy embolization, a catheter is fed through an artery in the groin directly into the tumor. A cocktail of chemotherapy drugs is injected along with PVA particles that directly stop the blood flow to the tumor, work to kill some of the tumor, and block the outflow of the chemotherapy. The chemotherapy stays within the tumor exponentially longer than if it had been injected into a vein.
“We increase the chemotherapy dwell time within the tumor itself. Because of that, we can use much less chemotherapy,” explains Dr. Cohen. “And the patient does not have systemic response including nausea, hair loss, and blood count drop.”
Studies have shown that chemotherapy embolization, which is a palliative rather than a curative procedure, does increase survival time. “Our ultimate goal is to get patients to experience tumor shrink-down long enough so that they can undergo transplant,” says Cohen.
Percutaneous Radiofrequency Ablation
For patients with soft tissue tumors that are not amenable to surgery and do not respond to other treatments, percutaneous radiofrequency ablation (PRA) is a novel treatment option. During this procedure, a probe is advanced from the skin into the tumor, which is then burned with radiofrequency waves.
“I often do PRA in the liver in combination with chemotherapy ablation,” says Dr. Cohen. “The synergy of the two procedures gives us a prolonged survival period.”
Percutaneous radiofrequency ablation has also been used in the treatment of unresectable bone tumors. “Metastatic bone tumors are unbelievably painful and debilitating,” says Cohen. “We have treated several patients in whom a tumor traveled to the shoulder and broke the bone. We have used PRA to treat the tumor and then percutaneously injected bone cement into the tumor, sealing the fracture and eliminating the pain.”
For more information about the many minimally invasive procedures offered by interventional radiologists at Temple, please contact Gary Cohen, M.D., by phone at 215-707-7002 or email at [email protected]., http://www.health.temple.edu