Devita, Hellman, and Rosenberg's Cancer

LWBK1006-15 LWW-Govindan-Review December 7, 2011 19:5

Chapter 15•Advances in Diagnostics and Intervention 173

is often reserved for patients with limited life expectancy. Most patients

will undergo a future cholecystectomy after the acute illness has resolved

because of the high incidence of recurrence of cholecystitis.

Answer 15.13. The answer is A.

Malignant pleural effusions are a common cause of chest pain, dyspnea,

and cough in patients with metastatic cancer, usually breast carcinoma,

lung carcinoma, and lymphoma. These effusions are usually symptomatic

and exudative. Thoracentesis will result in immediate relief of symptoms,

but the majority of these effusions will recur. Definitive treatment requires

tube drainage at first, which may be better accomplished via image guid-

ance so that the tube rests in the location of the majority of the fluid.

This is particularly true when the amount of fluid is small or the effusion

is loculated. Although surgical teaching suggests large-bore catheters are

required for successful drainage, recent data suggest that smaller bore

catheters are equally as effective and may be associated with less pain

and restriction of mobility. A majority of patients will not be adequately

treated with chest tube drainage alone. In these patients, pleurodesis is

performed to give better long-term results. Mechanical pleurodesis can be

performed at surgery (usually video-assisted thoracoscopic surgery) and

offers a slightly higher success rate than chemical pleurodesis (which relies

on a sclerosing agent such as talc, doxycycline, or bleomycin). Although

hospital stays are shorter with surgical pleurodesis, chemical pleurode-

sis is less invasive and expensive, and has a lower morbidity. Another

approach currently under investigation is the use of a long-term tunneled

chest tube drainage catheter. Drainage can be performed in an outpatient

setting. In this group, mechanical pleurodesis may be achieved in up to

50% of patients in 30 days.

Answer 15.14. The answer is B.

SVC obstruction is a fairly common consequence of thoracic malignancy,

usually lung cancer. Radiographic SVC occlusion is often asymptomatic

secondary to collateral formation throughout the mediastinum with diver-

sion of blood to the azygous or IVC systems. These patients do not war-

rant any treatment. In others, no collateral vessels have formed, resulting

in symptoms of head and neck swelling, headache, and mental status

changes. In these symptomatic patients, radiation may be beneficial when

the tumors are radiosensitive. This form of therapy usually works but may

require therapy over weeks with symptomatic relief over days. An alterna-

tive therapy is balloon angioplasty with stent deployment. This technique

(if the obstruction can be crossed intravascularly) results in immediate

symptomatic relief. Recurrent symptoms may follow stent deployment

and are usually related to tumor overgrowth, neointimal hyperplasia, and

rarely stent migration. Recurrent occlusion may be treated with throm-

bolysis, angioplasty, or repeat stenting.

Answer 15.15. The answer is D.

The incidence of pulmonary embolism in cancer is three times that in

the general population. The first-line treatment of pulmonary embolism