Devita, Hellman, and Rosenberg's Cancer

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

174 DeVita, Hellman, and Rosenberg’s CANCER: Principles and Practice of Oncology Review

or deep venous thrombosis is systemic anticoagulation. In patients in

whom anticoagulation is contraindicated (brain metastases, gastrointesti-

nal hemorrhage), an IVC interruption filter should be considered. An IVC

filter is also warranted when a deep venous thrombus continues to prop-

agate or emboli continue to be observed despite anticoagulation or if

surgery is planned. Free-floating clots within the IVC or a deep vein is

also another relative indication for a filter because these types of thrombi

tend to embolize. Eccentric, mural thrombi are usually chronic and less

likely to embolize. Their presence alone would initially warrant systemic

anticoagulation.

Answer 15.16. The answer is B.

IVC filters can be deployed by a femoral or jugular approach. The latter

is preferred because of a decreased chance of dislodging a clot in a deep

femoral vein or the IVC, the ability to place a simultaneous venous line

if needed, and the ability of the patient to sit upright in bed after the

procedure. A femoral approach requires the patient to lie flat in bed for

4 hours after the procedure, which is less comfortable. The predeploy-

ment cavogram is important in excluding any congenital anomalies or

IVC thrombus that may alter the site of deployment. Therefore, intra-

venous contrast is usually used for IVC filter placement. Complications

of IVC filter placement are fairly uncommon and include symptomatic

IVC thrombosis. Recent work suggests that this may be seen in less than

3% of patients with IVC filters. A retrievable filter was recently approved

for use in the United States. This filter can be left in place, however, if the

need for it persists.

Answer 15.17. The answer is C.

Ascites is a common association with malignancy, from either malignant

peritoneal deposits or end-stage liver disease. In the latter group, refrac-

tory ascites may be managed by a portal vein bypass in the form of a per-

cutaneous shunt known as a TIPS. In this procedure, a stent is placed in the

liver from the portal vein to the hepatic vein. Portal pressures are reduced

and ascites resolves. Although TIPS has gained in its use in patients with

portal hypertension, certain patients are not TIPS candidates: Those with

congestive heart failure and preexisting hepatic encephalopathy, because

the TIPS can exacerbate these underlying conditions. TIPS has been shown

to be superior to medical therapy alone in patients with ascites. In patients

with malignant ascites, large-volume paracentesis is the most common

means of managing their condition. Although this technique allows for

immediate, symptomatic relief, it is rarely definitive, and repeat treatments

with all their associated risks are often required. Long-term catheters have

been used with some degree of success. Another alternative is a perito-

neovenous shunt (e.g., a Denver shunt). Their role in the management of

malignant ascites remains unclear.

Answer 15.18. The answer is D.

Percutaneous techniques have dramatically changed the way postopera-

tive abdominal fluid collections are managed. A majority can be drained