Bethesda Handbook of Clinical Oncology, 2nd Edition

Common Procedures and Chemotherapy Drugs

46

Procedures in Medical Oncology

Suzanne G. Demko

Kerry Ryan

Medical Oncology Clinical Research Unit, National Cancer Institute, National Institutes of Health, Bethesda, Maryland

Medical Oncology Clinical Research Unit, National Cancer Institute, National Institutes of Health, Bethesda, Maryland

As in other subspecialties, procedures performed in an oncology setting can serve the dual purposes of diagnosis and treatment. This chapter outlines those medical oncology procedures that are commonly performed and briefly discusses any special considerations or techniques that may be of assistance in performing these procedures rapidly, with confidence, and with an eye toward patient comfort and education.

INFORMED CONSENT

Written informed consent, or a legally sufficient substitute, must be obtained before every procedure and should be filed in the patient's medical record.

ANESTHESIA

Local anesthesia should be used for all procedures, and premedication with a narcotic and benzodiazepine [preferably, fentanyl and midazolam (Versed)] should be considered for certain patients and procedures. Lidocaine, 1% mixed in a 3:1 or 5:1 ratio with sodium bicarbonate, will ensure proper anesthetic effect and will also virtually eliminate the typical sting of lidocaine.

INSTRUMENTATION

Most offices and hospitals are equipped with sterile trays or self-contained disposable kits that are specific to each procedure. Where additional instruments are needed because of operator preference or other considerations, they may be added.

PROCEDURES

Bone Marrow Aspirate/Bone Marrow Biopsy

Indications

Diagnostic: for the analysis of abnormality in production of blood cells and for the purpose of staging in hematologic and nonhematologic malignancies.

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Contraindications

• Severe thrombocytopenia (platelets <20,000; platelet transfusion may be given before the procedure)
• Skin infection at proposed site of biopsy
• Biopsy to a site that was radiated previously can cause fibrosis; should consider alternative site
• Sternal biopsy
• Sternal aspirate to be avoided in patients with thoracic aortic aneurysms and in patients with lytic bone disease of ribs or sternum.
• Patients taking heparin: heparin should be discontinued before procedure and resumed after hemostasis is achieved.

Anatomy

• Sternal aspiration:
• The patient is in supine position without elevation of the head.
• Landmarks are the sternal angle of Louis and the lateral borders of the sternum in the second intercostal space.
• Posterior superior iliac spine aspiration and biopsy (see Fig. 46.1):

FIG. 46.1. Biopsy site in the posterior superior iliac spine. The needle should be directed toward the anterior superior iliac spine. (From Chestnut MS, Dewar TN, Locksley RM, et al. Bone marrow aspiration & biopsy. In: Chestnut MS, Dewar TN, Locksley RM, eds. Office & bedside procedures. Norwalk, CT: Appleton & Lange, 1992:381, with permission.)

• The patient is in a prone or lateral decubitus position for posterior superior iliac spine aspiration and biopsy, and is supine for anterior iliac crest aspiration and biopsy (for patients with a history of radiation to pelvis or extremely obese patients).

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Procedure

• Sternal aspiration:

1. Once the landmarks have been identified, clean the area and drape with a fenestrated drape, using sterile technique.
2. Infiltrate the skin, subcutaneous tissues, and periosteum in the area to be aspirated with lidocaine, 1%, for anesthesia. “Sounding” of the surface of the bone can be done with the infiltration needle to approximate the distance from the skin to the periosteum.
3. Use a 16-gauge sternal aspiration needle with guard to prevent penetration of the posterior table of the sternum. The adjustment of the needle guard is based on an approximation of the distance from the skin to the periosteum.
4. Make a 2-mm superficial skin incision with a surgical blade in the midsternum, medial to the second intercostal space.
5. Introduce the aspirate needle with guard, using gentle, corkscrew-type pressure to advance the needle until it is fixed in bone. Remove the obturator, attach a 10- to 12-mL syringe, and aspirate. The aspiration will be painful. This cannot be prevented but will last only a few seconds.

One milliliter of aspirate should be obtained. An amount >1 mL will be diluted by peripheral blood. Spicules of bone marrow will be present unless significant fibrosis is present or the marrow is packed with leukemic or other malignant cells.

If no specimen is obtained, replace the obturator and carefully advance the needle 2mm to 3 mm. Repeat the aspiration process. Prepare smears for evaluation.

• Posterior superior iliac crest aspiration and biopsy:

1. In general, an 11-gauge Jamshidi-type needle is used to obtain biopsy specimens. Under special circumstances (e.g., spongy bone marrow or easily compressed marrow), a larger-gauge needle (8-gauge) may be used to obtain an adequate biopsy specimen.
2. The patient may be positioned prone; however, the lateral decubitus position may be used instead for better identification of anatomic sites or for patient comfort. For all but the most obese patients, these positions may be used for aspiration and biopsy. For extremely obese patients or for those who have had radiation to the pelvis, the anterior iliac crest may be used for sampling.
3. Once the site has been prepared and anesthetized, advance the needle into the cortex of the bone until it is fixed. Attempt aspiration and, if unsuccessful, advance the needle slightly and attempt again.
4. Once the aspirate is obtained, advance the needle using a twisting motion, without the obturator in place, to obtain the biopsy specimen. A 1.5- to 2-cm specimen is recommended. To ensure that the specimen is collected when the needle is removed, first rotate the needle briskly in one direction and then in the other direction, and then “rock” gently by exerting pressure perpendicular to the shaft of the needle in four directions with the needle capped. Then gently remove the needle while rotating in a corkscrew manner. Remove the specimen from the needle by pushing it up through the hub with a stylet provided for this purpose, taking care to avoid needlestick injuries while removing the specimen. Jamshidi needle kits provide a small, clear plastic guide to facilitate this process.

Aftercare

A pressure dressing is placed over the site, and external pressure is applied for 5 to 10 minutes. Direct pressure is the preferred method to avoid prolonged bleeding and hematoma formation. The pressure dressing should remain in place for 24 hours. The patient may remove the pressure dressing and shower after 24 hours; however, the patient should avoid immersion of the site in water for 1 week after the procedure in order to avoid infection.

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Complications

Infection and hematoma formation are the most common complications after bone marrow biopsy and aspiration, and can be minimized by using careful techniques during and after the procedure.

Documentation

Prepare a procedure note.

Lumbar Puncture

Indications

• Diagnostic [analysis of cerebrospinal fluid (CSF) to assess adequacy of treatment]
• CSF pressure measurement to assess adequacy of treatment
• Administration of intrathecal chemotherapy

Contraindications

• Increased intracranial pressure
• Coagulopathy
• Infectious process near the planned access site

Anatomy

• The conus medullaris rarely ends below L3 (i.e., L1 to L2 in adults and L2 to L3 in children), and interspaces above this should be avoided (see Fig. 46.2).

FIG. 46.2. Anatomy of the lumbar spine. (From Chestnut MS, Dewar TN, Locksley RM, et al. Lumbar puncture. In: Chestnut MS, Dewar TN, Locksley RM, eds. Office & bedside procedures. Norwalk, CT: Appleton & Lange, 1992:391, with permission.)

• The L4 spinous process or the L4-5 interspace lies in the center of the supracristal plane (a line drawn between the posterior superior iliac crests).

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• There are eight layers from the skin to the subarachnoid space; they are skin, supraspinous ligament, interspinous ligament, ligamentum flava, epidural space, dura, subarachnoid membrane, and subarachnoid space.

Procedure

1. Describe the procedure to the patient and assure him or her that you will explain what you are about to do before you do it.
2. Position the patient in the lateral decubitus position at the edge of the table or bed, with knees pulled upward and head flexed downward toward chest (see Fig. 46.3). If the spinal column appears to be misaligned, place a pillow beneath the patient to assure proper alignment. This position may be substituted with the seated position if the patient is obese or has difficulty remaining in the lateral decubitus position for any reason.

FIG. 46.3. Lateral decubitus position for lumbar puncture. (From Chestnut MS, Dewar TN, Locksley RM, et al. Lumbar puncture. In: Chestnut MS, Dewar TN, Locksley RM, eds. Office & bedside procedures. Norwalk, CT: Appleton & Lange, 1992:390, with permission.)

3. Assess the anatomic landmarks and identify the interspace to be used for the procedure.
4. Using sterile technique, prepare the area and one interspace above or below it with povidone–iodine solution. Drape the patient, establishing a sterile field.
5. Using 1% lidocaine–bicarbonate mixture, anesthetize the skin and deeper tissues, being careful to avoid administering epidural or spinal anesthesia.
6. Insert the spinal needle into the anesthetized skin and into the spinous ligament, keeping the needle parallel to the bed or table. Immediately change the angle of the needle to between 30 and 45 degrees, directing the needle cephalad. The bevel of the needle should be positioned to face the patient's flanks to allow the needle to spread rather than cut the dural sac. Begin to advance the needle in small increments through the layers and remove the stylet to check for CSF before each new advance of the needle. With practice, the operator may be able to identify the “pop” through the dura into the subarachnoid space, but even an experienced operator would be wise to check for CSF before each advance of the needle.
7. Having confirmed the presence of CSF, attach a manometer to measure the opening pressure. Collect appropriate samples of CSF. Send the samples in the following order: tube 1, cultures; tube 2, chemistries (especially glucose and protein); tube 3, cell count and

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differential; and tube 4, cytopathologic or other special studies (flow cytometry, cytogenetics, etc.). Typically, a total of 8 to 15 mL of CSF is removed during lumbar punctures (LPs). However, if special studies are required, 40 mL of fluid can be removed safely.

If intrathecal chemotherapy is to be administered, attach the syringe to the spinal needle, tube adapter, or stopcock, and administer by slow push.

8. Withdraw the needle, observe the site for CSF leak or hemorrhage, and place an appropriate bandage over the site.
9. Transfer the patient to a recumbent position and ask the patient to remain in this position for 5 to 10 minutes. There appears to be no relation between postprocedure positioning and spinal headache; however, a relationship does exist for needle size, CSF leak, and spinal headache. The patient should be instructed to drink 2 to 3 L of fluid over the next 24 hours, in order to replenish the CSF removed.

Complications

• Spinal headache can occur in approximately 20% of patients after LP. It is a characteristic headache, in that it is present as a pounding ache in the occipital region when the patient is upright and resolves when the patient lies down. Certain categories of patients are more likely to have a post-LP headache. Female patients, those with a history of headache prior to LP, or those of a younger age group (peak age 20 to 40 years) are associated with the highest incidence of post-LP headache. Fluid intake should be encouraged, over-the-counter analgesics should be suggested, and the patient should be instructed to remain recumbent, if possible. Spinal headaches can be quite severe and may last for about 1 week. If this is the case, stronger analgesia, caffeine, or a blood patch procedure may be indicated.
• Nerve root trauma can occur, but it does so only infrequently. This complication can be avoided by choosing a low interspace as the entry site.
• Cerebellar or medullar herniation occurs only rarely, in some patients who have increased intracranial pressure. If recognized early, this process can be reversed.
• Infections, including meningitis, can also occur.
• Bleeding resulting in a small number of red blood cells (RBCs) in the CSF is a common occurrence in patients undergoing an LP. However, serious bleeding can result in spinal compromise in approximately 1% to 2% of patients. Serious bleeding usually occurs only in patients who have thrombocytopenia or bleeding disorders, or who have received anticoagulants before or after undergoing an LP.

Paracentesis

Indications

• Patients with ascites as a result of tumor metastasis or obstruction often benefit from therapeutic paracentesis. Where the diagnosis is in doubt, or to assess diagnostic markers, diagnostic paracentesis can be performed.

Contraindications

• There are few situations in which one would hesitate to perform a paracentesis. The complication rate for this procedure is minuscule (about 1%), and the benefit derived by the patient can be quite remarkable. This is especially true of therapeutic paracentesis.
• Even in the event of a coagulopathy, the benefit outweighs the risks in performing this procedure.

Anatomy

• One should identify the area of greatest dullness in the abdomen by percussion. As an alternative, one can have the ascites “marked” by having the patient undergo an ultrasound. Care should be taken to avoid the abdominal vasculature and viscera.

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Procedure

1. Place the patient in a comfortable supine position on the edge of the bed or table.
2. Identify the area of the abdomen to be accessed (see Fig. 46.4).

FIG. 46.4. Sites for diagnostic paracentesis. (From Chestnut MS, Dewar TN, Locksley RM, et al. Gastrointestinal procedures. In: Chestnut MS, Dewar TN, Locksley RM, eds. Office & bedside procedures. Norwalk, CT: Appleton & Lange, 1992:269, with permission.)

3. Prepare the area with povidone–iodine solution and establish a sterile field by draping the patient.
4. Anesthetize the area with 1% lidocaine–bicarbonate mixture.
5. For diagnostic paracentesis, insert a 22- to 25-gauge needle attached to a sterile syringe into the skin, and pull the skin laterally before advancing the needle into the abdomen. After releasing the tension on the skin, advance the needle in the peritoneal cavity, withdraw an appropriate amount of fluid, and send for testing. The skin-retraction method creates a “Z” tract into the peritoneal cavity, and this minimizes the risk of ascitic leak after the procedure (see Fig. 46.5).

FIG. 46.5. “Z-tracking” technique for needle insertion into the peritoneal cavity. (From Chestnut MS, Dewar TN, Locksley RM, et al. Bone marrow aspiration & biopsy. In: Chestnut MS, Dewar TN, Locksley RM, eds. Office & bedside procedures. Norwalk, CT: Appleton & Lange, 1992:381, with permission.)

6. For therapeutic paracentesis, use the Z-tract method with a multiple-port flexible catheter over a guide needle. When the catheter is in place, evacuate the ascites into multiple containers. One must, however, be careful that the patient remains hemodynamically stable during the removal of large amounts of ascites.
7. When the procedure has been completed, withdraw the needle or catheter and place a pressure bandage over the site. Look for any bleeding or ascitic leak before placing the bandage.
8. After a therapeutic paracentesis is performed, the patient should remain in a supine position until all vital signs are stable and should be assisted when rising from the bed or table for the first time after the procedure.
9. If the patient becomes orthostatic, standard medical measures should be used to reverse this process, and he or she must be hemodynamically stable before being allowed to leave.

Complications

• Although the selection of an adequate site for paracentesis virtually eliminates complications, the following have been reported: hemorrhage, ascitic leak, infection, and perforated abdominal viscus.

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Thoracentesis

Indications

• For removal of pleural fluid for diagnostic or therapeutic purposes

Contraindications

There are no absolute contraindications to diagnostic thoracentesis if it is decided that the information gained from pleural fluid analysis is needed for diagnosis and/or therapy.

The relative contraindications are as follows:

• Coagulopathy (the coagulation abnormality should be corrected)
• Bullous emphysema (associated with increased risk of pneumothorax)
• Cardiovascular disease (cardiac dysrhythmias)
• Patients with a minimal amount of pleural fluid positive end-expiratory pressure (PEEP) are not at increased risk for developing pneumothorax when compared with nonventilated patients. Mechanically ventilated patients, however, are at increased risk for developing tension physiology or a persistent air leak, if pneumothorax does occur.
• Inability of patient to cooperate
• Cellulitis, if the thoracentesis requires penetrating the inflamed tissue.

Important Preprocedure Considerations

• Care must be taken to ascertain the location of the diaphragm before the procedure in order to avoid accidental injury to the abdominal organs and viscera.
• Chest radiographs should be viewed by the person who is performing the procedure and, if loculation of fluid is suspected, decubitus films and, possibly, computerized tomography scan or ultrasonography may be helpful before thoracentesis is attempted.

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Anatomy

• The procedure may be performed with the patient in a sitting position, with arms resting on a pillow placed on a table. This allows the patient to lean forward 10 to 15 degrees, allowing the intercostal spaces to spread.
• The procedure is performed through the seventh or eighth intercostal space in the posterior axillary line. With fluoroscopic, sonographic, or computerized tomographic guidance, the procedure may be performed below the fifth rib anteriorly, the seventh rib laterally, and the ninth rib posteriorly. Without such guidance, the underlying organs may be injured.
• Assessing the size of the pleural effusion by physical examination involves the detection of decreased tactile fremitus and dullness to percussion over the pleural effusion. The percussion is begun at the top of the chest, listening for any change in the sound of percussion while moving downward. When the change in sound is first noted, it should be compared with the percussion note in the same interspace and with the location on the opposite side of the chest. This indicates the highest level of the pleural effusion.

Procedure

1. With the patient in the proper position, clean the site with antiseptic solution and begin local anesthesia. Infiltrate the skin with 1% lidocaine using a 25-gauge needle. Infiltration to the deeper tissues is achieved using a 22-gauge needle, advancing the needle slowly, at a right angle to the chest wall in the center of the intercostal space. Direct the needle into the intercostal space just above the rib to avoid injury to the intercostal nerve and vessels that may run just below the rib. Aspirate frequently to ensure that no vessel has been entered and to determine the distance from the skin to the pleural fluid. Once the pleural fluid has been obtained, remove the anesthesia needle and note the depth.
2. A small skin incision may be needed to ease the passage of a larger-gauge thoracentesis needle into the pleural space. Generally, a 16- to 19-gauge needle with its intracath is introduced just to the level of obtaining pleural fluid. If, at this time, the fluid is bloody or different in appearance from that identified with the anesthesia needle, vessel injury must be suspected, and the procedure must be stopped. If the fluid appears to be the same as it was when previously aspirated, advance a flexible intracath and withdraw the needle to avoid puncture of the lung as the fluid is drained. The placement of a flexible intracath with a three-way stopcock allows the removal of large volumes of fluid with a lower risk of pneumothorax. (For sampling small amounts of pleural fluid without the need to drain large amounts of it, a 22-gauge needle connected to an airtight, three-way stopcock will suffice.) Attach tubing to the three-way stopcock and remove fluid by hand or by vacutainer. Monitor the hemodynamic status carefully when withdrawing more than 1,000 mL per procedure.
3. A chest radiograph should be performed after the procedure to determine the amount of fluid that remains, to look for the presence of pneumothorax, and to assess the lung parenchyma. A small pneumothorax does not need treatment, whereas a major pneumothorax (>50% lung collapse) does (see Fig. 46.6).

FIG. 46.6. Trocar technique for inserting a chest tube. A: Insertion of chest tube. B: Advancement of the chest tube off the trocar into the pleural space. (From Chestnut MS, Dewar TN, Locksley RM, et al. Bone marrow aspiration & biopsy. In: Office & bedside procedures. Norwalk, CT: Appleton & Lange, 1992:221, with permission.)

Complications

• Pneumothorax
• Air embolism (rare)
• Infection
• Pain at puncture site
• Bleeding
• Spleen or liver puncture.

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SUGGESTED READINGS

Butler E, Lichtman M, Giler B, et al. Williams hematology, 5th ed. New York: McGraw-Hill, 1995.

Evans RW, Armon C, Frohman EM, et al. Assessment: prevention of post-lumbar puncture headaches: report of the therapeutics and technology assessment subcommittee of the American Academy of Neurology. Neurology 2000;149:1087.

Isselbacher K, Braunwald E, Wilson JD, et al. Harrison's principles of internal medicine, 13th ed. New York: McGraw-Hill, 1994.

Jashidi K, Swaim WR. Bone marrow biopsy with unaltered architecture: a new biopsy device. J Lab Clin Med 1971;77:335.

Kuntz KM, Kokmen E, Stevens JC, et al. Post-lumbar puncture headaches: experience in 501 consecutive procedures. Neurology1992;42:1884.

LeMense JP, Sahn SA. Safety and value of thoracentesis in medical ICU patients. J Intensive Care Med 1998;13:144.

McCartney JE, Adams JS II, Hazard PP. Safe procedure in mechanically ventilated patients. Chest 1993;103:1920.

Rohling BM, Webb WR, Schlobom RM. Ventilator-related extra-alveolar air. Radiology 1976;121:25.

Zimmerman JE, Dunbar BS, Klingenmaier CH. Management of subcutaneous emphysema, pneumomediastinum, and pneumothorax during respiratory therapy. Crit Care Med 1975;3:69.