Intrathecal opioids have been used in cancer patients for pain control since the late 1970s [30, 35]. Addition of adjuvant drugs such as local anaesthetics and/or steroids to the injectate provides more effective analgesia than single agent injections [34]. Opioid dosing requirements are greater in the epidural space compared with the intrathecal administration, either as single injection or via infusion catheters [34]. When used, image guidance for epidural or intrathecal injections can be with CT or fluoroscopy for thoracic or lumbar region injections, whilst fluoroscopy is more often used for cervical injections. Epidural blocks with steroid and local anaesthetic are usually performed for vertebral cancer-induced bone pain, although evidence is limited [34].

Indications: Pain not adequately covered with oral analgesics or where the side effects of treatment are too inconvenient. Head and neck cancer patients with pain can benefit from cervical epidural steroid injection in particular.

Results: Intrathecal opioids are effective in treatment of cancer pain, and a small survival benefit has also been shown [30, 34].

Complications: The most feared complication is that of infection but fortunately is of low incidence up to 4.6 % superficial infections and 1.2 % deep infections (increased with longer duration of catheter placement) [30, 34]. Other self-limiting complications include dural puncture headache (15 %), epidural haematoma (0.5–0.9 %) and cerebrospinal fluid (CSF) leak [30, 34]. Medication effects also warrant consideration including respiratory depression due to cephalad spread of opioids, weakness and sensory disturbance (from local anaesthetics at higher doses) [34]. Complications of epidural injection of steroid are usually a result of misplacement of the needle (e.g. intrathecal injection, epidural haematoma, vascular injury).

Permanent pain relief with intrathecal injection of alcohol, particularly in advanced disease.

This has a more limited role in the palliative setting and is technically possible for most neural structures using predominantly US guidance for selective injections. Common targets include the suprascapular, paravertebral, intercostal, lumbar, obturator, sciatic and femoral nerves with blockade performed using a long-acting local anaesthetic (e.g. bupivacaine) with or without corticosteroid. Steroids are particularly effective when the peripheral nerve is involved by the disease process. The risk of peripheral nerve neurolysis is neuritis [34].

Indications: Exudative pleural effusion or loculated effusion. Simple method for diagnosis and immediate short-term symptom relief, but repeated thoracocentesis is not optimal for rapidly reaccumulating malignant effusions [40]. It may be of benefit in those with short survival expectancy or where fluid reaccumulation is slow [40].

Results: Success with US increased up to 88 %, with reduced pneumothorax rate [40]. Malignant pleural effusion will recur within 30 days post-thoracocentesis in nearly all patients [41].

Complications: Uncommon with low rate of pneumothorax (up to 6 %), haemothorax, reexpansion pulmonary oedema, organ laceration, intercostal artery injury and intercostal neuralgia [40]. Approximately half of patients with pneumothorax require formal drainage tube [40]. The bleeding risk is reduced by correcting coagulation parameters prior to the procedure and by ensuring needle placement above the rib margin to avoid the neurovascular bundle [10, 40, 41]. Risks of the procedure increase with repeated thoracocentesis [41].

Pigtail drainage tube insertion is commonly performed with US guidance using a modified Seldinger technique following dilatation of the tract, although some direct stick catheters are available [1, 41]. Tunneled catheters are inserted via a similar technique, with the proximal catheter tunneled in subcutaneous tissues to enable longer-term management of effusion due to reduced infection and dislodgement rates [40, 41, 43].

Indications: Long-term management of malignant pleural effusion enabling outpatient management, best with tunneled catheter [40, 41]. Tunneled drains can still be effective after failed formal pleurodesis [40].

Results: Symptomatic relief and control of malignant effusion occurs in 90–95 % of patients with tunneled catheter technique [40]. Spontaneous pleurodesis occurs in approximately 40 %, mostly within 1 month of the tube insertion [40, 41]. Tunneled catheters are safe, cost-effective and enable outpatient management of effusion [40, 43].

Complications: Most common is fluid loculation (8 %), with incomplete drainage [41]. Less commonly empyema, cellulitis, tube dislodgement, bleeding, tumour seeding and extrapleural migration of the catheter [40, 43]. Long-term non-tunneled catheter placement may eventually lead to empyema [1]. Tunneled catheters have the advantage of reduced risk for dislodgement and low risk of complications including tunnel or pleural infections or pericatheter leakage, due to development of a fibrous cuff around proximal portion of catheter, and a one-way valve at proximal hub of the catheter [40].

Pleurodesis obliterates the pleural space to prevent pleural effusion from reaccumulation [1, 40, 41]. Approximately two thirds of patients with malignant pleural effusion fail to respond to thoracocentesis or drainage catheters, without pleurodesis [40].

Chest tube insertion with pleurodesis and thoracoscopy can require hospitalisation for up to 1 week, which is neither desirable nor cost-effective as a palliative management in patients with a short life expectancy [40]. Intrapleural instillation of sclerosant material can be used to facilitate pleurodesis, and this can be performed as an outpatient, with small drainage catheter pleurodesis as effective as traditional large bore catheter use [2, 40, 41, 44, 45]. The procedure can be undertaken after one or two consecutive drainages of fluid [40]. Sclerosing agents include talc, tetracycline, doxycycline and bleomycin, with talc being the most commonly used [1, 41, 44, 46]. The chest tube can be removed when drainage is less than 50–100 ml/day, although protocols vary by institution [1, 18, 40].

Indications: Recurrent malignant pleural effusion.

Results: Recurrence rates of effusion can be as low as 10 % using talc slurry pleurodesis [1].

Complications: In addition to complications of drain insertion, minimal discomfort and mild fever are common side effects, with talc pneumonitis and respiratory failure less commonly observed [40].

Single drainage of ascites with nontunneled catheters is effective but if left in place long term are prone to complications such as infection (35 %), accidental removal, leakage (20 %) and occlusion (30 %) [1, 41]. As a result, unless the patient has a short life expectancy, tunneled catheters are preferred for long-term management of malignant ascites, as they have reduced infection risk [1, 41].

Indications: Malignant ascites.

Results: US-guided tunneled catheters have similar complication rates and patient satisfaction when compared to large volume paracentesis, although the reduced need for hospital visits to undergo paracentesis is an obvious advantage of a tunneled drain [41].

Complications: Peritonitis, leakage and loculation are all uncommon [41].

Common locations include hepatic, perihepatic (subphrenic and subhepatic), gallbladder bed, splenic bed, lesser sac, paracolic and the retroperitoneum [7].

Indications: Collection greater than 4 cm, symptomatic [7]. Collections <4 cm in diameter may well respond to conservative treatment, although aspiration when symptomatic can be beneficial [7].

Results: Percutaneous drainage is a safe, effective alternative to surgery with low complication rate (5 %), morbidity and likely a shorter hospital stay [7]. Multiple or multi-loculated collections are more challenging, and although there are high success rates for drainage in the noncancer setting up to 90 %, outcomes are not as impressive in infected tumour drainage, with higher rates of secondary or permanent drainage being required [7, 54, 55]. This relates to infected tumour tending to be a preterminal entity, with complete drainage unlikely unless the underlying tumour resolves, and these patients are often unfit for surgery to definitively treat the tumour [54]. Those with underlying hepatopancreatobiliary malignancy have poorer outcomes of drainage than in other malignancies [50].

Complications: Although uncommon, the major complications are haemorrhage (2 %), bowel or organ injury (~1 %) and sepsis (1–5 %) [7, 18]. In subphrenic abscess drainage, pneumothorax due to pleural transgression is possible with or without development of pleural effusion or empyema [7, 54].

Indications: Postoperative collections or lymphoceles, diverticular abscess, cystic tumour or infected tumour are common indications for drainage in patients with malignancy [7, 18]. Whilst infected collections can be symptomatic due to sepsis, other presentations can relate to mass effect of the collection, such as intractable pain and bowel obstruction [7, 18, 56].

Contraindications: Lack of safe access route and irreversible coagulopathy.

Modality for drainage: Collections superficial to the abdominal muscles can be drained with US guidance. Deeper collections may require CT to identify collection as separate from the bowel [7]. Posterior transgluteal approach via the greater sciatic foramen can be used in deep pelvic abscesses [7, 56]. Alternatively, transrectal (if adjacent rectum) or transvaginal (if in contact with vagina) drainage may be more feasible or even transperineal [7, 18, 56].

Results: Successful in up to 90 % in the noncancer setting and best if the collection is postsurgical, with slightly poorer outcomes associated with infected tumour or fistula [7, 56].

Complications: Rare (<5 %) including haemorrhage, bacteraemia, pain (particularly in transgluteal approach), organ injury, bowel injury and drain kinking or blockage [7, 56].

Obstructive jaundice can cause pruritus, cholangitis, sepsis, hepatic dysfunction and malnutrition and is associated with short life expectancy if untreated [1]. Endoscopic treatment of distal biliary obstruction due to pancreatic neoplasm is an effective treatment for the majority of patients [2, 57]. The role of percutaneous treatment is for effective primary or palliative management in those who fail endoscopic intervention, are unfit for endoscopy, or in those with proximal duct obstruction (due to hilar lymphadenopathy, hilar metastatic liver disease) [2, 57]. The efficacy of nonsurgical palliative treatments varies according to the location of obstruction, the technique and extent of decompression and the biliary stent prosthesis used, but biliary stents improve quality of life [1, 57].

Percutaneous drainage can be performed using a combination of US and fluoroscopic guidance [7]. Once biliary access is established, it may be possible to traverse the obstruction/stricture (using catheters and wires) to enable insertion of a stent or placement of an internal-external biliary drain as a temporising measure prior to stent insertion (Figs. 9.5a–d and 9.6a–c) [7, 57]. Percutaneous stent placement is less preferred than endoscopic metal stent placement due to theoretically more bleeding and pain complications, but this has not been confirmed in RCTs [1]. If the obstruction cannot be passed, then an external biliary drain is the only option, and this will likely be permanent, requiring regular drain exchanges to reduce infection risk and maintain patency [1, 7, 57].

Another topic of debate is that of metal versus plastic stents. Self-expanding metal stents have been shown to have better patency rates than plastic drains and plastic stents [1]. An advantage of plastic drains is that the patient is aware of blockage as soon as it happens due to bile leakage through the drainage bag or around the drain catheter [1]. Post-procedure pain associated with percutaneous drainage can usually be controlled with oral analgesia [1].

Less commonly, combined procedures with an endoscopist can be performed with side by side insertion of a duodenal or hepaticoduodenal stent. A problem with stent insertion is that they can block and need redilatation with a balloon catheter.