Vertébroplastie et Métastases Vertébrales J.Chiras

16h00-16h40 Vertébroplastie et Métastases Vertébrales J.Chiras

Transcript

1. J. CHIRAS, H. BARRAGAN CAMPOS,E. CORMIER, B. JEAN, M. ROSE Department of Neuroradiology - GH PITIE-SALPETRIERE Paris - France PERCUTANEOUS VERTEBROPLASTY for SPINE METASTASES
2. VERTEBROPLASTY - percutaneous injection - surgical cement - fluoroscopic control
3. Goal antalgic effet spine stabilisation complementary TT alternative TT
4. LOCAL TT for BONE METASTASES K SURGERY CHEMOEMBOLIZATION RTH CEMENTOPLASTY Local TT for Bone Metastase
5. indications • painfull and/or unstable metastases of the vertebral body C2 S2 • Lytic and sclerotic metastases • ( asymptomatic metastases )
6. osteosclerotic metastases
7. osteosclerotic metastases
8. • Clinical : - neurological deficit - predominent radicular pain - infection local or systemic - aplasia ( temporary ) • Radiological : - main epiduritis - predominent posterior arch metastase CONTRA INDICATIONS CHEMO CHEMO V°
9. • Clinical : - neurological deficit - predominent radicular pain - infection local or systemic - aplasia ( temporary ) • Radiological : - main epiduritis - predominent posterior arch metastase CONTRA INDICATIONS CHEMO CHEMO V°
10. INDICATIONS vertebroplasty/other local treatments • recurrence of pain after radiotherapy • first step of local treatment for pain relief or spine stabilization ( in association with general TT ) • multidisciplinary group ( oncologist, radiotherapist, spinsurgeon, interventional neuroradiologist )
11. MATERIAL - 803 patients - 982 vertebroplasties - 2168 vertebrae: cervical 221 thoracic 1093 lumbar 835 sacrum 19 Primary N % breast 348 43,3 lung 96 12,0 Thyroid 64 6,7 kidney 54 6,6 unknown 49 6,1 Prostat 33 4,1 other 170 21,2 TOTAL 603 100,0
12. therapeutic protocol • PAIN RECURRENCE 397 cases (after local treatment) • INITIAL TREATMENT 585 cases - vert 191 cases - vert + Rth 253 cases - vert + surg. ± Rth 56 cases - vert + surg. 85 cases
13. recurrent pain after local treatment ( breast K )
14. recurrent pain after local treatment ( breast K )
16. malignant pheochromocytoma
17. malignant pheochromocytoma
18. Initial treatment of vertebral metastases • point of therapeutic decision - radio / chemo sensitivity - spine instability • Combined local TT : RF ablation RTH Surgery Chemoembolization
21. F. 31 y, breast K. , …
22. F. 31 y, breast K. , …
23. 1 year later…
24. 1 year later…
25. Osteosclerotic metastases prostat K.
26. Osteosclerotic metastases prostat K.
27. Association Rth and vertebroplasty (First)
28. Association Rth and vertebroplasty (First)
29. Breast K.
30. Breast K.
31. Vertebroplasty + Surg. ± Rth renal carcinoma
32. Vertebroplasty + Surg. ± Rth renal carcinoma
37. RESULTS 803 patients 1° ANTALGIC EFFECT (relief of pain) 731 91% - clear or complete 177 22% - partial 554 69% - poor 72 9% 2°CARCINOLYTIC EFFECT no local recurrence 90% of cases
38. LONGTERM RESULTS NO RECURRENCE AT 5 YEARS FOLLOW UP NO RECURRENCE AT 4 YEARS FOLLOW UP ( breast k. ) ( m. pheo )
39. Complications • Local (1,6%) - hematomas 1 cervical requiring intubation - radicular pain 14 all resolutive after TT ( 8 NSAIDs TT - 5 FORAMINAL BLOCKAGE, 1 surgical debulking ) - paraplegia non resolutive despite surgical TT 1 • General (0,7%) Major complications: 1° cervical vert. :arterial migration fatal stroke ( 0,4% ) 2° thoracic vert. :cord compression paraplegia ( 0,1% ) ( during last 4 years no major complication )
40. Local complications/ Technical problems extra-vertebral leak: - veins - soft tissues mecanism: - fluid cement - hyper pressure - needle position
41. Complications/posterior wall disruption (R=1) (2168 vertebrae) Radicular pain Paraplegia R=1 N=1068 7 R=0 N=1100 7 1 N=2168 14 (7% ) 1 (0,5% ) 0  
42. Osteoclerotic metastases - clinical improvement : 90 % - complications : 10 % ( radicular pain PULM - EMB )
43. MATERIAL • 52 patients - M 6 - F 46 Age : 27 - 84 Y ( M = 54,7 ) •Primary cancer: - Breast 4 - Prostate 3 - Other 9 • CT evaluation: pure osteoclerotic 53 mixed sclerotic / lytic 50
44. METHOD - 59 procedures - 103 vertebrae ( C: 2 - Th: 59 - L: 42 )
45. INDICATION ( 103 vertebrae ) • primary local TT 66V • local recurrence 37V THERAPEUTIC PROTOCOL • VERT 92 • VERT + RTH 6 • VERT + SURG 6
46. TECHNICAL PROBLEMS - HARDNESS OF THE VERTEBRA Difficulties for needle position - DENSITY OF THE BONE High pressure injection ⇑ the risk of leakage. HETEROGENEOUS FILLING
47. RESULTS ANATOMICAL RESULT CLINICAL RESULT
48. ANATOMICAL RESULT (FILLING) - 103 V - • FAILURE 8% • POOR 25% • MODERATE 20% • ADEQUATE 55% •LEAKAGE 50,5%
55. CLINICAL RESULTS ( 1M ) - PAIN RELEASE COMPLETE 71% - PAIN RELEASE PARTIAL 21% COMPLICATIONS ( POST-OP ) 11,9% • LOCAL: - RADICULALGIE 3 ( TRANSCIENT 1 PERSISTENT 2 ï LOCAL TT) - CAUDAEQUINA SYNDROM 1 ( EPIDURITIS ) - HEMOTHORAX 1 • GENERAL : PULMONARY EMBOLISM 2
56. Clinical results • antalgic effect : - immediate (< 3 days) - clear 22 % - partial 60 % • prolonged reinforcement 95 % of cases
57. Clinical results • antalgic effect : - immediate (< 3 days) - clear 22 % - partial 60 % • prolonged reinforcement 95 % of cases
58. CONCLUSIONS • Low rate of definitive complications (0.7%) • High rate of pain release (70 → 90%) • Potential carcinolytic effect ⇒  INDICATIONS
59. CONCLUSIONS • Low rate of definitive complications (0.7%) • High rate of pain release (70 → 90%) • Potential carcinolytic effect ⇒  INDICATIONS
60. Department of Neuroradiology - GH PITIE-SALPETRIERE Paris - France