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 )

15. None

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
19. None
20. None

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

33. None
34. None
35. None
36. None

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%
49. None
50. None
51. None
52. None
53. None
54. None

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