Radiologie Interventionnelle Oncologique

Pr Frank Boudghene

Radiologie Hôpital Tenon

APHP.6 - Sorbonne Université

PARIS

Radiologie Interventionnelle

• Guidage par imagerie => Mini invasif • Induit moins de complications, et réduit la durée d’hospitalisation

Movable gantryputs cliniciansin controlThe Discovery IGS provides full flexibility in your clinical

space. Controls available at tableside and at the back

of the gantry let you maneuver the system easily and

conveniently. When in position for imaging, the gantry

swivels around the table on a defined path, with

precise laser guidance. Combined gantry and GE OR

table movement enables you to stop and image at any

point for coverage from head to toe.

6 Discovery IGS Discovery IGS 7

One-touch back-in and back-out means fully

flexible procedures

With the Discovery IGS, you can t ruly have it both

ways: Move the gantry to the table for imaging,

move it aside when not needed – and all at the

touch of a button. From seven posit ions at the

table, you can back the gantry out to predefined

locat ions. Back-out distances are customizable to

suit different room sizes.

Customized parking provides the maximum

freedom

When it ’s not needed for imaging, you can move

the gantry aside completely, allowing complete

pat ient access at the table and enabling easy

room cleaning. You can pre-configure two parking

spaces to suit your room size and shape.

Teams work better with nothing in their way

The Discovery IGS gives physicians, nurses,

anesthesiologists and technologists ample space

to work together effect ively. Clinicians can

posit ion on either side of the pat ient according

to preference. With the offset C-arm, the

anesthesiologist can work comfortably at the

patient’s head. Addit ionally y ou can work with the

system posit ioned slight ly to the left to facilitate

access to the patient when using TEE.

La RI n’est pas de la Chirurgie : elles sont complémentaires

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Radiologie Interventionnelle dédiée à la prise en charge des cancers Comprend toutes les techniques percutanées et/ou endovasculaires/endoluminales guidées par l’image:

– Diagnostic – Traitement – Management des incidents

• Sous guidage par l’image (US, TDM, IRM, PET)

• Très liée à la recherche comme à l’ innovation

• «Optimisation de la prise en charge»

- ambulatoire - sans anesthésie générale - récupération rapide

«activité préservée »

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Oncologie Interventionnelle

Quelles procédures ?

Biopsies guidées

Drainages

Stents, filtres caves

Embolisations

Ablations tumorales

patient à jeun, perfusé

crase sanguine, groupe sanguin …..

consultation RI (48h)

antalgiques + anti inflammatoires

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Oncologie Interventionnelle

BIOPSIES et médecine de précision

Biopsie du FOIE sous TDM

Biopsie OSSEUSE sous PET-CT

Biopsie liquide (CTC)

Biopsie solide

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Biopsie du SEIN sous ECHO

Biopsie du SEIN sous IRM

Quels équipements? => CBCT

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Procédures ENDOLUMINALES

Drainages

Procédures ENDOVASCULAIRES

PIC et PAC Filtres Caves

Stents Emboles

Procédures ENDOVASCULAIRES

Quels traitements? EMBOLISATIONS

CHIMIO Embolisation

RADIO Embolisation

TACE - LIPIODOL

HCC

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Quels traitements? ABLATIONS

Radio Frequence Micro Ondes

Cryotherapie Electroporation

TOUS ORGANES

(initialement pour tumeurs du foie)

Ablations = Médecine personnalisée

Ablations thermiques

Techniques « chaudes » Techniques « froides »

Apoptose Nécrose

Résultats

3 mois de suivi

CBCT de planification

Même dans des zones difficiles d’accès

Radio Fréquence ou Cryothérapie?

Radio Fréquence Cryothérapie

Accessibilité X 0

Volume d’ablation 0 X

Proximité des structures « sensibles » (nerfs, peau, vaisseaux)

0 X

Anesthesie locale 0 X

Injection de ciment X 0

Durée de la procedure X 0

Cout = =

En pratique courante nous avons souvent à choisir

Effet abscopal

Complémentaire de l’ablation 17

10/2015 01/2016 04/2016 09/2017

Avant embolisation portale

Foie gauche/ Foie total = 29 %

Après embolisation portale

Foie gauche/ Foie total = 48 %

Embolisation portale pré-opératoire

Techniques non concurrentes mais complémentaires

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Traitements combinés = embolisation + chirurgie

Complémentaire de la chirurgie ce qui permet de traiter plus de patients 19

Traitements combinés = radiofréquence + chirurgie

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Pluri étagée

Traitements combinés = cimentoplastie + chirurgie

Nouveaux matériels développés pour RIO = Kiva, Vexim, VBS, LPBS

RANDOMIZED TRIAL KAST Study: The Kiva System • Tutton et al

870 www.spinejournal.com June 2015

In the 285 AT subjects, VAS scores improved signifi cantly

over baseline in both groups after 12 months (Kiva: 70.8 ±

26.3; and BK: 71.8 ± 23.5). ODI scores also improved sig-

nifi cantly at 12 months over baseline in both groups (Kiva:

38.1 ± 19.8; and BK: 42.2 ± 21.7). A comparison of VAS

( Figure 5A ) and ODI ( Figure 5B ) scores over time across

groups is presented.

In the AT subjects at 12 months, 20.9% (28/134) of the

Kiva group and 22.3% (29/130) of the BK group had expe-

rienced a new adjacent level compression fracture (symptom-

atic and asymptomatic combined rate), meeting the endpoint

of noninferiority in the Kiva group. An analysis of the per

protocol population showed that 13.8% (16/116) of the Kiva

group and 20.2% (23/114) of the BK group had experienced

a new adjacent level fracture.

Extravasation of bone cement observed at the procedure

was assessed independently by the CL and IPA. Statisti-

cal noninferiority was met for the extravasation rate by CL

and IPA. The extravasation rate as reported by the site was

signifi cantly lower in the Kiva group when compared with

BK (Kiva: 16.9%; and BK: 25.8%). Secondary endpoints are

summarized in Table 5 .

DISCUSSION The KAST study was a prospective, multicenter, randomized

controlled trial designed to evaluate the safety and effective-

ness of the Kiva system, a novel implant-based vertebral aug-

mentation device. Given its randomized controlled design,

large cohort, and 12-month follow-up, it provides level 1

evidence in the study of 2 treatment arms for osteoporotic

compression fractures. Focal tenderness and marrow edema

on magnetic resonance imaging were required inclusion cri-

teria. These refi ned inclusion criteria identifi ed patients with

acute or subacute osteoporotic VCF-related pain, unlike ear-

lier reported randomized controlled trials without correlative

examination or strict imaging criteria. 1 , 7 The KAST study

incorporated the use of an independent CL for radiographical

evaluations and used an IPA for adjudication of safety data

in an effort to remove bias in its assessment of effi cacy and

safety.

The KAST study was able to prove that Kiva is noninferior

to BK in its ability to safely relieve pain and improve func-

tion in the treatment of osteoporotic VCFs. Pain and func-

tion were signifi cantly improved from baseline at 30 days,

6 months, and 12 months in both groups, demonstrating the

clinical success of these techniques in treating painful VCFs.

No cement-related clinical complications were reported in

the 300 subjects enrolled. The observed rate of extravasation

Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.

Figure 1. Image of the Kiva system used for vertebral augmentation.

Figure 2. Image under fl uoroscopy of ( A ) the Kiva implant being de-

ployed during treatment of VCF and ( B ) post-VCF treatment with the

Kiva system. The Kiva implant provides a predictable reservoir for bone

cement and the vertebra is restored. VCF indicates vertebral compres-

sion fracture.

Figure 3. Image of ( A ) polymethylmethacrylate being injected and con-

tained within the Kiva implant. ( B ) The Kiva implant.

SPINE141054_LR 870 21/05/15 10:31 AM

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Y-strut®

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Non thermique = Electroporation/Electrochimiothérapie

Pour préserver nerfs and tissus sensibles

Pulses courts à haut Voltage

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ECT = pour traverser les membranes

Tenon 01/10/2018

Première ECT Française

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Electro Chimio Therapie

Tenon 05/09/2018

Premiere ECT Francaise

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Outils d’aide

Prendre en compte l’Anxiété

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Bien-être Visuel et Acoustique

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Suite d’Oncologie Interventionnelle

Equipes/ salles dédiées

Maternité

Salles d’Endoscopie

USI

Bloc opératoire

Salle de Radiologie Interventionnelle

Oncologie

RIO = 4ème Mousquetaire contre le Cancer

Chirurgie Oncologie

Radiothérapie Oncologie Interventionnelle

Personnalisée / Précision Médecine

Encourager les jeunes radiologues à développer cette activité essentielle 28

Oncologie Interventionnelle

Radiologie Interventionnelle Avancée = Médecine de Précision OI = une des 3 surspécialités de Radiologie Interventionnelle - décret d’activité et pratique encadrée - formation spécifique (> 30% des promotions d’internes) - valorisation des actes (pas une sous spécialité chirurgicale)

Encourager les jeunes radiologues à développer la RIA

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