Objetivo: O objetivo do estudo foi avaliar se o uso da terapia hemodinâmica pós-operatória guiada pelo índice cardíaco por método minimamente invasivo reduz o desfecho combinado de mortalidade em 30 dias e de complicações graves durante a internação hospitalar em pacientes com câncer submetidos à cirurgia de alto risco. Desenho: Estudo fase III, de superioridade, unicêntrico, randomizado e controlado realizado no Instituto do Câncer do Estado de São Paulo, Faculdade de Medicina da Universidade de São Paulo, Brasil. População: Pacientes adultos submetidos a cirurgia de alto risco para tratamento de câncer e que necessitaram de cuidados pós-operatórios em unidade de terapia intensiva. Intervenção: Um protocolo de terapia hemodinâmica pós-operatória guiada por metas (incluindo reposição volêmica, fármacos vasoativos e transfusão de hemácias para manter índice cardíaco maior ou igual a 2,5 L/min/m2) foi comparado a uma terapia padrão nas primeiras 8 horas de admissão dos pacientes na Unidade de Terapia Intensiva. Desfecho primário: Desfecho composto por mortalidade em 30 dias e complicações graves durante a internação hospitalar (infarto agudo do miocárdio, síndrome do baixo débito cardíaco, isquemia mesentérica, isquemia vascular periférica, embolia pulmonar, síndrome do desconforto respiratório agudo, acidente vascular cerebral, insuficiência renal aguda, infecção de ferida operatória profunda e reoperação). Resultados: Foram incluídos 128 pacientes, 64 no grupo terapia guiada por metas (TGM) e 64 no grupo terapia padrão (TP). Durante as 8 horas de intervenção, não houve diferença entre os grupos TGM e TP na quantidade de fluidos administrada (1295,1 mL ± 613,2 mL vs 1129 mL ± 557,5 mL, P=0,189), no número de pacientes que receberam norepinefrina (65,5% vs 51,6%, P= 0,211) e no número de pacientes expostos a transfusão de hemácias (3,1% vs 0, P=0,496). Um número maior de pacientes do grupo TGM recebeu dobutamina durante a intervenção quando comparado aos pacientes do grupo TP (54,7% vs 15,65%, P < 0,001. Não houve diferença entre os grupos em relação ao desfecho primário (53,1% no grupo TGM vs 43,8% no grupo TP, P= 0,289). Conclusão: A terapia hemodinâmica guiada pelo índice cardíaco aplicada nas primeiras 8h de pós-operatório não reduziu a mortalidade em 30 dias e as complicações graves durante a internação hospitalar quando comparada a estratégia padrão em pacientes com câncer submetidos a cirurgia de alto risco. A terapia hemodinâmica resultou em maior exposição dos pacientes à dobutamina, sem resultar em redução das complicações. Registro no Clinical Trials: NCT01946269 / Objectives: The aim of this study was to determine whether a postoperative hemodynamic therapy guided by the cardiac index based on minimally invasive cardiac output monitoring decreases the incidence of 30-day mortality and postoperative complications in oncologic patients undergoing high-risk non-cardiac surgery. Design: Phase III, single center, superiority, randomized and controlled trial performed at the Instituto do Câncer do Estado de São Paulo, Faculdade de Medicina da Universidade de São Paulo, Brazil. Population: Adult patients undergoing high-risk cancer surgery who required intensive care unit admission. Intervention: A hemodynamic goal directed therapy protocol (including fluids, vasoactive agents and red blood cells transfusion to reach a cardiac index equal or higher than 2.5 L/min/m2) was compared to usual care during the first 8 h of postoperative. Primary outcome: The primary outcome was a composite endpoint of 30-day mortality and severe complications during hospital stay (acute myocardial infarction, low cardiac output syndrome, mesenteric ischemia, peripheral vascular ischemia, pulmonary embolism, acute respiratory distress syndrome, stroke, acute kidney injury, deep wound infection and reoperation). Results: 128 patients were included in the study; 64 were allocated to the goal directed therapy group (GDT) and 64 to the usual care group (UC). During the 8-hour intervention, there were no differences between GDT and UC groups in the amount of administered fluid (1295.1 mL ± 613.2 mL) vs (1129 mL ± 557.5 mL), P=0.189), in the number of patients who received norepinephrine (65.5% vs. 51.6%, P= 0.211) and in the number of patients exposed to red blood cells transfusion (3.1% vs. 0, P= 0,496). However, more patients in GDT group needed dobutamine during intervention when compared to patients from the UC group (54.7% vs. 15.65%, P < 0.001). The primary outcome was reached by a similar proportion of patients in both groups (53.1% in GDT group vs. 43.8% in UC group, P=0.289). Conclusion: Postoperative hemodynamic therapy guided by cardiac index monitoring in the first 8-hour of postoperative does not reduce 30-day mortality and severe complications during hospital stay when compared to the usual care in cancer patients undergoing high-risk surgery. Also, hemodynamic therapy resulted in a higher needing of dobutamine without improving outcomes. Clinical Trials Register: NCT01946269.

No description available.

Les travaux de cette Thèse porte sur des éléments de guidage d'une thérapie focale du cancer de la prostate par Ultrasons Focalisés Haute Intensité (HIFU). Actuellement l'IRM est la seule technique d'imagerie qui permet de localiser la tumeur dans la prostate. Par contre, la tumeur n'est pas visible dans l'échographie qui est l'imagerie utilisée pour la planification et le guidage de la thérapie. L'objectif de la Thèse est de proposer des techniques de recalage de l'IRM T2 vers l'échographie. Deux approches ont été explorées : 1) Une approche basée région et plus particulièrement une méthode de descripteurs de la texture en échographie basée sur des moments invariants en rotation et en échelle. Ces descripteurs sont sensibles à la distribution du speckle quelle que soit son échelle ou son orientation. Certains de ces descripteurs permettent de caractériser les régions présentant une même distribution de speckle, mais nous avons également constaté que certains autres de ces descripteurs étaient sensibles aux contours de ces régions. Cette caractéristique nous semble très utile pour les méthodes de segmentation intégrant à la fois l'information de contours et l'information de régions (contours actifs, graph cut, etc.). 2) Une approche basée surface. Nous avons adapté une méthode de Définition Optimale de la Surface (OSD) à la segmentation de la prostate en IRM T2. Et plus particulièrement une segmentation concurrente de la prostate, de la vessie et du rectum par OSD multi-objets. Les surfaces de la prostate extraites du volume échographique et du volume IRM T2 nous ont permis d'envisager une première tentative de recalage surface/surface par la méthode des démons. / The work of this Thesis is focused on image guided focal therapy of prostate cancer by High Intensity Focused Ultrasound (HIFU). Currently MRI is the only imaging technique that can locate the tumor in prostate. In contrast, the tumor is not visible in the ultrasound image which is used to guide the HIFU planning and therapy. The aim of the Thesis is to provide registration techniques of T2 MRI to ultrasound. Two approaches were explored: 1) Region-based registration. More particularly, we studied an ultrasound texture descriptors based on moments invariant to rotation and scaling. These descriptors are sensitive to speckle distribution regardless of the scale or the orientation. As we expected, some of these descriptors can be used to characterize regions sharing a similar speckle spatial distribution. But, we also found that some other descriptors were sensitive to the contours of these regions. This property seems very useful to adapt the classical boundary-based or mixed region/boundary-based segmentation methods (active contours, graph cut, etc.) to process US images. 2) Surface-based registration approach.. We adapted the Optimal Definition Surface (OSD) method to the segmentation of the prostate in T2 MRI, Furthermore, we proposed the multiple-objects OSD which is a concurrent segmentation of the prostate, bladder and rectum. Finally we used the prostate surface extracted from the ultrasound volume and from T2 MRI in a surface-to-surface elastic registration scheme. This registration allowed us to merge the preoperative MR information in the peroperative US volume.

No description available.

No description available.

The work of this Thesis is focused on image guided focal therapy of prostate cancer by High Intensity Focused Ultrasound (HIFU). Currently MRI is the only imaging technique that can locate the tumor in prostate. In contrast, the tumor is not visible in the ultrasound image which is used to guide the HIFU planning and therapy. The aim of the Thesis is to provide registration techniques of T2 MRI to ultrasound. Two approaches were explored: 1) Region-based registration. More particularly, we studied an ultrasound texture descriptors based on moments invariant to rotation and scaling. These descriptors are sensitive to speckle distribution regardless of the scale or the orientation. As we expected, some of these descriptors can be used to characterize regions sharing a similar speckle spatial distribution. But, we also found that some other descriptors were sensitive to the contours of these regions. This property seems very useful to adapt the classical boundary-based or mixed region/boundary-based segmentation methods (active contours, graph cut, etc.) to process US images. 2) Surface-based registration approach.. We adapted the Optimal Definition Surface (OSD) method to the segmentation of the prostate in T2 MRI, Furthermore, we proposed the multiple-objects OSD which is a concurrent segmentation of the prostate, bladder and rectum. Finally we used the prostate surface extracted from the ultrasound volume and from T2 MRI in a surface-to-surface elastic registration scheme. This registration allowed us to merge the preoperative MR information in the peroperative US volume.