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Martin RCG. Multi-disciplinary management of locally advanced pancreatic cancer with irreversible electroporation. J Surg Oncol 2017; 116:35-45. [PMID: 28475814 DOI: 10.1002/jso.24640] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2017] [Accepted: 03/22/2017] [Indexed: 12/13/2022]
Abstract
The essential diagnosis for LAPC is based on high-quality cross-sectional imaging, which demonstrates tumor invasion into the celiac/superior mesenteric arteries and/or superior mesenteric/portal venous system that is not reconstructable. The optimal management of these patients is evolving quickly with the advent of newer chemotherapeutics, radiation, and non-thermal ablation modalities. This review will present the current status of initial chemotherapy, surgical therapy, ablative therapy, and radiation therapy for patients with nonmetastatic locally advanced unresectable pancreatic cancer.
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Affiliation(s)
- Robert C G Martin
- Division of Surgical Oncology, Department of Surgery, University of Louisville, Louisville, Kentucky
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Yao C, Dong S, Zhao Y, Lv Y, Liu H, Gong L, Ma J, Wang H, Sun Y. Bipolar Microsecond Pulses and Insulated Needle Electrodes for Reducing Muscle Contractions During Irreversible Electroporation. IEEE Trans Biomed Eng 2017; 64:2924-2937. [PMID: 28391185 DOI: 10.1109/tbme.2017.2690624] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
OBJECTIVE To minimize the effect of muscle contractions during irreversible electroporation (IRE), this paper attempts to research the ablation effect and muscle contractions by applying high-frequency IRE (H-FIRE) ablation to liver tissue in vivo. METHODS An insulated needle electrode was produced by painting an insulating coating on the outer surface of the needle electrode tip. A series of experiments were conducted using insulated needle electrodes and traditional needle electrodes to apply H-FIRE pulses and traditional monopolar IRE pulses to rabbit liver tissues. The finite element model of the rabbit liver tissue was established to determine the lethal thresholds of H-FIRE in liver tissues. Muscle contractions were measured by an accelerometer. RESULTS With increased constitutive pulse width and pulse voltage, the ablation area and muscle contraction strength are also increased, which can be used to optimize the ablation parameters of H-FIRE. Under the same pulse parameters, the ablation areas are similar for the two types of electrodes, and the ablation region has a clear boundary. H-FIRE and insulated needle electrodes can mitigate the extent of muscle contractions. The lethal thresholds of H-FIRE in rabbit liver tissues were determined. CONCLUSION This paper describes the relationships between the ablation area, muscle contractions, and pulse parameters; the designed insulated needle electrodes can be used in IRE for reducing muscle contraction. SIGNIFICANCE The study provides guidance for treatment planning and reducing muscle contractions in the clinical application of H-FIRE.
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Latouche EL, Sano MB, Lorenzo MF, Davalos RV, Martin RCG. Irreversible electroporation for the ablation of pancreatic malignancies: A patient-specific methodology. J Surg Oncol 2017; 115:711-717. [PMID: 28185295 DOI: 10.1002/jso.24566] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2016] [Accepted: 01/07/2017] [Indexed: 12/18/2022]
Abstract
BACKGROUND AND OBJECTIVES Irreversible Electroporation (IRE) is a focal ablation technique highly attractive to surgical oncologists due to its non-thermal nature that allows for eradication of unresectable tumors in a minimally invasive procedure. In this study, our group sought to address the challenge of predicting the ablation volume with IRE for pancreatic procedures. METHODS In compliance with HIPAA and hospital IRB approval, we established a pre-treatment planning methodology for IRE procedures in pancreas, which optimized treatment protocols for individual cases of locally advanced pancreatic cancer (LAPC). A new method for confirming treatment plans through intraoperative monitoring of tissue resistance was also proved feasible in three patients. RESULTS Results from computational models showed good correlation with experimental data available in the literature. By implementing the proposed resistance measurement system 210 ± 26.1 (mean ± standard deviation) fewer pulses were delivered per electrode-pair. CONCLUSION The proposed physics-based pre-treatment plan through finite element analysis and system for actively monitoring resistance changes can be paired to significantly reduce ablation times and risk of thermal effects during IRE procedures for LAPC.
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Affiliation(s)
- Eduardo L Latouche
- Biomedical Engineering and Mechanics, Virginia Polytechnic Institute and State University, Blacksburg, Virginia
| | - Michael B Sano
- Radiation Oncology, Stanford University School of Medicine, Stanford, California.,UNC/NCSU Joint Department of Biomedical Engineering, Chapel Hill, North Carolina
| | - Melvin F Lorenzo
- Biomedical Engineering and Mechanics, Virginia Polytechnic Institute and State University, Blacksburg, Virginia
| | - Rafael V Davalos
- Biomedical Engineering and Mechanics, Virginia Polytechnic Institute and State University, Blacksburg, Virginia
| | - Robert C G Martin
- Surgery, Division of Surgical Oncology, University of Louisville, Louisville, Kentucky
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Bond L, Schulz B, VanMeter T, Martin R. Intra-operative navigation of a 3-dimensional needle localization system for precision of irreversible electroporation needles in locally advanced pancreatic cancer. Eur J Surg Oncol 2017; 43:337-343. [DOI: 10.1016/j.ejso.2016.09.009] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2016] [Revised: 08/29/2016] [Accepted: 09/06/2016] [Indexed: 12/18/2022] Open
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Underhill CE, Walsh NJ, Bateson BP, Mentzer C, Kruse EJ. Feasibility and Safety of Irreversible Electroporation in Locally Advanced Pelvic and Retroperitoneal Tumors. Am Surg 2016. [DOI: 10.1177/000313481608200916] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Casey E. Underhill
- Department of Surgery Medical College of Georgia Augusta University Augusta, Georgia
| | - Nathaniel J. Walsh
- Department of Surgery Medical College of Georgia Augusta University Augusta, Georgia
| | - Brian P. Bateson
- Department of Surgery Medical College of Georgia Augusta University Augusta, Georgia
| | - Caleb Mentzer
- Department of Surgery Medical College of Georgia Augusta University Augusta, Georgia
| | - Edward J. Kruse
- Department of Surgery Medical College of Georgia Augusta University Augusta, Georgia
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Papamichail M, Ali A, Pizanias M, Peddu P, Karani J, Heaton N. Irreversible electroporation for the treatment of pancreatic neuroendocrine tumors. KOREAN JOURNAL OF HEPATO-BILIARY-PANCREATIC SURGERY 2016; 20:116-20. [PMID: 27621748 PMCID: PMC5018952 DOI: 10.14701/kjhbps.2016.20.3.116] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/25/2016] [Revised: 05/30/2016] [Accepted: 06/19/2016] [Indexed: 12/18/2022]
Abstract
Backgrounds/Aims Resection or enucleation is currently the treatment of choice for small pancreatic neuroendocrine tumors (NETs). Irreversible electroporation is a novel ablative method that is used for locally advanced pancreatic adenocarcinoma, but little data exists for its use for pancreatic NETs. We report an early experience of IRE for early pancreatic NETs. Methods Between April 2014 and March 2015, 3 patients with small (<2 cm) pancreatic NETs were treated with percutaneous IRE. Results There were no adverse effects during the procedure. Mean hospital stay was 2.6 days. All patients remained disease free on 12-19 months follow up. One patient developed recurrent pancreatitis with pseudocyst formation. Conclusions IRE for small tumors of the pancreas is practical and may offer advantages over other thermal ablative techniques, since it preserves vital structures such as blood vessels, bile and pancreatic ducts. Further data regarding the long term disease free interval is required to establish efficacy.
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Affiliation(s)
- Michail Papamichail
- Institute of Liver Studies, Kings Health Partners at King's College Hospital NHS Trust, London, United Kingdom
| | - Amir Ali
- Institute of Liver Studies, Kings Health Partners at King's College Hospital NHS Trust, London, United Kingdom
| | - Michail Pizanias
- Institute of Liver Studies, Kings Health Partners at King's College Hospital NHS Trust, London, United Kingdom
| | - Praveen Peddu
- Institute of Liver Studies, Kings Health Partners at King's College Hospital NHS Trust, London, United Kingdom
| | - John Karani
- Institute of Liver Studies, Kings Health Partners at King's College Hospital NHS Trust, London, United Kingdom
| | - Nigel Heaton
- Institute of Liver Studies, Kings Health Partners at King's College Hospital NHS Trust, London, United Kingdom
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Martin RCG, Durham AN, Besselink MG, Iannitti D, Weiss MJ, Wolfgang CL, Huang KW. Irreversible electroporation in locally advanced pancreatic cancer: A call for standardization of energy delivery. J Surg Oncol 2016; 114:865-871. [PMID: 27546233 DOI: 10.1002/jso.24404] [Citation(s) in RCA: 55] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2016] [Accepted: 07/30/2016] [Indexed: 02/06/2023]
Abstract
Irreversible Electroporation (IRE) is used to treat locally advanced cancers, commonly of the pancreas, liver, kidney, and other soft tissues. Precise eligibility for IRE should be established in each individual patient by a multidisciplinary team based on comprehensive clinical, imaging, and laboratory assessment. Standardization of IRE technique and protocols is expected to improve safety, lead to reproducible outcomes, and facilitate further research into IRE. The present article provides a set of technical recommendations for the use of IRE in the treatment of locally advanced pancreatic cancer. J. Surg. Oncol. 2016;114:865-871. © 2016 2016 Wiley Periodicals, Inc.
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Affiliation(s)
- Robert C G Martin
- Division of Surgical Oncology, Hiram C Polk Jr Department of Surgery, University of Louisville School of Medicine, Louisville, Kentucky.
| | - Alan North Durham
- Division of Surgical Oncology, Hiram C Polk Jr Department of Surgery, University of Louisville School of Medicine, Louisville, Kentucky
| | - Marc G Besselink
- Department of Surgery, Academic Medical Center Amsterdam, Amsterdam, The Netherlands
| | | | | | - Christopher L Wolfgang
- Department of Surgery and Hepatitis Research Center, National Taiwan University Hospital, China and Singapore Universities Graduate Institute of Clinical Medicine, National Taiwan University, Taipei, Taiwan
| | - Kai-Wen Huang
- Department of Surgery and Hepatitis Research Center, National Taiwan University Hospital, China and Singapore Universities Graduate Institute of Clinical Medicine, National Taiwan University, Taipei, Taiwan
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van den Bos W, Jurhill R, de Bruin D, Savci-Heijink C, Postema A, Wagstaff P, Muller B, Varkarakis I, Skolarikos A, Zondervan P, Laguna Pes M, de Reijke T, de la Rosette J. Histopathological Outcomes after Irreversible Electroporation for Prostate Cancer: Results of an Ablate and Resect Study. J Urol 2016; 196:552-9. [PMID: 27004693 DOI: 10.1016/j.juro.2016.02.2977] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/03/2016] [Indexed: 12/18/2022]
Affiliation(s)
- W. van den Bos
- Department of Urology, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands
| | - R.R. Jurhill
- Department of Pathology, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands
| | - D.M. de Bruin
- Department of Urology, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands
- Department of Biomedical Engineering & Physics, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands
| | - C.D. Savci-Heijink
- Department of Pathology, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands
| | - A.W. Postema
- Department of Urology, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands
| | - P.G.K. Wagstaff
- Department of Urology, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands
| | - B.G. Muller
- Department of Urology, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands
| | - I.M. Varkarakis
- 2nd Department of Urology, Athens Medical University, University of Athens, Athens, Greece
| | - A. Skolarikos
- 2nd Department of Urology, Athens Medical University, University of Athens, Athens, Greece
| | - P.J. Zondervan
- Department of Urology, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands
| | - M.P. Laguna Pes
- Department of Urology, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands
| | - T.M. de Reijke
- Department of Urology, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands
| | - J.J.M.C.H. de la Rosette
- Department of Urology, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands
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van den Bos W, de Bruin DM, Jurhill RR, Savci-Heijink CD, Muller BG, Varkarakis IM, Skolarikos A, Zondervan PJ, Laguna-Pes MP, Wijkstra H, de Reijke TM, de la Rosette JJMCH. The correlation between the electrode configuration and histopathology of irreversible electroporation ablations in prostate cancer patients. World J Urol 2016; 34:657-64. [PMID: 26296371 PMCID: PMC4841841 DOI: 10.1007/s00345-015-1661-x] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2015] [Accepted: 07/30/2015] [Indexed: 01/19/2023] Open
Abstract
PURPOSE Irreversible electroporation (IRE) is a novel minimally invasive therapy for prostate cancer using short electric pulses to ablate prostate tissue. The purpose of this study is to determine the IRE effects in prostate tissue and correlate electrode configuration with the histology of radical prostatectomy (RP) specimens. We hypothesize that the area within the electrode configuration is completely ablated and that the area within the electrode configuration is predictive for the ablated area after treatment. METHODS A prospective phase I/II study was conducted in 16 consecutive patients with histopathologically confirmed prostate cancer scheduled for RP. Focal or extended IRE treatment of the prostate was performed 4 weeks prior to RP. The locations of the electrodes were used to calculate the planned ablation zone. Following RP, the specimens were processed into whole-mount sections, histopathology (PA) was assessed and ablation zones were delineated. The area of the tissue alteration was determined by measuring the surface. The planned and the histological ablation zones were compared, analysed per individual patient and per protocol (focal vs. extended). RESULTS All cells within the electrode configuration were completely ablated and consisted only of necrotic and fibrotic tissue without leaving any viable cells. The histological ablation zone was always larger than the electrodes configuration (2.9 times larger for the 3 electrodes configuration and 2.5 times larger for the ≥4 electrode configuration). These ablation effects extended beyond the prostatic capsule in the neurovascular bundle in 13 out of 15 cases. CONCLUSIONS IRE in prostate cancer results in completely ablated, sharply demarcated lesions with a histological ablation zone beyond the electrode configuration. No skip lesions were observed within the electrode configuration. CLINICAL TRIALS ClinicalTrials.gov Identifier: NCT01790451 https://clinicaltrials.gov/ct2/show/NCT01790451.
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Affiliation(s)
- W van den Bos
- Department of Urology Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands.
| | - D M de Bruin
- Department of Urology Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
- Department of Biomedical Engineering and Physics. Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - R R Jurhill
- Department of Pathology, Academic Medical Center, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - C D Savci-Heijink
- Department of Pathology, Academic Medical Center, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - B G Muller
- Department of Urology Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - I M Varkarakis
- 2nd Department of Urology, Athens Medical University, University of Athens, Athens, Greece
| | - A Skolarikos
- 2nd Department of Urology, Athens Medical University, University of Athens, Athens, Greece
| | - P J Zondervan
- Department of Urology Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - M P Laguna-Pes
- Department of Urology Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - H Wijkstra
- Department of Urology Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
- Department of Electrical Engineering, Eindhoven University of Technology, Eindhoven, The Netherlands
| | - T M de Reijke
- Department of Urology Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - J J M C H de la Rosette
- Department of Urology Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
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Local Ablative Strategies for Ductal Pancreatic Cancer (Radiofrequency Ablation, Irreversible Electroporation): A Review. Gastroenterol Res Pract 2016; 2016:4508376. [PMID: 26981115 PMCID: PMC4770121 DOI: 10.1155/2016/4508376] [Citation(s) in RCA: 49] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2015] [Revised: 10/28/2015] [Accepted: 01/13/2016] [Indexed: 02/07/2023] Open
Abstract
Pancreatic ductal adenocarcinoma (PDAC) has still a dismal prognosis. Locally advanced pancreatic cancer (LAPC) accounts for the 40% of the new diagnoses. Current treatment options are based on chemo- and radiotherapy regimens. Local ablative techniques seem to be the future therapeutic option for stage-III patients with PDAC. Radiofrequency Ablation (RFA) and Irreversible Electroporation (IRE) are actually the most emerging local ablative techniques used on LAPC. Initial clinical studies on the use of these techniques have already demonstrated encouraging results in terms of safety and feasibility. Unfortunately, few studies on their efficacy are currently available. Even though some reports on the overall survival are encouraging, randomized studies are still required to corroborate these findings. This study provides an up-to-date overview and a thematic summary of the current available evidence on the application of RFA and IRE on PDAC, together with a comparison of the two procedures.
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Bonakdar M, Latouche EL, Mahajan RL, Davalos RV. The Feasibility of a Smart Surgical Probe for Verification of IRE Treatments Using Electrical Impedance Spectroscopy. IEEE Trans Biomed Eng 2015; 62:2674-84. [PMID: 26057529 DOI: 10.1109/tbme.2015.2441636] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
SIGNIFICANCE Irreversible electroporation (IRE) is gaining popularity as a focal ablation modality for the treatment of unresectable tumors. One clinical limitation of IRE is the absence of methods for real-time treatment evaluation, namely actively monitoring the dimensions of the induced lesion. This information is critical to ensure a complete treatment and minimize collateral damage to the surrounding healthy tissue. GOAL In this study, we are taking advantage of the biophysical properties of living tissues to address this critical demand. METHODS Using advanced microfabrication techniques, we have developed an electrical impedance microsensor to collect impedance data along the length of a bipolar IRE probe for treatment verification. For probe characterization and interpretation of the readings, we used potato tuber, which is a suitable platform for IRE experiments without having the complexities of in vivo or ex vivo models. We used the impedance spectra, along with an electrical model of the tissue, to obtain critical parameters such as the conductivity of the tissue before, during, and after completion of treatment. To validate our results, we used a finite element model to simulate the electric field distribution during treatments in each potato. RESULTS It is shown that electrical impedance spectroscopy could be used as a technique for treatment verification, and when combined with appropriate FEM modeling can determine the lesion dimensions. CONCLUSIONS This technique has the potential to be readily translated for use with other ablation modalities already being used in clinical settings for the treatment of malignancies.
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Treatment of 200 locally advanced (stage III) pancreatic adenocarcinoma patients with irreversible electroporation: safety and efficacy. Ann Surg 2015; 262:486-94; discussion 492-4. [PMID: 26258317 DOI: 10.1097/sla.0000000000001441] [Citation(s) in RCA: 265] [Impact Index Per Article: 29.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVES Ablative therapies have been increasingly utilized in the treatment of locally advanced pancreatic cancer (LAPC). Irreversible electroporation (IRE) is an energy delivery system, effective in ablating tumors by inducing irreversible membrane destruction of cells. We aimed to demonstrate efficacy of treatment with IRE as part of multimodal treatment of LAPC. METHODS From July 2010 to October 2014, patients with radiographic stage III LAPC were treated with IRE and monitored under a multicenter, prospective institutional review board-approved registry. Perioperative 90-day outcomes, local failure, and overall survival were recorded. RESULTS A total of 200 patients with LAPC underwent IRE alone (n = 150) or pancreatic resection plus IRE for margin enhancement (n = 50). All patients underwent induction chemotherapy, and 52% received chemoradiation therapy as well for a median of 6 months (range, 5-13 months) before IRE. IRE was successfully performed in all patients. Thirty-seven percent of patients sustained complications, with a median grade of 2 (range, 1-5). Median length of stay was 6 days (range, 4-36 days). With a median follow-up of 29 months, 6 patients (3%) have experienced local recurrence. Median overall survival was 24.9 months (range: 4.9-85 months). CONCLUSIONS For patients with LAPC (stage III), the addition of IRE to conventional chemotherapy and radiation therapy results in substantially prolonged survival compared with historical controls. These results suggest that ablative control of the primary tumor may prolong survival.
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Sano MB, Arena CB, Bittleman KR, DeWitt MR, Cho HJ, Szot CS, Saur D, Cissell JM, Robertson J, Lee YW, Davalos RV. Bursts of Bipolar Microsecond Pulses Inhibit Tumor Growth. Sci Rep 2015; 5:14999. [PMID: 26459930 PMCID: PMC4602310 DOI: 10.1038/srep14999] [Citation(s) in RCA: 69] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2015] [Accepted: 09/02/2015] [Indexed: 02/06/2023] Open
Abstract
Irreversible electroporation (IRE) is an emerging focal therapy which is demonstrating utility in the treatment of unresectable tumors where thermal ablation techniques are contraindicated. IRE uses ultra-short duration, high-intensity monopolar pulsed electric fields to permanently disrupt cell membranes within a well-defined volume. Though preliminary clinical results for IRE are promising, implementing IRE can be challenging due to the heterogeneous nature of tumor tissue and the unintended induction of muscle contractions. High-frequency IRE (H-FIRE), a new treatment modality which replaces the monopolar IRE pulses with a burst of bipolar pulses, has the potential to resolve these clinical challenges. We explored the pulse-duration space between 250 ns and 100 μs and determined the lethal electric field intensity for specific H-FIRE protocols using a 3D tumor mimic. Murine tumors were exposed to 120 bursts, each energized for 100 μs, containing individual pulses 1, 2, or 5 μs in duration. Tumor growth was significantly inhibited and all protocols were able to achieve complete regressions. The H-FIRE protocol substantially reduces muscle contractions and the therapy can be delivered without the need for a neuromuscular blockade. This work shows the potential for H-FIRE to be used as a focal therapy and merits its investigation in larger pre-clinical models.
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Affiliation(s)
- Michael B. Sano
- School of Biomedical Engineering and Sciences, Virginia Tech, USA
- Department of Radiation Oncology, Division of Radiation Physics, Stanford University, USA
| | | | | | | | - Hyung J. Cho
- School of Biomedical Engineering and Sciences, Virginia Tech, USA
| | | | | | | | - John Robertson
- School of Biomedical Engineering and Sciences, Virginia Tech, USA
| | - Yong W. Lee
- School of Biomedical Engineering and Sciences, Virginia Tech, USA
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Venkat S, Hosein PJ, Narayanan G. Percutaneous Approach to Irreversible Electroporation of the Pancreas: Miami Protocol. Tech Vasc Interv Radiol 2015; 18:153-8. [DOI: 10.1053/j.tvir.2015.06.006] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
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Martin RCG. Irreversible electroporation of locally advanced pancreatic neck/body adenocarcinoma. J Gastrointest Oncol 2015; 6:329-35. [PMID: 26029461 DOI: 10.3978/j.issn.2078-6891.2015.012] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2014] [Accepted: 01/05/2015] [Indexed: 12/25/2022] Open
Abstract
OBJECTIVE Irreversible electroporation (IRE) of locally advanced pancreatic adenocarcinoma of the neck has been used to palliate appropriate stage 3 pancreatic cancers without evidence of metastasis and who have undergone appropriate induction therapy. Currently there has not been a standardized reported technique for pancreatic mid-body tumors for patient selection and intra-operative technique. PATIENTS Subjects are patients with locally advanced pancreatic adenocarcinoma of the body/neck who have undergone appropriate induction chemotherapy for a reasonable duration. MAIN OUTCOME MEASURES Technique of open IRE of locally advanced pancreatic adenocarcinoma of the neck/body is described, with the emphasis on intra-operative ultrasound and intra-operative electroporation management. RESULTS The technique of open IRE of the pancreatic neck/body with bracketing of the celiac axis and superior mesenteric artery with continuous intraoperative ultrasound imaging and consideration of intraoperative navigational system is described. CONCLUSIONS IRE of locally advanced pancreatic adenocarcinoma of the body/neck is feasible for appropriate patients with locally advanced unresectable pancreatic cancer.
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Affiliation(s)
- Robert C G Martin
- Division of Surgical Oncology, Department of Surgery, University of Louisville, Louisville, KY, USA
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Martin RCG, Schwartz E, Adams J, Farah I, Derhake BM. Intra - operative Anesthesia Management in Patients Undergoing Surgical Irreversible Electroporation of the Pancreas, Liver, Kidney, and Retroperitoneal Tumors. Anesth Pain Med 2015; 5:e22786. [PMID: 26161319 PMCID: PMC4493723 DOI: 10.5812/aapm.22786] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2014] [Revised: 09/14/2014] [Accepted: 10/13/2014] [Indexed: 12/18/2022] Open
Abstract
Background: Irreversible electroporation (IRE) is a relatively new approach to the management of multiple types of locally advanced soft tissue tumors. Unique peri-procedural anesthetic management is needed in the safe and effective delivery of this therapy. Objectives: This study analyzed IRE therapy in relation to anesthetic management for our initial cohort and then established and validated a set of best practical guidelines for general anesthesia in patients undergoing IRE for abdominal tumors. Patients and Methods: An IRB-approved prospective data collection outcome protocol was utilized. This study was broken up into two cohorts as follows: the initial 38 patients (pts) undergoing IRE in which anesthetic management was not defined or optimized and then a 40-pt validation cohort to establish the most efficacious anesthetic protocols. Results: During IRE delivery, a deeper neuromuscular blockade is required to ensure that all retroperitoneal muscle excitation was minimized. In the initial 38-pt cohort, attempts to treat hypertension (median SBP 190, range 185–215 and median diastolic 98, range 91–115) were made with various types of anti-hypertensives with minimal-to-insufficient effects. The established inhalation was sevoflurane with an approximate median dose of 8.0 volume percentage. Analgesic management of continuous remifentanil was utilized with epidural management, which optimized HTN and tolerance to IRE therapy. Conclusions: Anesthetic management for IRE of soft tissue deviates from standard anesthetic medical therapy in regards to depth of neuromuscular blockade and analgesic management during IRE energy delivery. However, minor modifications in anesthesia management allow for a safe and efficient patient procedure.
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Affiliation(s)
- Robert CG. Martin
- Division of Surgical Oncology, University of Louisville School of Medicine, Louisville, USA
- James Graham Brown Cancer Center, Louisville, USA
- Corresponding author: Robert CG. Martin, Division of Surgical Oncology, University of Louisville School of Medicine, Louisville, USA. Tel: +1-5026293355, Fax: +1-5026293030, E-mail:
| | - Eric Schwartz
- Division of Surgical Oncology, University of Louisville School of Medicine, Louisville, USA
| | - JoAnn Adams
- Department of Anesthesiology, University of Louisville School of Medicine, Louisville, USA
| | - Ian Farah
- Department of Anesthesiology, University of Louisville School of Medicine, Louisville, USA
| | - Brian M Derhake
- Department of Anesthesiology, University of Louisville School of Medicine, Louisville, USA
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Efficacy of irreversible electroporation in human pancreatic adenocarcinoma: advanced murine model. MOLECULAR THERAPY-METHODS & CLINICAL DEVELOPMENT 2015; 2:15001. [PMID: 26029712 PMCID: PMC4444995 DOI: 10.1038/mtm.2015.1] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/05/2014] [Revised: 11/30/2014] [Accepted: 12/22/2014] [Indexed: 02/07/2023]
Abstract
Irreversible electroporation (IRE) is a promising cell membrane ablative modality for pancreatic cancer. There have been recent concerns regarding local recurrence and the potential use of IRE as a debulking (partial ablation) modality. We hypothesize that incomplete ablation leads to early recurrence and a more aggressive biology. We created the first ever heterotopic murine model by inoculating BALB/c nude mice in the hindlimb with a subcutaneous injection of Panc-1 cells, an immortalized human pancreatic adenocarcinoma cell line. Tumors were allowed to grow from 0.75 to 1.5 cm and then treated with the goal of complete ablation or partial ablation using standard IRE settings. Animals were recovered and survived for 2 days (n = 6), 7 (n = 6), 14 (n = 6), 21 (n = 6), 30 (n = 8), and 60 (n = 8) days. All 40 animals/tumors underwent successful IRE under general anesthesia with muscle paralysis. The mean tumor volume of the animals undergoing ablation was 1,447.6 mm3 ± 884). Histologically, in the 14-, 21-, 30-, and 60-day survival groups the entire tumor was nonviable, with a persistent tumor nodule completely replaced fibrosis. In the group treated with partial ablation, incomplete electroporation/recurrences (N = 10 animals) were seen, of which 66% had confluent tumors and this was a significant predictor of recurrence (P < 0.001). Recurrent tumors were also significantly larger (mean 4,578 mm3 ± SD 877 versus completed electroporated tumors 925.8 ± 277, P < 0.001). Recurrent tumors had a steeper growth curve (slope = 0.73) compared with primary tumors (0.60, P = 0.02). Recurrent tumors also had a significantly higher percentage of EpCAM expression, suggestive of stem cell activation. Tumors that recur after incomplete electroporation demonstrate a biologically aggressive tumor that could be more resistant to standard of care chemotherapy. Clinical correlation of this data is limited, but should be considered when IRE of pancreatic cancer is being considered.
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Irreversible Electroporation (IRE) Fails to Demonstrate Efficacy in a Prospective Multicenter Phase II Trial on Lung Malignancies: The ALICE Trial. Cardiovasc Intervent Radiol 2015; 38:401-8. [DOI: 10.1007/s00270-014-1049-0] [Citation(s) in RCA: 48] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2014] [Accepted: 12/11/2014] [Indexed: 12/18/2022]
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70
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Current status of Interventional Radiology in the management of Gastro-Entero-Pancreatic Neuroendocrine Tumours (GEP-NETs). Cardiovasc Intervent Radiol 2014; 38:13-24. [PMID: 25366087 DOI: 10.1007/s00270-014-1005-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2014] [Accepted: 08/18/2014] [Indexed: 12/18/2022]
Abstract
Within the group of Gastro-Entero-Pancreatic Neuroendocrine tumours (GEP-NETs), several heterogeneous malignancies are included with a variety of clinical manifestations and imaging characteristics. Often these cases are inoperable and minimal invasive treatment offered by image-guided procedures appears to be the only option. Interventional radiology offers a valid solution in the management of primary and metastatic GEP-NETs. The purpose of this review article is to describe the current status of the role of Interventional Radiology in the management of GEP-NETs.
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Kwon D, McFarland K, Velanovich V, Martin RC. Borderline and locally advanced pancreatic adenocarcinoma margin accentuation with intraoperative irreversible electroporation. Surgery 2014; 156:910-20. [DOI: 10.1016/j.surg.2014.06.058] [Citation(s) in RCA: 79] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2014] [Accepted: 06/24/2014] [Indexed: 02/08/2023]
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Nickfarjam A, Firoozabadi SMP. Parametric study of irreversible electroporation with different needle electrodes: Electrical and thermal analysis. Int J Hyperthermia 2014; 30:335-47. [DOI: 10.3109/02656736.2014.937775] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
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73
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Scheffer HJ, Nielsen K, van Tilborg AAJM, Vieveen JM, Bouwman RA, Kazemier G, Niessen HWM, Meijer S, van Kuijk C, van den Tol MP, Meijerink MR. Ablation of colorectal liver metastases by irreversible electroporation: results of the COLDFIRE-I ablate-and-resect study. Eur Radiol 2014; 24:2467-75. [DOI: 10.1007/s00330-014-3259-x] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2013] [Revised: 05/05/2014] [Accepted: 05/21/2014] [Indexed: 12/18/2022]
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Advances in Interventional Oncology: Percutaneous Therapies. CURRENT RADIOLOGY REPORTS 2014. [DOI: 10.1007/s40134-014-0052-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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