1
|
Tasu JP, Herpe G, Damion J, Richer JP, Debeane B, Vionnet M, Rouleau L, Carretier M, Ferru A, Ingrand P, Tougeron D. Irreversible electroporation to bring initially unresectable locally advanced pancreatic adenocarcinoma to surgery: the IRECAP phase II study. Eur Radiol 2024:10.1007/s00330-024-10613-x. [PMID: 38494526 DOI: 10.1007/s00330-024-10613-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2023] [Revised: 12/10/2023] [Accepted: 01/08/2024] [Indexed: 03/19/2024]
Abstract
OBJECTIVES The aim of the IRECAP study was to evaluate the rate of locally advanced pancreas cancer patients (LAPC) who could undergo R0 or R1 surgery after irreversible electroporation (IRE). MATERIALS AND METHODS IRECAP study is a phase II, single-center, open-label, prospective, non-randomized trial registered at clinicaltrials.gov (NCT03105921). Patients with LAPC were first treated by 3-month neo-adjuvant chemotherapy in order to avoid inclusion of either patients with LAPC having become resectable after chemotherapy or patients with rapid disease progression. In cases of stable disease, IRE was performed percutaneously under CT guidance. Surgery was planned between 28 and 90 days after IRE. Tumor specimens were studied to evaluate the resection margins (R0/R1/R2). RESULTS Six men and 11 women were included (median age 61 years, range 37-77 years). No IRE-related death was observed. Ten patients (58%, 10/17) experienced 25 serious adverse events related to IRE. Four patients progressed between IRE and surgery and were excluded from surgery. Thirteen patients were finally operated, six withheld for pancreas resection, three for diffuse peritoneal carcinosis, two for massive vascular entrapment, and one for hepato-cellular carcinoma not diagnosed before surgery. Rate of R1-R0 was 35% (n = 6/17). Median overall survival was 31 months (95% CI; 4-undefined) for the six patients with R0/R1 resection and 21 months (95% CI; 4-25) for the 11 patients without resection or R2 resection (logrank p = 0.044). CONCLUSION After neoadjuvant chemotherapy, IRE could provide R0 or R1 resection in 35% of LAPC, which seems to be associated with higher OS. CLINICAL RELEVANCE STATEMENT After induction chemotherapy, stable locally advanced pancreatic cancers can be treated by irreversible electroporation, which could lead to a secondary 35% rate of R0 or R1 surgical resection which may be associated with a significantly higher overall survival. KEY POINTS • In cases of unresectable LAPC (locally advanced pancreatic cancer), percutaneous irreversible electroporation (pIRE) is feasible (100% success rate of the procedure), but is associated with a 58% rate of grade 3-4 adverse events. • In patients with unresectable LAPC, pIRE could lead 35% of patients to R0-R1 surgical resection. • From IRE, median overall survival was 31 months (95% CI; 4-undefined) for the patients with R0/R1 resection and 21 months (95% CI; 4-25) for the patients without resection or R2 resection (logrank p = 0.044).
Collapse
Affiliation(s)
- Jean-Pierre Tasu
- Department of Diagnosis and Interventional Radiology, University Hospital of Poitiers, 86021, Poitiers Cedex, France.
- LaTim, UBO and INSERM 1101, University of Brest, 29000, Brest, France.
| | - Guillaume Herpe
- Department of Diagnosis and Interventional Radiology, University Hospital of Poitiers, 86021, Poitiers Cedex, France
| | - Jérôme Damion
- Department of Pancreatic Surgery, University Hospital of Poitiers, 86021, Poitiers Cedex, France
| | - Jean-Pierre Richer
- Department of Pancreatic Surgery, University Hospital of Poitiers, 86021, Poitiers Cedex, France
| | - Bertrand Debeane
- Department of Anesthesiology, University Hospital of Poitiers, 86021, Poitiers Cedex, France
| | - Mathilde Vionnet
- Department of Diagnosis and Interventional Radiology, University Hospital of Poitiers, 86021, Poitiers Cedex, France
| | - Laetitia Rouleau
- Department of Anesthesiology, University Hospital of Poitiers, 86021, Poitiers Cedex, France
| | - Michel Carretier
- Department of Pancreatic Surgery, University Hospital of Poitiers, 86021, Poitiers Cedex, France
| | - Aurélie Ferru
- Department of Abdominal Oncology, University Hospital of Poitiers, 86021, Poitiers Cedex, France
| | - Pierre Ingrand
- Department of Biostastistic and Epidemiology, University of Poitiers, 86000, Poitiers, France
| | - David Tougeron
- Department of Abdominal Oncology, University Hospital of Poitiers, 86021, Poitiers Cedex, France
| |
Collapse
|
2
|
Spiliopoulos S, Reppas L, Filippiadis D, Delvecchio A, Conticchio M, Memeo R, Inchingolo R. Irreversible electroporation for the management of pancreatic cancer: Current data and future directions. World J Gastroenterol 2023; 29:223-231. [PMID: 36687122 PMCID: PMC9846938 DOI: 10.3748/wjg.v29.i2.223] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Revised: 11/13/2022] [Accepted: 12/21/2022] [Indexed: 01/06/2023] Open
Abstract
Pancreatic cancer is currently the seventh leading cause of cancer death (4.5% of all cancer deaths) while 80%-90% of the patients suffer from unresectable disease at the time of diagnosis. Prognosis remains poor, with a mean survival up to 15 mo following systemic chemotherapy. Loco-regional thermal ablative techniques are rarely implemented due to the increased risk of thermal injury to the adjacent structures, which can lead to severe adverse events. Irreversible electroporation, a promising novel non-thermal ablative modality, has been recently introduced in clinical practice for the management of inoperable pancreatic cancer as a safer and more effective loco-regional treatment option. Experimental and initial clinical data are optimistic. This review will focus on the basic principles of IRE technology, currently available data, and future directions.
Collapse
Affiliation(s)
- Stavros Spiliopoulos
- Second Department of Radiology, School of Medicine, National and Kapodistrian University of Athens, Athens 12461, Attiki, Greece
| | - Lazaros Reppas
- Second Department of Radiology, School of Medicine, National and Kapodistrian University of Athens, Athens 12461, Attiki, Greece
| | - Dimitrios Filippiadis
- Second Department of Radiology, School of Medicine, National and Kapodistrian University of Athens, Athens 12461, Attiki, Greece
| | - Antonella Delvecchio
- Unit of Hepato-Pancreatic-Biliary Surgery, “F. Miulli” Regional General Hospital, Acquaviva delle Fonti 70021, Bari, Italy
| | - Maria Conticchio
- Unit of Hepato-Pancreatic-Biliary Surgery, “F. Miulli” Regional General Hospital, Acquaviva delle Fonti 70021, Bari, Italy
| | - Riccardo Memeo
- Unit of Hepato-Pancreatic-Biliary Surgery, “F. Miulli” Regional General Hospital, Acquaviva delle Fonti 70021, Bari, Italy
| | - Riccardo Inchingolo
- Interventional Radiology Unit, “F. Miulli” Regional General Hospital, Acquaviva delle Fonti 70021, Italy
| |
Collapse
|
3
|
Yan L, Liang B, Feng J, Zhang HY, Chang HS, Liu B, Chen YL. Safety and feasibility of irreversible electroporation for the pancreatic head in a porcine model. World J Gastrointest Oncol 2022; 14:1499-1509. [PMID: 36160734 PMCID: PMC9412922 DOI: 10.4251/wjgo.v14.i8.1499] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2022] [Revised: 05/12/2022] [Accepted: 07/11/2022] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Irreversible electroporation (IRE) is a local non-thermal ablative technique which has been suggested as a potential cancer therapy. However, the specific anatomic characteristics of the pancreatic head make it challenging to perform any local ablation in this region. Therefore, the safety and feasibility of IRE in the pancreatic head region should be further explored.
AIM To evaluate the safety of IRE in pancreatic head region including its effects on pancreatic ducts, vessels, and adjacent gastrointestinal organs.
METHODS Eight landrace miniature pigs underwent IRE of pancreatic head tissue successfully, with a total of 16 lesions created. Laboratory testing including white blood cell (WBC) count and serum amylase before IRE with follow-up laboratory analysis and pathological examination at 1, 7, 14, and 28 d postablation were performed.
RESULTS All pigs tolerated the ablation procedure without serious perioperative complications. Transiently elevated WBC count and amylase were observed at 24 h post-IRE, suggesting an acute pancreatic tissue damage which was confirmed by pathological observations. Vascular endothelial cells and pancreatic duct epithelial cells in ablation zone were also positive in terminal deoxynucleotidyl transferase dUTP nick end labeling staining. There was extensive duodenum mucosa damage with local hemorrhage 24 h after ablation, while regeneration of new villous structures were observed at 7 and 28 d post-IRE. Masson’s trichromatic staining showed that the extracellular matrix was still intact in vessels and pancreatic ducts, and even in the duodenum.
CONCLUSION IRE ablation to the pancreatic head may be safe and feasible without long-term damage to the surrounding vital structures. However, risks of stress injuries in acute phase should be taken into consideration to prevent severe perioperative complications.
Collapse
Affiliation(s)
- Li Yan
- Faculty of Hepato-Pancreato-Biliary Surgery, Institute of Hepatobiliary Surgery of Chinese PLA, Key Laboratory of Digital Hepetobiliary Surgery, The First Medical Centre, Chinese PLA General Hospital, Beijing 100853, China
| | - Bin Liang
- Faculty of Hepato-Pancreato-Biliary Surgery, Institute of Hepatobiliary Surgery of Chinese PLA, Key Laboratory of Digital Hepetobiliary Surgery, The First Medical Centre, Chinese PLA General Hospital, Beijing 100853, China
| | - Jian Feng
- Department of Hepatopancreatobiliary Surgery, Peking University Shougang Hospital, Beijing 100144, China
| | - Hang-Yu Zhang
- Faculty of Hepato-Pancreato-Biliary Surgery, Institute of Hepatobiliary Surgery of Chinese PLA, Key Laboratory of Digital Hepetobiliary Surgery, The First Medical Centre, Chinese PLA General Hospital, Beijing 100853, China
| | - Hao-Sheng Chang
- Faculty of Hepato-Pancreato-Biliary Surgery, Institute of Hepatobiliary Surgery of Chinese PLA, Key Laboratory of Digital Hepetobiliary Surgery, The First Medical Centre, Chinese PLA General Hospital, Beijing 100853, China
| | - Bing Liu
- Faculty of Hepato-Pancreato-Biliary Surgery, Institute of Hepatobiliary Surgery of Chinese PLA, Key Laboratory of Digital Hepetobiliary Surgery, The First Medical Centre, Chinese PLA General Hospital, Beijing 100853, China
| | - Yong-Liang Chen
- Faculty of Hepato-Pancreato-Biliary Surgery, Institute of Hepatobiliary Surgery of Chinese PLA, Key Laboratory of Digital Hepetobiliary Surgery, The First Medical Centre, Chinese PLA General Hospital, Beijing 100853, China
| |
Collapse
|
4
|
Heger U, Mack C, Tjaden C, Pan F, Pausch T, Hinz U, Sommer CM, Hackert T. Open irreversible electroporation for isolated local recurrence of pancreatic ductal adenocarcinoma after primary surgery. Pancreatology 2021; 21:1349-1355. [PMID: 34404600 DOI: 10.1016/j.pan.2021.08.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2021] [Revised: 07/28/2021] [Accepted: 08/11/2021] [Indexed: 12/11/2022]
Abstract
BACKGROUND/OBJECTIVES Irreversible electroporation (IRE) is an emerging treatment for locally advanced pancreatic cancer (LAPC) which in some cohorts has been associated with severe complications. Additionally, re-resection of isolated local recurrence (ILR) after pancreatic ductal adenocarcinoma (PDAC) can improve survival. We investigated safety, feasibility and oncologic outcomes in the first report on open IRE for unresectable ILR of PDAC in a staged surgical approach. METHODS Records of the prospectively documented institutional database were screened for patients undergoing laparotomy in IRE-standby due to questionable resectability. Endpoints were morbidity, mortality and overall (OS) and progression free survival (PFS). Data of LAPC and ILR were compared statistically for safety and feasibility analysis. RESULTS Intraoperative IRE was performed in 11 ILR and 14 LAPC. Six (54.5%) ILR and 10 (71.4%) LAPC patients had postoperative complications, type and frequency did not differ significantly. Major complications occurred in one ILR and two LAPC patients. Median OS was 20.0 months (95% CI: 2.7-37.3) after IRE for ILR and 28 (17.4-38.6) for LAPC. Median PFS after IRE was seven months for both ILR (4.1-9.9; n = 9) and LAPC (2.3-11.7; n = 13). CONCLUSION Open IRE for unresectable ILR was associated with acceptable perioperative risk. In this small, highly selected subset of patients with limited therapeutic options ancillary treatment with IRE might improve survival. Randomized treatment studies are required to establish the definitive role of IRE as compared to palliative standards of care in unresectable recurrence of PDAC and inconvertible LAPC.
Collapse
Affiliation(s)
- Ulrike Heger
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Im Neuenheimer Feld 420, 69120 Heidelberg, Germany
| | - Claudia Mack
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Im Neuenheimer Feld 420, 69120 Heidelberg, Germany
| | - Christine Tjaden
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Im Neuenheimer Feld 420, 69120 Heidelberg, Germany
| | - Feng Pan
- Clinic of Diagnostic and Interventional Radiology, Heidelberg University Hospital, Im Neuenheimer Feld 420, 69120 Heidelberg, Germany; Home Address: Department of Radiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Hubei Sheng, China
| | - Thomas Pausch
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Im Neuenheimer Feld 420, 69120 Heidelberg, Germany
| | - Ulf Hinz
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Im Neuenheimer Feld 420, 69120 Heidelberg, Germany
| | - Christof M Sommer
- Clinic of Diagnostic and Interventional Radiology, Heidelberg University Hospital, Im Neuenheimer Feld 420, 69120 Heidelberg, Germany; Department of Nuclear Medicine, Heidelberg University Hospital, Im Neuenheimer Feld 400, 69120 Heidelberg, Germany
| | - Thilo Hackert
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Im Neuenheimer Feld 420, 69120 Heidelberg, Germany.
| |
Collapse
|
5
|
Lee EW, Shahrouki P, Peterson S, Tafti BA, Ding PX, Kee ST. Safety of Irreversible Electroporation Ablation of the Pancreas. Pancreas 2021; 50:1281-1286. [PMID: 34860812 DOI: 10.1097/mpa.0000000000001916] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVES To evaluate the safety of irreversible electroporation (IRE) on swine pancreatic tissue including its effects on peripancreatic vessels, bile ducts, and bowel. METHODS Eighteen Yorkshire pigs underwent IRE ablation of the pancreas successfully and without clinical complications. Contrast-enhanced computed tomography angiography and laboratory studies before the IRE ablation with follow-up computed tomography angiography, laboratory testing, and pathological examination up to 4 weeks postablation were performed. RESULTS In a subset of cases, anatomic peripancreatic vessel narrowing was seen by 1 week postablation, persisting at 4 weeks postablation, without apparent functional impairment of blood flow. Laboratory studies revealed elevated amylase and lipase at 24 hours post-IRE, suggestive of acute pancreatitis, which normalized by 4 weeks post-IRE. There was extensive pancreatic tissue damage 24 hours after IRE with infiltration of immune cells, which was gradually replaced by fibrotic tissue. Ductal regeneration without loss of pancreatic acinar tissue and glandular function was observed at 1 and 4 weeks postablation. CONCLUSIONS In our study, we demonstrated and confirmed the safety and minimal complications of IRE ablation in the pancreas and its surrounding vital structures. These results show the potential of IRE as an alternative treatment modality in patients with pancreatic cancer, especially those with locally advanced disease.
Collapse
Affiliation(s)
| | - Puja Shahrouki
- From the Division of Interventional Radiology, Department of Radiology, UCLA Medical Center
| | - Stephanie Peterson
- From the Division of Interventional Radiology, Department of Radiology, UCLA Medical Center
| | - Bashir A Tafti
- From the Division of Interventional Radiology, Department of Radiology, UCLA Medical Center
| | - Peng-Xu Ding
- From the Division of Interventional Radiology, Department of Radiology, UCLA Medical Center
| | - Stephen T Kee
- From the Division of Interventional Radiology, Department of Radiology, UCLA Medical Center
| |
Collapse
|
6
|
Rai ZL, Feakins R, Pallett LJ, Manas D, Davidson BR. Irreversible Electroporation (IRE) in Locally Advanced Pancreatic Cancer: A Review of Current Clinical Outcomes, Mechanism of Action and Opportunities for Synergistic Therapy. J Clin Med 2021; 10:1609. [PMID: 33920118 PMCID: PMC8068938 DOI: 10.3390/jcm10081609] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2021] [Revised: 04/04/2021] [Accepted: 04/07/2021] [Indexed: 12/11/2022] Open
Abstract
Locally advanced pancreatic cancer (LAPC) accounts for 30% of patients with pancreatic cancer. Irreversible electroporation (IRE) is a novel cancer treatment that may improve survival and quality of life in LAPC. This narrative review will provide a perspective on the clinical experience of pancreas IRE therapy, explore the evidence for the mode of action, assess treatment complications, and propose strategies for augmenting IRE response. A systematic search was performed using PubMed regarding the clinical use and safety profile of IRE on pancreatic cancer, post-IRE sequential histological changes, associated immune response, and synergistic therapies. Animal data demonstrate that IRE induces both apoptosis and necrosis followed by fibrosis. Major complications may result from IRE; procedure related mortality is up to 2%, with an average morbidity as high as 36%. Nevertheless, prospective and retrospective studies suggest that IRE treatment may increase median overall survival of LAPC to as much as 30 months and provide preliminary data justifying the well-designed trials currently underway, comparing IRE to the standard of care treatment. The mechanism of action of IRE remains unknown, and there is a lack of data on treatment variables and efficiency in humans. There is emerging data suggesting that IRE can be augmented with synergistic therapies such as immunotherapy.
Collapse
Affiliation(s)
- Zainab L. Rai
- Centre of Surgical Innovation, Organ Regeneration and Transplantation, University College London (UCL), London NW3 2QG, UK;
- Wellcome/EPSRC Center for Interventional and Surgical Sciences (WEISS), London W1W 7TY, UK
- Royal Free NHS Foundation Trust, London NW3 2QG, UK;
| | - Roger Feakins
- Royal Free NHS Foundation Trust, London NW3 2QG, UK;
| | - Laura J. Pallett
- Division of Infection and Immunity, Institute of Immunity and Transplantation, University College London, London WC1E 6BT, UK;
| | - Derek Manas
- Newcastle Upon Tyne NHS Foundation Trust, Newcastle-Upon-Tyne NE7 7DN, UK;
| | - Brian R. Davidson
- Centre of Surgical Innovation, Organ Regeneration and Transplantation, University College London (UCL), London NW3 2QG, UK;
- Royal Free NHS Foundation Trust, London NW3 2QG, UK;
| |
Collapse
|
7
|
Kwon JH, Chung MJ, Park JY, Lee HS, Hwang HK, Kang CM, Lee WJ, Park MS, Kim N, Bang S, Kim MD. Initial experience of irreversible electroporation for locally advanced pancreatic cancer in a Korean population. Acta Radiol 2021; 62:164-171. [PMID: 32295390 DOI: 10.1177/0284185120917118] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND Locally advanced pancreatic cancer (LAPC) is one of the most aggressive malignancies. Irreversible electroporation (IRE) is a novel technique that uses a non-thermal ablation to avoid vessel or duct injury. PURPOSE To investigate the safety and efficacy of IRE for the management of LAPC in a Korean population. MATERIAL AND METHODS Twelve patients (median age 64 years; age range 46-73 years) treated between December 2015 and March 2017 underwent intraoperative IRE for LAPC. Technical success and clinical outcomes, including complications, serum pancreatic enzyme levels, overall survival (OS), and progression-free survival (PFS), were evaluated. RESULTS Tumors were located in the pancreas head in 7 (58.3%) patients and in the body/tail in 5 (41.7%) patients. The median tumor diameter in the longest axis was 3.1 cm. Vascular invasion was observed in all patients and bowel abutment in 3 (25%) patients. Technical success was achieved in all patients. The median serum levels of amylase and lipase were 55 U/L and 31 U/L, respectively, at baseline, increased to 141.5 U/L (P = 0.008) and 53 U/L (P = 0.505), respectively, one day after IRE, and normalized after one week. The rate of 30-day mortality of unknown relation was 8.3% (one individual experienced massive hematemesis 12 days after IRE). The median OS from diagnosis and IRE was 24.5 months and 13.5 months, respectively. The median PFS from diagnosis and IRE was 19.2 months and 8.6 months, respectively. CONCLUSION For patients with LAPC, IRE appears to be a promising treatment modality with an acceptable safety profile.
Collapse
Affiliation(s)
- Joon Ho Kwon
- Department of Radiology, Severance Hospital, Research Institute of Radiological Science, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Moon Jae Chung
- Department of Internal Medicine, Severance Hospital, Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Jeong Youp Park
- Department of Internal Medicine, Severance Hospital, Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Hee Seung Lee
- Department of Internal Medicine, Severance Hospital, Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Ho Kyoung Hwang
- Department of Surgery, Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Chang Moo Kang
- Department of Surgery, Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Woo Jung Lee
- Department of Surgery, Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Mi-Suk Park
- Department of Radiology, Severance Hospital, Research Institute of Radiological Science, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Namo Kim
- Department of Anesthesiology and Pain Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Seungmin Bang
- Department of Internal Medicine, Severance Hospital, Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Man-Deuk Kim
- Department of Radiology, Severance Hospital, Research Institute of Radiological Science, Yonsei University College of Medicine, Seoul, Republic of Korea
| |
Collapse
|
8
|
An experimental system for real-time fluorescence recordings of cell membrane changes induced by electroporation. EUROPEAN BIOPHYSICS JOURNAL: EBJ 2019; 49:105-111. [DOI: 10.1007/s00249-019-01417-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/22/2019] [Revised: 11/28/2019] [Accepted: 12/16/2019] [Indexed: 02/02/2023]
|
9
|
Frey GT, Padula CA, Stauffer JA, Toskich BB. Intraoperative Irreversible Electroporation in Locally Advanced Pancreatic Cancer: A Guide for the Interventional Radiologist. Semin Intervent Radiol 2019; 36:386-391. [PMID: 31798212 DOI: 10.1055/s-0039-1697640] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Efforts to improve mortality associated with locally advanced pancreatic cancer (LAPC) have shown minimal gains despite advances in surgical technique, systemic treatments, and radiation therapy. Locoregional therapy with ablation has not been routinely adopted due to the high risk of complications associated with thermal destruction of the pancreas. Irreversible electroporation (IRE) is an emerging, nonthermal, ablative technology that has demonstrated the ability to generate controlled ablation of LAPC while preserving pancreatic parenchymal integrity. IRE may be performed percutaneously or via laparotomy and will commonly involve multidisciplinary treatment teams. This article will describe the technical aspects of how multidisciplinary IRE is performed during laparotomy at a single tertiary care institution.
Collapse
Affiliation(s)
- Gregory T Frey
- Division of Interventional Radiology, Department of Radiology, Mayo Clinic, Jacksonville, Florida
| | - Carlos A Padula
- Division of Interventional Radiology, Department of Radiology, Mayo Clinic, Jacksonville, Florida
| | | | - Beau B Toskich
- Division of Interventional Radiology, Department of Radiology, Mayo Clinic, Jacksonville, Florida
| |
Collapse
|
10
|
Abstract
Irreversible electroporation (IRE) is a relatively recent method of ablation. In contrast to many ablation devices that use thermal methods to induce cell death, IRE employs the use of an electric field to cause irreversible permeability of the cell membrane, thus inducing apoptosis. Since its use in the pancreas was first described in 2012, IRE has become established as part of the armamentarium of ablation devices currently available. The crucial advantage of IRE compared with other devices employing thermal ablation is the safety around vital structures such as vessels and ducts. This is especially important in the pancreas due to the close proximity of multiple major vascular structures, biliary ducts, and adjacent gastrointestinal organs. This article will explore the current evidence regarding the use of IRE in the pancreas.
Collapse
Affiliation(s)
- Gabriel Chan
- Department of Diagnostic Radiology, Tan Tock Seng Hospital, Singapore
| | - Uei Pua
- Department of Diagnostic Radiology, Tan Tock Seng Hospital, Singapore.,Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| |
Collapse
|
11
|
Rashid MF, Hecht EM, Steinman JA, Kluger MD. Irreversible electroporation of pancreatic adenocarcinoma: a primer for the radiologist. Abdom Radiol (NY) 2018; 43:457-466. [PMID: 29051982 DOI: 10.1007/s00261-017-1349-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Irreversible electroporation (IRE) is increasingly used for the ablation of unresectable locally advanced pancreatic adenocarcinoma. Unlike other ablation technologies that cannot be safely used around critical vasculature or ducts for risk of thermal damage, IRE uses high-voltage pulses to disrupt cellular membranes. This causes cell death by apoptosis and inflammation. IRE has been deployed by both open and percutaneous approaches. Generator parameters are the same for both approaches, and settings are pancreas specific. Variations in settings, probe placement, and probe exposure can result in thermal damage or reversible electroporation and resultant treatment failure, morbidity, or mortality. When used properly, IRE appears to improve overall survival and local recurrence, but does not influence the rate of distant recurrence. However, studies of both open and percutaneous approaches have been relatively small, non-controlled, and without appropriate comparisons. It is challenging for the radiologist to interpret treatment effects after IRE because of a dearth of guiding literature and pathologic correlates. This primer describes technical aspects, pathology correlates, post-IRE imaging, and outcomes for percutaneous and open approaches.
Collapse
Affiliation(s)
- M Farzan Rashid
- Division of Gastrointestinal and Endocrine Surgery, Department of Surgery, Columbia University College of Physicians and Surgeons, 161 Fort Washington Ave - 8th Floor, New York, NY, USA
| | - Elizabeth M Hecht
- Division of Abdominal Imaging, Department of Radiology, Columbia University College of Physicians and Surgeons, New York, NY, 10032, USA
| | - Jonathan A Steinman
- Division of Abdominal Imaging, Department of Radiology, Columbia University College of Physicians and Surgeons, New York, NY, 10032, USA
| | - Michael D Kluger
- Division of Gastrointestinal and Endocrine Surgery, Department of Surgery, Columbia University College of Physicians and Surgeons, 161 Fort Washington Ave - 8th Floor, New York, NY, USA.
| |
Collapse
|
12
|
Clinical and pathological outcomes after irreversible electroporation of the pancreas using two parallel plate electrodes: a porcine model. HPB (Oxford) 2017; 19:1058-1065. [PMID: 29029985 DOI: 10.1016/j.hpb.2017.02.443] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2016] [Revised: 02/02/2017] [Accepted: 02/28/2017] [Indexed: 12/12/2022]
Abstract
BACKGROUND Irreversible electroporation (IRE) by inserting needles around the tumor as treatment for locally advanced pancreatic cancer entails several disadvantages, such as incomplete ablation due to field inhomogeneity, technical difficulties in needle placement and a risk of pancreatic fistula development. This experimental study evaluates outcomes of IRE using paddles in a porcine model. METHODS Six healthy pigs underwent laparotomy and were treated with 2 separate ablations (in head and tail of the pancreas). Follow-up consisted of clinical and laboratory parameters and contrast-enhanced computed tomography (ceCT) imaging. After 2 weeks, pancreatoduodenectomy was performed for histology and the pigs were terminated. RESULTS All animals survived 14 days. None of the animals developed signs of infection or significant abdominal distention. Serum amylase and lipase peaked at day 1 postoperatively in all pigs, but normalized without signs of pancreatitis. On ceCT-imaging the ablation zone was visible as an ill-defined, hypodense lesion. No abscesses, cysts or ascites were seen. Histology showed a homogenous fibrotic lesion in all pigs. CONCLUSION IRE ablation of healthy porcine pancreatic tissue using two plate electrodes is feasible and safe and creates a homogeneous fibrotic lesion. IRE-paddles should be tested on pancreatic adenocarcinoma to determine the effect in cancer tissue.
Collapse
|
13
|
Ansari D, Kristoffersson S, Andersson R, Bergenfeldt M. The role of irreversible electroporation (IRE) for locally advanced pancreatic cancer: a systematic review of safety and efficacy. Scand J Gastroenterol 2017; 52:1165-1171. [PMID: 28687047 DOI: 10.1080/00365521.2017.1346705] [Citation(s) in RCA: 49] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVES Irreversible electroporation (IRE) is a new modality for tumor ablation. Electrodes are placed around the tumor, and a pulsed, direct current with a field strength of 2000 V/cm is delivered. The direct current drives cells into apoptosis and cell death without causing significant heating of the tissues, which spares the extracellular matrix and proteins. The purpose of this review was to evaluate current experience of IRE for the ablation of pancreatic cancer. MATERIAL AND METHODS We searched PubMed for all studies of IRE in human pancreatic cancer in English reporting at least 10 patients. RESULTS The search yielded 10 studies, comprising a total of 446 patients. Percutaneous IRE was done in 142 patients, while 304 patients were treated during laparotomy. Tumor sizes ranged from median 2.8 to 4.5 cm. Post-procedural complications occurred in 35% of patients, most of them were less severe. Nine patients (2.0%) died after the procedure. The technical success rate was 85-100%. The median recurrence-free survival was 2.7-12.4 months after IRE treatment. The median overall survival was 7-23 months postoperatively. The longest overall survival was noted when IRE was used in conjunction with pancreatic resection. CONCLUSIONS IRE seems feasible and safe with a low post-procedural mortality. Further efforts are needed to address patient selection and efficacy of IRE, as well as the use of IRE for 'margin accentuation' during surgical resection.
Collapse
Affiliation(s)
- Daniel Ansari
- a Department of Surgery, Clinical Sciences Lund , Lund University, Skåne University Hospital , Lund , Sweden
| | - Stina Kristoffersson
- a Department of Surgery, Clinical Sciences Lund , Lund University, Skåne University Hospital , Lund , Sweden
| | - Roland Andersson
- a Department of Surgery, Clinical Sciences Lund , Lund University, Skåne University Hospital , Lund , Sweden
| | - Magnus Bergenfeldt
- a Department of Surgery, Clinical Sciences Lund , Lund University, Skåne University Hospital , Lund , Sweden
| |
Collapse
|
14
|
Successful ablation of lymph nodes using irreversible electroporation (IRE) in a porcine survival model. Langenbecks Arch Surg 2017; 402:465-473. [DOI: 10.1007/s00423-017-1579-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2016] [Accepted: 03/24/2017] [Indexed: 12/18/2022]
|
15
|
Sánchez-Velázquez P, Clavien PA. The role of the irreversible electroporation in the hepato-pancreatico-biliary surgery. Cir Esp 2017; 95:307-312. [PMID: 28318494 DOI: 10.1016/j.ciresp.2017.01.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2017] [Accepted: 01/26/2017] [Indexed: 12/19/2022]
Abstract
Irreversible electroporation is a novel technique growing in popularity over the last years among the ablative modalities. Its unique action mechanism produces irreversible nanopores in the membrane of the cell leading to apoptosis; therefore irreversible electroporation can be used to ablate substantial volumes of tissue without the undesirable thermal effects as the "heat sink effect". Moreover the extracellular matrix is left unperturbed, thus sparing the structural architecture of surrounding structures such as bile ducts and blood vessels. In the last years its use has been widespread in both liver and pancreatic ablation. Irreversible electroporation has shown its safety with however some caution, feasibility and favorable outcomes in clinical settings such as unresectable locally advanced disease in which the surgical and therapeutic options are very limited.
Collapse
Affiliation(s)
| | - Pierre-Alain Clavien
- Departmento de cirugía y transplante, Hospital universitario de Zürich, Zúrich, Suiza.
| |
Collapse
|
16
|
Abstract
Pancreatic adenocarcinoma has a very poor prognosis. Complete surgical resection remains the only current curative treatment. Locally advanced pancreatic cancers are considered as unresectable because of involvement of celiac and/or mesenteric vessels. Irreversible electroporation has recently been introduced to induce permanent cell death by apoptosis. Irreversible electroporation is a nonthermal cell-destruction technique that was claimed to allow destruction of cancerous cells with less damage to surrounding supporting connective tissues with collagenic structure (such as nearby blood vessels, biliary ducts, and nerves) than other types of treatment. Applications on pancreatic adenocarcinoma seem promising, and this article is an up-to-date review of the first results.
Collapse
|
17
|
Rombouts SJE, Nijkamp MW, van Dijck WPM, Brosens LAA, Konings M, van Hillegersberg R, Borel Rinkes IHM, Hagendoorn J, Wittkampf FH, Molenaar IQ. Irreversible Electroporation of the Pancreas Using Parallel Plate Electrodes in a Porcine Model: A Feasibility Study. PLoS One 2017; 12:e0169396. [PMID: 28052102 PMCID: PMC5213381 DOI: 10.1371/journal.pone.0169396] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2016] [Accepted: 12/06/2016] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Irreversible electroporation (IRE) with needle electrodes is being explored as treatment option in locally advanced pancreatic cancer. Several studies have shown promising results with IRE needles, positioned around the tumor to achieve tumor ablation. Disadvantages are the technical difficulties for needle placement, the time needed to achieve tumor ablation, the risk of needle track seeding and most important the possible occurrence of postoperative pancreatic fistula via the needle tracks. The aim of this experimental study was to evaluate the feasibility of a new IRE-technique using two parallel plate electrodes, in a porcine model. METHODS Twelve healthy pigs underwent laparotomy. The pancreas was mobilized to enable positioning of the paddles. A standard monophasic external cardiac defibrillator was used to perform an ablation in 3 separate parts of the pancreas; either a single application of 50 or 100J or a serial application of 4x50J. After 6 hours, pancreatectomy was performed for histology and pigs were terminated. RESULTS Histology showed necrosis of pancreatic parenchyma with neutrophil influx in 5/12, 11/12 and 12/12 of the ablated areas at 50, 100, and 4x50J respectively. The electric current density threshold to achieve necrosis was 4.3, 5.1 and 3.4 A/cm2 respectively. The ablation threshold was significantly lower for the serial compared to the single applications (p = 0.003). The content of the ablated areas differed between the applications: areas treated with a single application of 50 J often contained vital areas without obvious necrosis, whereas half of the sections treated with 100 J showed small islands of normal looking cells surrounded by necrosis, while all sections receiving 4x 50 J showed a homogeneous necrotic lesion. CONCLUSION Pancreatic tissue can be successfully ablated using two parallel paddles around the tissue. A serial application of 4x50J was most effective in creating a homogeneous necrotic lesion.
Collapse
Affiliation(s)
- Steffi J. E. Rombouts
- Department of Surgery, University Medical Center Utrecht Cancer Center, Utrecht, the Netherlands
- * E-mail:
| | - Maarten W. Nijkamp
- Department of Surgery, University Medical Center Utrecht Cancer Center, Utrecht, the Netherlands
| | | | | | - Maurits Konings
- Department of Innovation research, University Medical Center Utrecht, Utrecht, the Netherlands
| | - R. van Hillegersberg
- Department of Surgery, University Medical Center Utrecht Cancer Center, Utrecht, the Netherlands
| | - Inne H. M. Borel Rinkes
- Department of Surgery, University Medical Center Utrecht Cancer Center, Utrecht, the Netherlands
| | - Jeroen Hagendoorn
- Department of Surgery, University Medical Center Utrecht Cancer Center, Utrecht, the Netherlands
| | - Fred H. Wittkampf
- Department of Cardiology, University Medical Center Utrecht, Utrecht, the Netherlands
| | - I. Quintus Molenaar
- Department of Surgery, University Medical Center Utrecht Cancer Center, Utrecht, the Netherlands
| |
Collapse
|
18
|
Irreversible electroporation for locally advanced pancreatic cancer. Diagn Interv Imaging 2016; 97:1297-1304. [DOI: 10.1016/j.diii.2016.10.001] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2016] [Accepted: 10/04/2016] [Indexed: 12/18/2022]
|
19
|
Vogel JA, van Veldhuisen E, Agnass P, Crezee J, Dijk F, Verheij J, van Gulik TM, Meijerink MR, Vroomen LG, van Lienden KP, Besselink MG. Time-Dependent Impact of Irreversible Electroporation on Pancreas, Liver, Blood Vessels and Nerves: A Systematic Review of Experimental Studies. PLoS One 2016; 11:e0166987. [PMID: 27870918 PMCID: PMC5117758 DOI: 10.1371/journal.pone.0166987] [Citation(s) in RCA: 53] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2016] [Accepted: 11/07/2016] [Indexed: 12/12/2022] Open
Abstract
Introduction Irreversible electroporation (IRE) is a novel ablation technique in the treatment of unresectable cancer. The non-thermal mechanism is thought to cause mostly apoptosis compared to necrosis in thermal techniques. Both in experimental and clinical studies, a waiting time between ablation and tissue or imaging analysis to allow for cell death through apoptosis, is often reported. However, the dynamics of the IRE effect over time remain unknown. Therefore, this study aims to summarize these effects in relation to the time between treatment and evaluation. Methods A systematic search was performed in Pubmed, Embase and the Cochrane Library for original articles using IRE on pancreas, liver or surrounding structures in animal or human studies. Data on pathology and time between IRE and evaluation were extracted. Results Of 2602 screened studies, 36 could be included, regarding IRE in liver (n = 24), pancreas (n = 4), blood vessels (n = 4) and nerves (n = 4) in over 440 animals (pig, rat, goat and rabbit). No eligible human studies were found. In liver and pancreas, the first signs of apoptosis and haemorrhage were observed 1–2 hours after treatment, and remained visible until 24 hours in liver and 7 days in pancreas after which the damaged tissue was replaced by fibrosis. In solitary blood vessels, the tunica media, intima and lumen remained unchanged for 24 hours. After 7 days, inflammation, fibrosis and loss of smooth muscle cells were demonstrated, which persisted until 35 days. In nerves, the median time until demonstrable histological changes was 7 days. Conclusions Tissue damage after IRE is a dynamic process with remarkable time differences between tissues in animals. Whereas pancreas and liver showed the first damages after 1–2 hours, this took 24 hours in blood vessels and 7 days in nerves.
Collapse
Affiliation(s)
- J. A. Vogel
- Department of Surgery, Academic Medical Center, Amsterdam, the Netherlands
| | - E van Veldhuisen
- Department of Surgery, Academic Medical Center, Amsterdam, the Netherlands
| | - P. Agnass
- Department of Radiation Therapy, Academic Medical Center, Amsterdam, the Netherlands
| | - J. Crezee
- Department of Radiation Therapy, Academic Medical Center, Amsterdam, the Netherlands
| | - F. Dijk
- Department of Pathology, Academic Medical Center, Amsterdam, the Netherlands
| | - J. Verheij
- Department of Pathology, Academic Medical Center, Amsterdam, the Netherlands
| | - T. M. van Gulik
- Department of Surgery, Academic Medical Center, Amsterdam, the Netherlands
- Department of Experimental Surgery, Academic Medical Center, Amsterdam, the Netherlands
| | - M. R. Meijerink
- Department of Radiology and Nuclear Medicine, VU University Medical Center, Amsterdam, the Netherlands
| | - L. G. Vroomen
- Department of Radiology and Nuclear Medicine, VU University Medical Center, Amsterdam, the Netherlands
| | - K. P. van Lienden
- Department of Radiology, Academic Medical Center, Amsterdam, the Netherlands
| | - M. G. Besselink
- Department of Surgery, Academic Medical Center, Amsterdam, the Netherlands
- * E-mail:
| |
Collapse
|
20
|
Ultrasound validation of mathematically modeled irreversible electroporation ablation areas. Surgery 2016; 159:1032-40. [DOI: 10.1016/j.surg.2015.10.030] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2015] [Revised: 10/06/2015] [Accepted: 10/28/2015] [Indexed: 12/18/2022]
|