Cryosurgery with combination of (125)iodine seed implantation for the treatment of locally advanced pancreatic cancer

The Assessment of a Novel Endoscopic Ultrasound-Compatible Cryocatheter to Ablate Pancreatic Cancer

Pancreatic ductal adenocarcinoma (PDAC) is a highly lethal disease that may be treated utilizing thermal therapies. Cryoablation is an effective, minimally invasive therapy that has been utilized for the treatment of various cancers, offering patients a quicker recovery and reduced side effects. Cryoablation has been utilized on a limited basis for the treatment of PDAC. With the recent reports on the success of cryoablation, there is a growing interest in the use of cryoablation as a standalone, minimally invasive procedure to treat PDAC. While offering a promising path, the application of cryoablation to PDAC is limited by current technologies. As such, there is a need for the development of new devices to support advanced treatment strategies for PDAC. To this end, this study investigated the performance of a new endoscopic ultrasound-compatible cryoablation catheter technology, FrostBite. We hypothesized that FrostBite would enable the rapid, effective, minimally invasive delivery of ultra-cold temperatures to target tissues, resulting in effective ablation via an endoscopic approach. Thermal properties and ablative efficacy were evaluated using a heat-loaded gel model, tissue-engineered models (TEMs), and an initial in vivo porcine study. Freeze protocols evaluated included single and repeat 3 and 5 min applications. Isotherm assessment revealed the generation of a 2.2 cm diameter frozen mass with the -20 °C isotherm reaching a diameter of 1.5 cm following a single 5 min freeze. TEM studies revealed the achievement of temperatures ≤ -20 °C at a diameter of 1.9 cm after a 5 min freeze. Fluorescent imaging conducted 24 h post-thaw demonstrated a uniformly shaped ellipsoidal ablative zone with a midline diameter of 2.5 cm, resulting in a total ablative volume of 6.9 cm3 after a single 5 min freeze. In vivo findings consistently demonstrated the generation of ablative areas measuring 2.03 cm × 3.2 cm. These studies demonstrate the potential of the FrostBite cryocatheter as an endoscopic ultrasound-based treatment option. The data suggest that FrostBite may provide for the rapid, effective, controllable freezing of cancerous pancreatic and liver tissues. This ablative power also offers the potential of improved safety margins via the minimally invasive nature of an endoscopic ultrasound-based approach or natural orifice transluminal endoscopic surgery (NOTES)-based approach. The results of this pre-clinical feasibility study show promise, affirming the need for further investigation into the potential of the FrostBite cryocatheter as an advanced, minimally invasive cryoablative technology.

Comprehensive multimodal management of borderline resectable pancreatic cancer: Current status and progress

Borderline resectable pancreatic cancer (BRPC) is a complex clinical entity with specific biological features. Criteria for resectability need to be assessed in combination with tumor anatomy and oncology. Neoadjuvant therapy (NAT) for BRPC patients is associated with additional survival benefits. Research is currently focused on exploring the optimal NAT regimen and more reliable ways of assessing response to NAT. More attention to management standards during NAT, including biliary drainage and nutritional support, is needed. Surgery remains the cornerstone of BRPC treatment and multidisciplinary teams can help to evaluate whether patients are suitable for surgery and provide individualized management during the perioperative period, including NAT responsiveness and the selection of surgical timing.

Renal cryoablation - a practical guide for interventional radiologists

Renal cryoablation is a treatment option for early stage renal cell carcinomas with excellent oncological outcomes and low morbidity. This review outlines the technique of renal cryoablation and provides a guide for interventional radiologists on setting up an integrated service within a renal cancer network multidisciplinary setting. Patient selection and preparation, together with the technical aspects which ensure optimal oncological outcomes and avoid collateral damage to adjacent organs are highlighted.

Locally Advanced Pancreatic Cancer: A Review of Local Ablative Therapies

Pancreatic cancer is typically characterized by its aggressive tumor growth and dismal prognosis. Approximately 30% of patients with pancreatic cancer present with locally advanced disease, broadly defined as having a tumor-to-artery interface >180°, having an unreconstructable portal vein or superior mesenteric vein and no signs of metastatic disease. These patients are currently designated to palliative systemic chemotherapy, though median overall survival remains poor (approximately 11 months). Therefore, several innovative local therapies have been investigated as new treatment options for locally advanced pancreatic cancer (LAPC). This article provides an overview of available data with regard to morbidity and oncological outcome of novel local therapies for LAPC.

Survival of patients with advanced pancreatic cancer after iodine125 seeds implantation brachytherapy: A meta-analysis

BACKGROUND

Brachytherapy with iodine-labeled seeds (I-seeds) implantation is increasingly being used to treat tumors because of its positional precision, minimal invasion, least damage to noncancerous tissue due to slow and continuous release of radioactivity and facilitation with modern medical imaging technologies. This study evaluates the survival and pain relief outcomes of the I-seeds implantation brachytherapy in advanced pancreatic cancer patients.

METHODS

Literature search was carried out in multiple electronic databases (Google Scholar, Embase, Medline/PubMed, and Ovid SP) and studies reporting I seeds implantation brachytherapy in pancreatic cancer patients with unresectable tumor were selected by following predetermined eligibility criteria. Random effects meta-analysis was performed to achieve inverse variance weighted effect size of the overall survival rate after the intervention. Sensitivity and subgroups analyses were also carried out.

RESULTS

Twenty-three studies (824 patients' data) were included in the meta-analysis. I-seeds implantation brachytherapy alone was associated with 8.98 [95% confidence interval (CI): 6.94, 11.03] months (P < 0.00001) overall survival with 1-year survival of 25.7 ± 9.3% (mean ± standard deviation; SD) and 2-year survival was 17.9 ± 8.6% (mean ± SD). In stage IV pancreatic cancer patients, overall survival was 7.13 [95% CI: 4.75, 9.51] months (P < 0.00001). In patients treated with I-seeds implantation along with 1 or more therapies, overall survival was 11.75 [95% CI: 9.84, 13.65] months (P < 0.00001) with 1-year survival of 47.4 ± 22.75% (mean ± SD) and 2-year survival was 16.97 ± 3.1% (mean ± SD). I-seeds brachytherapy was associated with relief of pain in 79.7 ± 9.9% (mean ± SD) of the patients.

CONCLUSIONS

Survival of pancreatic cancer patients after I-seeds implantation brachytherapy is found to be 9 months, whereas a combined treatment with I-seeds brachytherapy and other therapies was associated with approximately 12 months' survival. The majority of patients who underwent I-seeds brachytherapy had their pain relieved.

Ablation Strategies for Locally Advanced Pancreatic Cancer

With the advent of novel and somewhat effective chemotherapy against pancreas cancer, several groups developed a new interest on locally advanced pancreatic cancer (LAPC). Unresectable tumors constitute up to 80% of pancreatic cancer (PC) at the time of diagnosis and are associated with a 5-year overall survival of less than 5%. To control those tumors locally, with perhaps improved patients survival, significant advances were made over the last 2 decades in the development of ablation methods including cryoablation, radiofrequency ablation, microwave ablation, high intensity focused ultrasound and irreversible electroporation (IRE). Many suggested a call for caution for possible severe or lethal complications in using such techniques on the pancreas. Most fears were on the heating or freezing of the pancreas, while non-thermal ablation (IRE) could offer safer approaches. The multimodal therapies along with high-resolution imaging guidance have created some enthusiasm toward ablation for LAPC. The impact of ablation techniques on primarily non-resectable PC remains, however, unclear.

Temperature feedback-controlled photothermal treatment with diffusing applicator: theoretical and experimental evaluations

To minimize thermal injury, the current study evaluated the real-time temperature monitoring with a proportional-integrative-derivative (PID) controller during 980-nm photothermal treatment with a radially-diffusing applicator. Both simulations and experiments demonstrated comparable thermal behaviors in temperature distribution and the degree of irreversible tissue denaturation. The PID-controlled application constantly maintained the pre-determined temperature of 353 K (steady-state error = < 1 K). Due to constant energy delivery, coagulation volumes linearly increased up to 1.04 ± 0.02 cm(3) with irradiation time. Integration of temperature feedback with diffuser-assisted photothermal treatments can provide a feasible therapeutic modality to treat pancreatic tumors in an effective manner.

Irreversible electroporation of the pancreas is feasible and safe in a porcine survival model

OBJECTIVES

Use of thermal tumor ablation in the pancreatic parenchyma is limited because of the risk of pancreatitis, pancreatic fistula, or hemorrhage. This study aimed to evaluate the feasibility and safety of irreversible electroporation (IRE) in a porcine model.

METHODS

Ten pigs were divided into 2 study groups. In the first group, animals received IRE of the pancreatic tail and were killed after 60 minutes. In the second group, animals received IRE at the head of the pancreas and were followed up for 7 days. Clinical parameters, computed tomography imaging, laboratory results, and histology were obtained.

RESULTS

All animals survived IRE ablation, and no cardiac adverse effects were noted. Sixty minutes after IRE, a hypodense lesion on computed tomography imaging indicated the ablation zone. None of the animals developed clinical signs of acute pancreatitis. Only small amounts of ascites fluid, with a transient increase in amylase and lipase levels, were observed, indicating that no pancreatic fistula occurred.

CONCLUSIONS

This porcine model shows that IRE is feasible and safe in the pancreatic parenchyma. Computed tomography imaging reveals significant changes at 60 minutes after IRE and therefore might serve as an early indicator of therapeutic success. Clinical studies are needed to evaluate the efficacy of IRE in pancreatic cancer.

Systematic review of innovative ablative therapies for the treatment of locally advanced pancreatic cancer

BACKGROUND

Locally advanced pancreatic cancer (LAPC) is associated with a very poor prognosis. Current palliative (radio)chemotherapy provides only a marginal survival benefit of 2-3 months. Several innovative local ablative therapies have been explored as new treatment options. This systematic review aims to provide an overview of the clinical outcomes of these ablative therapies.

METHODS

A systematic search in PubMed, Embase and the Cochrane Library was performed to identify clinical studies, published before 1 June 2014, involving ablative therapies in LAPC. Outcomes of interest were safety, survival, quality of life and pain.

RESULTS

After screening 1037 articles, 38 clinical studies involving 1164 patients with LAPC, treated with ablative therapies, were included. These studies concerned radiofrequency ablation (RFA) (7 studies), irreversible electroporation (IRE) (4), stereotactic body radiation therapy (SBRT) (16), high-intensity focused ultrasound (HIFU) (5), iodine-125 (2), iodine-125-cryosurgery (2), photodynamic therapy (1) and microwave ablation (1). All strategies appeared to be feasible and safe. Outcomes for postoperative, procedure-related morbidity and mortality were reported only for RFA (4-22 and 0-11 per cent respectively), IRE (9-15 and 0-4 per cent) and SBRT (0-25 and 0 per cent). Median survival of up to 25·6, 20·2, 24·0 and 12·6 months was reported for RFA, IRE, SBRT and HIFU respectively. Pain relief was demonstrated for RFA, IRE, SBRT and HIFU. Quality-of-life outcomes were reported only for SBRT, and showed promising results.

CONCLUSION

Ablative therapies in patients with LAPC appear to be feasible and safe.

Cryosurgery for pancreatic cancer

The procedure of pancreatic cryosurgery is performed with intraoperative or percutaneous approaches. Based on current data and our initial experience, cryoablation appears to be a feasible, potentially safe and promising option in patients with locally advanced and unresectable pancreatic cancer. It is suggested that there are almost no known contraindications to the use of cryosurgery for pancreatic cancer. For most patients with pancreatic cancer, cryosurgery can substitute conventional surgery.

Systematic review of novel ablative methods in locally advanced pancreatic cancer

Unresectable locally advanced pancreatic cancer with or without metastatic disease is associated with a very poor prognosis. Current standard therapy is limited to chemotherapy or chemoradiotherapy. Few regimens have been shown to have a substantial survival advantage and novel treatment strategies are urgently needed. Thermal and laser based ablative techniques are widely used in many solid organ malignancies. Initial studies in the pancreas were associated with significant morbidity and mortality, which limited widespread adoption. Modifications to the various applications, in particular combining the techniques with high quality imaging such as computed tomography and intraoperative or endoscopic ultrasound has enabled real time treatment monitoring and significant improvements in safety. We conducted a systematic review of the literature up to October 2013. Initial studies suggest that ablative therapies may confer an additional survival benefit over best supportive care but randomised studies are required to validate these findings.

Comparison of percutaneous cryoablation with microwave ablation in a porcine liver model

We compared imaging and pathological changes between argon-helium cryosurgical (AH) and microwave (MW) ablation in a porcine liver model. Immediately after ablation, computed tomography (CT) imaging showed that the area affected by MW ablation was considerably greater than that affected by AH ablation; moreover, the surface area of necrotic tissue was considerably greater in the AH group, whereas the depth of the necrotic area was similar. Seven days after ablation, the affected area had not changed much in the AH group, but it had significantly increased in the MW group; similarly, the surface and depth of the necrotic areas had not changed much in the AH group, but they had increased significantly in the MW group. The pathological findings showed similar definitive areas for both groups at both time points. The findings indicated that long time after both therapies, complete tissue necrosis can be achieved, but the extent and depth of necrosis differ: necrosis foci after AH ablation could be predicted by ice ball under CT image, and necrosis foci after MW ablation will increase obviously. MW ablation might therefore be suitable for tumors with a larger volume and simple anatomical structures, and AH ablation might be suitable for tumors with complex anatomical structures or those located near important organs. These two methods could therefore be used in combination in clinical settings, but details of the procedure need to be studied.

Combination treatment with comprehensive cryoablation and immunotherapy in metastatic pancreatic cancer

OBJECTIVE

The aim of this study was to retrospectively assess the effect of comprehensive cryosurgery (ablation of intrapancreatic and extrapancreatic tumors) plus immunotherapy in metastatic pancreatic cancer.

METHODS

We divided 106 patients (57 men, 49 women; median age, 65 years) into the cryoimmunotherapy (31 patients), cryotherapy (36 patients), immunotherapy (17 patients), and chemotherapy groups (22 patients). Pretreatment immune function was tested in patients who underwent immunotherapy. Overall survival (OS) after diagnosis of metastatic pancreatic cancer was assessed after a 4-year follow-up.

RESULTS

Median OS was higher in the cryoimmunotherapy (13 months) and cryotherapy groups (7 months) than in the chemotherapy group (3.5 months; both P < 0.001) and was higher in the cryoimmunotherapy group than in the cryotherapy (P < 0.05) and immunotherapy groups (5 months; P < 0.001). In both the cryoimmunotherapy and cryotherapy groups, median OS was higher after multiple cryoablations than after a single cryoablation (P = 0.0048 and 0.041, respectively). In both groups, the median OS was higher in patients with normal immunologic function than in those with immune dysfunction (P < 0.0001 and P = 0.0004, respectively).

CONCLUSIONS

Cryoimmunotherapy significantly increased OS in metastatic pancreatic cancer. Multiple cryoablations and normal pretreatment immunologic function were associated with better prognosis.

Cryosurgery in combination with brachytherapy of iodine-125 seeds for pancreatic cancer

A major limit of cryoablation is incomplete destruction of cells in the border zone of the cryogenic lesion in which the tissue temperature is warmer than (-)20 °C. The use of iodine-125 seed implantation is likely to be complementary to cryosurgery for treatment of pancreatic cancer. The procedure of cryosurgery and iodine-125 seed implantation is performed with percutaneous approaches under guidance of ultrasound and/or CT. The number of iodine-125 seeds implanted for every patient was 34 in median. Forty-nine patients with locally advanced pancreatic cancer received cryosurgery with combination of iodine-125 seed implantation. During a median follow-up of 18 months, the median of over all survival was 16.2 months. The 6-, 12-, 24- and 36-month overall survival rates were 94.9%, 63.1%, 22.8% and 9.5%, respectively. Compared with patients with cryosurgery alone, combination treatment shows higher the 6- and 12-month survival rates and longer the median survival.

Two case reports of pilot percutaneous cryosurgery in familial multiple endocrine neoplasia type 1

We report 2 cases of familial multiple endocrine neoplasia type 1 syndrome (MEN 1) in related Malaysian Chinese individuals: the son had simultaneous primary lesions in the pancreatic tail, parathyroid, adrenal gland, and hypophysis, with metastatic tumors in the left lung, mediastinum and spine; his mother had simultaneous primary lesions in the pancreatic head, parathyroid, and hypophysis, with metastatic tumors in the liver, spine, ilium, chest wall, and rib. Genetic testing of the 2 patients showed the same mutation in exon 9 of MEN1 (c.1288G>T, Glu430, encoding a stop codon). The tumors with the poorest prognosis and clinical sequelae were in the pancreas of both patients, and these were treated by percutaneous cryoablation. The number of hypoglycemic episodes in the son improved for more than 120 days, and the abdominal space occupying lesion resolved in his mother.

Alleviating visceral cancer pain in patients with pancreatic cancer using cryoablation and celiac plexus block

Little is known about the effects of pancreas cryoablation (PCA) on abdominalgia in pancreatic cancer patients or its synergism with celiac plexus block (CPB). In patients without abdominalgia, to investigate the effects of PCA; in patients with abdominalgia, to investigate the pain-alleviating effects of PCA+CPB. Sixty-two patients were enrolled in this retrospective review; 12 without abdominalgia refused PCA, 15 without abdominalgia received PCA to reduce their tumor load and 35 with abdominalgia received PCA+CPB to reduce tumor load and alleviate pain. All PCA and PCA+CPB procedures were performed successfully. Some slight adverse effects (e.g. increased serum amylase, abdominal distension and nausea, abdominal bleeding) had disappeared by 3weeks, spontaneously or after symptomatic treatment. In patients without abdominalgia, pain occurred in one-third of cases (all with pancreatic head cancer) after PCA but had stopped 1-12days after treatment; in patients with abdominalgia before treatment, pain stopped immediately after PCA+CPB in 18 cases and 2-24days after treatment in 17 (all with pancreatic head cancer); a significant difference was found between pretreatment and post-treatment pain frequency (P=0.0019), regardless of the presence of advanced (P=0.0096) or metastatic (P=0.0072) cancer. The average time to pain relief was approximately 7days after both PCA and PCA+CPB, and abdominalgia did not recur for more than 8weeks. PCA may cause short-term pain in some pancreatic cancer patients. Combined PCA+CPB can alleviate cancer pain for more than 8weeks, without severe side effects.

Radical treatment of stage IV pancreatic cancer by the combination of cryosurgery and iodine-125 seed implantation

AIM: To investigate the therapeutic effect of radical treatment and palliative treatment in stage IV pancreatic cancer patients.

METHODS: 81 patients were enrolled in the study. Radical treatment was performed on 51 patients, while 30 patients were put under palliative treatment. The procedural safety and interval survival for stage IV pancreatic cancer (IS-IV) was assessed by almost 2.5 years of follow-ups. The IS-IV of patients under the two kinds of treatment, and the effects of treatment timing and frequency on IS-IV, were compared.

RESULTS: The IS-IV of patients who received radical treatment was significantly longer than those who received palliative treatment (P < 0.001). The IS-IV of patients who received delayed radical or palliative treatment was longer than those who received accordingly timely treatment (P = 0.0034 and 0.0415, respectively). Multiple treatments can play an important role in improving the IS-IV of patients who received radical treatment (P = 0.0389), but not for those who received palliative treatment (P = 0.99).

CONCLUSION: The effect of radical treatment was significantly more obvious than that of palliative treatment, and multiple radical treatments may contribute more to patients than a single radical treatment.

Percutaneous ultrasonography and computed tomography guided pancreatic cryoablation: feasibility and safety assessment

OBJECTIVE

To assess the safety and feasibility of percutaneous cryoablation on pancreatic cancer via ultrasonography (US) and computed tomography (CT) guidance.

MATERIALS AND METHODS

This retrospective review was approved by the institutional review board and of informed consent. Thirty-two patients (18 men and 14 women; median age 62; age range, 30-77 years) with pancreatic cancer (stage II/III/IV, 3/11/18) treated with percutaneous US and CT guided cryoablations between February 2009 and February 2010 were eligible for this review. Thirteen tumors in pancreatic head and 19 in pancreatic body and/or tail measuring 2-11 cm (mean, 5.2 cm±8 [standard deviation]) were ablated with 49 procedures in total. Feasibility was analyzed by enhanced CT 1-3 months post procedure and safety was assessed by clinical signs, symptoms and laboratory results.

RESULTS

Neither procedural death nor serious complications occurred. Fifteen tumors (46.9%) smaller than 5 cm were successfully ablated by one session of cryoablation. Twenty-seven patients experienced a ≥50% reduction in pain score, 22 experienced a 50% decrease in analgesic consumption and 16 experienced a ≥20 increase in Karnofsky Performance Status (KPS) Score. Partial response (PR) and stable disease (SD) turned up in 9 and 21 patients, respectively, lesions in whom were identified controlled by none enhancement on enhanced CT. Mean and median survival was 15.9 and 12.6 months, respectively. The 6-, 12- and 24-month survival rates were 82.8%, 54.7% and 27.3%, respectively.

CONCLUSION

US and CT guided percutaneous cryoablation is a safe and promising local treatment for pancreatic cancer.

Experimental study of the safety of pancreas cryosurgery: the comparison of 2 different techniques of cryosurgery

OBJECTIVES

To test the feasibility of cryosurgery for pancreatic carcinoma and to observe the consequence of cryosurgery by 2 different techniques.

METHODS

Twelve healthy pigs underwent laparotomy, during which, chop amputation of common bile duct and duodenum were performed, meanwhile other intra-abdominal organs with the pancreas were isolated. Two different techniques of cryosurgery were performed on the pancreas. Group A (n = 6) accepted the mild hypothermic cryosurgery with liquid nitrogen superficial refrigeration, and group B (n = 6) were performed with the deep hypothermic cryosurgery at -170 degrees C with LCS2000 cryogenic surgical system. All the animals' digestive tract was reconstructed with cholecystojejunostomy and gastroenterostomy, respectively.

RESULTS

Acute necrotizing pancreatitis occurred on all animals in group A, of which 5 of the 6 died within 1 week, whereas only 1 of the 6 reported a 4-week survival. All animals in group B survived during the observation, in which only a transient increment and a gradual correction of pancreatic amylase level were recorded. Small pancreatic pseudocyst occurred in 1 case.

CONCLUSIONS

Mild hypothermic cryosurgery with liquid nitrogen superficial refrigeration might lead to pancreatic injury and induce acute pancreatitis, yet deep hypothermic cryosurgery with adequate time showed a promising effect in destroying pancreatic tissue and preventing acute pancreatitis.