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Kinny-Köster B, Habib JR, van Oosten F, Javed AA, Cameron JL, Burkhart RA, Burns WR, He J, Wolfgang CL. Conduits in Vascular Pancreatic Surgery: Analysis of Clinical Outcomes, Operative Techniques, and Graft Performance. Ann Surg 2023; 278:e94-e104. [PMID: 35838419 DOI: 10.1097/sla.0000000000005575] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES We analyze successes and failures of pushing the boundaries in vascular pancreatic surgery to establish safety of conduit reconstructions. BACKGROUND Improved systemic control from chemotherapy in pancreatic cancer is increasing the demand for surgical solutions of extensive local vessel involvement, but conduit-specific data are scarce. METHODS We identified 63 implanted conduits (41% autologous vessels, 37% allografts, 18% PTFE) in 56 pancreatic resections of highly selected cancer patients between October 2013 and July 2020 from our prospectively maintained database. Assessed parameters were survival, perioperative complications, operative techniques (anatomic and extra-anatomic routes), and conduit patency. RESULTS For vascular reconstruction, 25 arterial and 38 venous conduits were utilized during 39 pancreatoduodenectomies, 14 distal pancreatectomies, and 3 total pancreatectomies. The median postoperative survival was 2 years. A Clavien-Dindo grade ≥IIIa complication was apparent in 50% of the patients with a median Comprehensive Complication Index of 29.6. The 90-day mortality in this highly selected cohort was 9%. Causes of mortality were conduit related in 3 patients, late postpancreatectomy hemorrhage in 1 patient, and early liver metastasis in 1 patient. Image-based patency rates of conduits were 66% and 45% at postoperative days 30 and 90, respectively. CONCLUSIONS Our perioperative mortality of vascular pancreatic surgery with conduits in the arterial or venous system is 9%. Reconstructions are technically feasible with different anatomic and extra-anatomic strategies, while identifying predictors of early conduit occlusion remains challenging. Optimizing reconstructed arterial and venous hemodynamics in the context of pancreatic malignancy will enable long-term survival in more patients responsive to chemotherapies.
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Affiliation(s)
- Benedict Kinny-Köster
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MA
- Department of Surgery, New York University Grossman School of Medicine and NYU-Langone Health, New York, NY
| | - Joseph R Habib
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MA
| | - Floortje van Oosten
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MA
| | - Ammar A Javed
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MA
- Department of Surgery, New York University Grossman School of Medicine and NYU-Langone Health, New York, NY
| | - John L Cameron
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MA
| | - Richard A Burkhart
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MA
| | - William R Burns
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MA
| | - Jin He
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MA
| | - Christopher L Wolfgang
- Department of Surgery, New York University Grossman School of Medicine and NYU-Langone Health, New York, NY
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Agnass P, Rodermond HM, van Veldhuisen E, Vogel JA, Ten Cate R, van Lienden KP, van Gulik TM, Franken NAP, Oei AL, Kok HP, Besselink MG, Crezee J. Quantitative analysis of contribution of mild and moderate hyperthermia to thermal ablation and sensitization of irreversible electroporation of pancreatic cancer cells. J Therm Biol 2023; 115:103619. [PMID: 37437370 DOI: 10.1016/j.jtherbio.2023.103619] [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: 02/28/2023] [Revised: 05/09/2023] [Accepted: 05/30/2023] [Indexed: 07/14/2023]
Abstract
INTRODUCTION Irreversible electroporation (IRE) is an ablation modality that applies short, high-voltage electric pulses to unresectable cancers. Although considered a non-thermal technique, temperatures do increase during IRE. This temperature rise sensitizes tumor cells for electroporation as well as inducing partial direct thermal ablation. AIM To evaluate the extent to which mild and moderate hyperthermia enhance electroporation effects, and to establish and validate in a pilot study cell viability models (CVM) as function of both electroporation parameters and temperature in a relevant pancreatic cancer cell line. METHODS Several IRE-protocols were applied at different well-controlled temperature levels (37 °C ≤ T ≤ 46 °C) to evaluate temperature dependent cell viability at enhanced temperatures in comparison to cell viability at T = 37 °C. A realistic sigmoid CVM function was used based on thermal damage probability with Arrhenius Equation and cumulative equivalent minutes at 43 °C (CEM43°C) as arguments, and fitted to the experimental data using "Non-linear-least-squares"-analysis. RESULTS Mild (40 °C) and moderate (46 °C) hyperthermic temperatures boosted cell ablation with up to 30% and 95%, respectively, mainly around the IRE threshold Eth,50% electric-field strength that results in 50% cell viability. The CVM was successfully fitted to the experimental data. CONCLUSION Both mild- and moderate hyperthermia significantly boost the electroporation effect at electric-field strengths neighboring Eth,50%. Inclusion of temperature in the newly developed CVM correctly predicted both temperature-dependent cell viability and thermal ablation for pancreatic cancer cells exposed to a relevant range of electric-field strengths/pulse parameters and mild moderate hyperthermic temperatures.
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Affiliation(s)
- P Agnass
- Amsterdam UMC Location University of Amsterdam, Radiation Oncology, Meibergdreef 9, Amsterdam, the Netherlands; Amsterdam UMC Location University of Amsterdam, Surgery, Meibergdreef 9, Amsterdam, the Netherlands; Amsterdam UMC Location University of Amsterdam, Experimental Oncology and Radiobiology, Meibergdreef 9, Amsterdam, the Netherlands.
| | - H M Rodermond
- Amsterdam UMC Location University of Amsterdam, Radiation Oncology, Meibergdreef 9, Amsterdam, the Netherlands; Amsterdam UMC Location University of Amsterdam, Experimental Oncology and Radiobiology, Meibergdreef 9, Amsterdam, the Netherlands; Amsterdam UMC Location University of Amsterdam, Experimental Molecular Medicine, Meibergdreef 9, Amsterdam, the Netherlands.
| | - E van Veldhuisen
- Amsterdam UMC Location University of Amsterdam, Surgery, Meibergdreef 9, Amsterdam, the Netherlands.
| | - J A Vogel
- Amsterdam UMC Location University of Amsterdam, Gastroenterology & Hepatology, Meibergdreef 9, Amsterdam, the Netherlands.
| | - R Ten Cate
- Amsterdam UMC Location University of Amsterdam, Radiation Oncology, Meibergdreef 9, Amsterdam, the Netherlands; Amsterdam UMC Location University of Amsterdam, Experimental Oncology and Radiobiology, Meibergdreef 9, Amsterdam, the Netherlands; Amsterdam UMC Location University of Amsterdam, Experimental Molecular Medicine, Meibergdreef 9, Amsterdam, the Netherlands.
| | - K P van Lienden
- Department of Intervention Radiology, St. Antonius Hospital, Nieuwegein, the Netherlands.
| | - T M van Gulik
- Amsterdam UMC Location University of Amsterdam, Surgery, Meibergdreef 9, Amsterdam, the Netherlands.
| | - N A P Franken
- Amsterdam UMC Location University of Amsterdam, Radiation Oncology, Meibergdreef 9, Amsterdam, the Netherlands; Amsterdam UMC Location University of Amsterdam, Experimental Oncology and Radiobiology, Meibergdreef 9, Amsterdam, the Netherlands; Amsterdam UMC Location University of Amsterdam, Experimental Molecular Medicine, Meibergdreef 9, Amsterdam, the Netherlands.
| | - A L Oei
- Amsterdam UMC Location University of Amsterdam, Radiation Oncology, Meibergdreef 9, Amsterdam, the Netherlands; Amsterdam UMC Location University of Amsterdam, Experimental Oncology and Radiobiology, Meibergdreef 9, Amsterdam, the Netherlands; Amsterdam UMC Location University of Amsterdam, Experimental Molecular Medicine, Meibergdreef 9, Amsterdam, the Netherlands.
| | - H P Kok
- Amsterdam UMC Location University of Amsterdam, Radiation Oncology, Meibergdreef 9, Amsterdam, the Netherlands; Cancer Center Amsterdam, Treatment and Quality of Life, Cancer Biology and Immunology, Amsterdam, the Netherlands.
| | - M G Besselink
- Amsterdam UMC Location University of Amsterdam, Surgery, Meibergdreef 9, Amsterdam, the Netherlands.
| | - J Crezee
- Amsterdam UMC Location University of Amsterdam, Radiation Oncology, Meibergdreef 9, Amsterdam, the Netherlands; Cancer Center Amsterdam, Treatment and Quality of Life, Cancer Biology and Immunology, Amsterdam, the Netherlands.
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3
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van Veldhuisen E, Klompmaker S, Janssen QP, Hilal MA, Alseidi A, Balduzzi A, Balzano G, Bassi C, Berrevoet F, Bonds M, Busch OR, Butturini G, Conlon KC, Frigerio IM, Fusai GK, Gagnière J, Griffin O, Hackert T, Halimi A, Keck T, Kleeff J, Klaiber U, Labori KJ, Lesurtel M, Malleo G, Marino MV, Molenaar IQ, Mortensen MB, Nikov A, Pagnanelli M, Pandé R, Pfeiffer P, Pietrasz D, Rangelova E, Roberts KJ, Cunha AS, Salvia R, Strobel O, Tarvainen T, Wilmink JW, Koerkamp BG, Besselink MG. Surgical and Oncological Outcomes After Preoperative FOLFIRINOX Chemotherapy in Resected Pancreatic Cancer: An International Multicenter Cohort Study. Ann Surg Oncol 2023; 30:1463-1473. [PMID: 36539580 PMCID: PMC9908650 DOI: 10.1245/s10434-022-12387-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Accepted: 07/25/2022] [Indexed: 12/24/2022]
Abstract
BACKGROUND Preoperative FOLFIRINOX chemotherapy is increasingly administered to patients with borderline resectable (BRPC) and locally advanced pancreatic cancer (LAPC) to improve overall survival (OS). Multicenter studies reporting on the impact from the number of preoperative cycles and the use of adjuvant chemotherapy in relation to outcomes in this setting are lacking. This study aimed to assess the outcome of pancreatectomy after preoperative FOLFIRINOX, including predictors of OS. METHODS This international multicenter retrospective cohort study included patients from 31 centers in 19 European countries and the United States undergoing pancreatectomy after preoperative FOLFIRINOX chemotherapy (2012-2016). The primary end point was OS from diagnosis. Survival was assessed using Kaplan-Meier analysis and Cox regression. RESULTS The study included 423 patients who underwent pancreatectomy after a median of six (IQR 5-8) preoperative cycles of FOLFIRINOX. Postoperative major morbidity occurred for 88 (20.8%) patients and 90-day mortality for 12 (2.8%) patients. An R0 resection was achieved for 243 (57.4%) patients, and 259 (61.2%) patients received adjuvant chemotherapy. The median OS was 38 months (95% confidence interval [CI] 34-42 months) for BRPC and 33 months (95% CI 27-45 months) for LAPC. Overall survival was significantly associated with R0 resection (hazard ratio [HR] 1.63; 95% CI 1.20-2.20) and tumor differentiation (HR 1.43; 95% CI 1.08-1.91). Neither the number of preoperative chemotherapy cycles nor the use adjuvant chemotherapy was associated with OS. CONCLUSIONS This international multicenter study found that pancreatectomy after FOLFIRINOX chemotherapy is associated with favorable outcomes for patients with BRPC and those with LAPC. Future studies should confirm that the number of neoadjuvant cycles and the use adjuvant chemotherapy have no relation to OS after resection.
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Affiliation(s)
- Eran van Veldhuisen
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Sjors Klompmaker
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Cancer Center Amsterdam, Amsterdam, The Netherlands
- Department of Radiology, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - Quisette P Janssen
- Department of Surgery, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Mohammed Abu Hilal
- Department of Surgery, University Hospital Southampton NHS, Southampton, UK
- Department of General Surgery, Istituto Ospedaliero Fondazione Poliambulanza, Brescia, Italy
| | - Adnan Alseidi
- Department of Surgery, University of California, San Francisco, USA
| | - Alberto Balduzzi
- Department of General and Pancreatic Surgery, The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - Gianpaolo Balzano
- Department of Surgery, Pancreas Unit, Ospedale San Raffaele, Milan, Italy
| | - Claudio Bassi
- Department of General and Pancreatic Surgery, The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - Frederik Berrevoet
- Department of General and HPB Surgery, Gent University Hospital, Gent, Belgium
| | - Morgan Bonds
- Department of Surgery, University of California, San Francisco, USA
| | - Olivier R Busch
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Giovanni Butturini
- HPB Surgery Unit, Pederzoli Hospital, Peschiera del Garda, Verona, Italy
| | - Kevin C Conlon
- Department of Surgery, Trinity College Dublin and St. Vincent's University Hospital, Dublin, Ireland
| | | | - Giuseppe K Fusai
- HPB Surgery and Liver Transplantation Unit, Royal Free Hospital, London, UK
| | - Johan Gagnière
- U1071 INSERM, Clermont-Auvergne University, Clermont-Ferrand, France
- Department of General, Visceral and Transplantation Surgery, Universitätsklinikum Heidelberg, Heidelberg, Germany
| | - Oonagh Griffin
- Department of Surgery, Trinity College Dublin and St. Vincent's University Hospital, Dublin, Ireland
| | - Thilo Hackert
- Department of General, Visceral and Transplantation Surgery, Universitätsklinikum Heidelberg, Heidelberg, Germany
| | - Asif Halimi
- Department of Surgery, Karolinska Institutet, Stockholm, Sweden
| | - Tobias Keck
- Department of Surgery, Universitaet zu Luebeck, Luebeck, Germany
| | - Jörg Kleeff
- Department of Visceral, Vascular and Endocrine Surgery, Martin Luther University Halle-Wittenberg, Halle, Germany
| | - Ulla Klaiber
- Department of General, Visceral and Transplantation Surgery, Universitätsklinikum Heidelberg, Heidelberg, Germany
| | - Knut J Labori
- Department of Hepato-Pancreato-Biliary Surgery, Oslo University Hospital, Oslo, Norway
| | - Mickael Lesurtel
- Department of Surgery and Liver Transplantation, Croix Rousse University Hospital, University of Lyon, Hospices Civils de LyonLyon, France
| | - Giuseppe Malleo
- Department of General and Pancreatic Surgery, The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - Marco V Marino
- Department of General Surgery, Azienda Ospedaliera, Ospedali Riuniti Villa Sofia-Cervello, Palermo, Italy
- Department of General Surgery, Hospital Universitario Marques de Valdecilla, Santander, Spain
| | - I Quintus Molenaar
- Department of Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Michael B Mortensen
- Department of Surgery, Odense Pancreas Center (OPAC), Odense University Hospital, Odense, Denmark
| | - Andrej Nikov
- Department of Surgery, 2nd Faculty of Medicine, Charles University and Central Military Hospital, Prague, Czech Republic
| | - Michele Pagnanelli
- Department of Surgery, Pancreas Unit, Ospedale San Raffaele, Milan, Italy
| | - Rupaly Pandé
- Department of Surgery, University Hospital Birmingham, Birmingham, UK
| | - Per Pfeiffer
- Department of Medical Oncology, Odense University Hospital, Odense, Denmark
| | - Daniel Pietrasz
- Department of Hepato-Biliary-Pancreatic Surgery, Liver Transplant Center, Paul Brousse Hospital, Université Paris-Sud, Université Paris-Saclay, Villejuif, France
| | - Elena Rangelova
- Department of Surgery, Karolinska Institutet, Stockholm, Sweden
| | - Keith J Roberts
- Department of Surgery, University Hospital Birmingham, Birmingham, UK
| | - Antonio Sa Cunha
- Department of Hepato-Biliary-Pancreatic Surgery, Liver Transplant Center, Paul Brousse Hospital, Université Paris-Sud, Université Paris-Saclay, Villejuif, France
| | - Roberto Salvia
- Department of General and Pancreatic Surgery, The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - Oliver Strobel
- Department of General, Visceral and Transplantation Surgery, Universitätsklinikum Heidelberg, Heidelberg, Germany
| | - Timo Tarvainen
- Department of Gastroenterological Surgery, Helsinki University Hospital, Helsinki, Finland
| | - Johanna W Wilmink
- Department of Medical Oncology, Amsterdam UMC, University of Amsterdam, Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Bas Groot Koerkamp
- Department of Surgery, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Marc G Besselink
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Cancer Center Amsterdam, Amsterdam, The Netherlands.
- Department of Digestive and Hepatobiliary Surgery-Liver Transplantation, University Hospital of Clermont-Ferrand, Clermont-Ferrand, France.
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Davis JM, Salibi PN, Motz BM, Vrochides D, McKillop IH, Iannitti DA. Irreversible Electroporation-Assisted Resection for Locally Advanced Pancreas Cancer. Surg Innov 2023:15533506231157442. [PMID: 36792137 DOI: 10.1177/15533506231157442] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/17/2023]
Abstract
BACKGROUND A significant number of patients with advanced pancreatic cancer are unable to undergo resection due to vascular involvement. Irreversible electroporation (IRE) has shown promise in improving survival. This study sought to assess a novel IRE application whereby IRE was performed pre-resection to alter tissue plasticity and assist tumor removal from underlying vasculature when surgical excision was otherwise precluded. METHODS After multidisciplinary evaluation appropriate patients were consented for IRE therapy. All IRE cases were tracked prospectively using an institutional review board-approved database that was retrospectively queried for patients undergoing IRE-assisted resection (IRE-AR) for pancreatic adenocarcinoma located in the head/uncinate process. Patients who underwent other IRE therapy or had disease location elsewhere were excluded. RESULTS 5 patients met the study inclusion criteria with a mean tumor size of 3.2 cm (range 2.4-4.1 cm). Using IRE-AR median recurrence free survival was 10.6 months, with 21.6 month overall survival. The average comprehensive complication index score was 23.23. One patient had grade 3 [or higher] complications and there were no 90 day mortalities. DISCUSSION Employing a high-starting voltage for ablation along resection margins allows for resection when margins are anticipated to be positive. Patients with locally advanced pancreatic adenocarcinoma who underwent IRE-AR had promising outcomes. CONCLUSION This study reports IRE-AR as a novel approach for resecting locally advanced pancreatic adenocarcinoma. A prospective trial of IRE-AR for inoperable pancreatic adenocarcinoma will provide additional data for the long-term application of this approach.
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Affiliation(s)
- Joshua Mk Davis
- Hepato-Pancreato-Biliary Surgery, 2351Atrium Health, Charlotte, NC, USA
| | - Patrick N Salibi
- Hepato-Pancreato-Biliary Surgery, 2351Atrium Health, Charlotte, NC, USA
| | - Benjamin M Motz
- Hepato-Pancreato-Biliary Surgery, 2351Atrium Health, Charlotte, NC, USA
| | | | - Iain H McKillop
- Hepato-Pancreato-Biliary Surgery, 2351Atrium Health, Charlotte, NC, USA
| | - David A Iannitti
- Hepato-Pancreato-Biliary Surgery, 2351Atrium Health, Charlotte, NC, USA
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Polyakov AN, Patyutko YI, Kudashkin NE, Kantieva DM, Romanova KA, Nasonova EA, Korshak AV, Egenov OA, Podluzhnyi DV. [Irreversible electroporation in locally advanced pancreatic cancer]. Khirurgiia (Mosk) 2023:29-38. [PMID: 37916555 DOI: 10.17116/hirurgia202310129] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2023]
Abstract
OBJECTIVE To determine the feasibility of irreversible electroporation (IRE) for locally advanced pancreatic adenocarcinoma. MATERIAL AND METHODS Twenty-three patients underwent IRE after chemotherapy for locally advanced pancreatic cancer between 2015 and 2022. IRE was performed during laparotomy as a rule (n=22). In one case, IRE was combined with palliative pancretoduodenectomy. Nineteen (86.3%) patients received adjuvant chemotherapy after the procedure. The follow-up examination included contrast-enhanced CT/MRI of the abdomen, chest X-ray or CT, analysis of CA 19-9 marker one month after surgery and then every three months. RESULTS Complications after IRE developed in 5 (21.7%) patients. Three patients (13.0%) had arrhythmia, two (8.7%) ones had pancreatic necrosis. A 90-day mortality after the procedure was 4.3% (n=1), the cause was pancreatic necrosis. According to intraoperative data and the first examination (CT/MRI), the entire tumor infiltrate was treated in 21 (91.3%) cases. Median follow-up was 19 months. Median period until local recurrence was 15 months. Isolated local recurrence was observed in 7 patients. Of these, 3 ones underwent radiotherapy, one patient underwent repeated IRE. Distant metastases were found in 11 patients; systemic therapy was restarted. Median time to progression was 7 months after IRE and 14 months after initiation of chemotherapy. The median overall survival was 16 months after electroporation and 25 months after chemotherapy. CONCLUSION Irreversible electroporation may be useful in carefully selected patients with unresectable locally advanced pancreatic adenocarcinoma after successful induction chemotherapy. This procedure provides local control, but the impact on long-term outcomes and feasibility of routine use should be analyzed in randomized trials.
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Affiliation(s)
- A N Polyakov
- Blokhin National Medical Cancer Research Center, Moscow, Russia
| | - Yu I Patyutko
- Blokhin National Medical Cancer Research Center, Moscow, Russia
| | - N E Kudashkin
- Blokhin National Medical Cancer Research Center, Moscow, Russia
| | - D M Kantieva
- Blokhin National Medical Cancer Research Center, Moscow, Russia
| | - K A Romanova
- Blokhin National Medical Cancer Research Center, Moscow, Russia
| | - E A Nasonova
- Blokhin National Medical Cancer Research Center, Moscow, Russia
| | - A V Korshak
- Blokhin National Medical Cancer Research Center, Moscow, Russia
| | - O A Egenov
- Blokhin National Medical Cancer Research Center, Moscow, Russia
| | - D V Podluzhnyi
- Blokhin National Medical Cancer Research Center, Moscow, Russia
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Thomas AS, Kwon W, Horowitz DP, Bates SE, Fojo AT, Manji GA, Schreibman S, Schrope BA, Chabot JA, Kluger MD. Long-term follow-up experience with adjuvant therapy after irreversible electroporation of locally advanced pancreatic cancer. J Surg Oncol 2022; 126:1442-1450. [PMID: 36048146 DOI: 10.1002/jso.27085] [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: 05/10/2022] [Revised: 08/09/2022] [Accepted: 08/24/2022] [Indexed: 11/10/2022]
Abstract
BACKGROUND Irreversible electroporation (IRE) expands the surgical options for patients with unresectable pancreatic cancer. This study evaluated for differences in survival stratified by type of IRE and receipt of adjuvant chemotherapy. METHODS Patients with locally advanced pancreatic cancer treated by IRE (2012-2020) were retrospectively included. Overall survival (OS) and recurrence-free survival (RFS) were compared by type of IRE (in situ for local tumor control or IRE of potentially positive margins with resection) and by receipt of adjuvant chemotherapy. RESULTS Thirty-nine patients had IRE in situ, 61 had IRE for margin extension, and 19 received adjuvant chemotherapy. Most (97.00%) underwent induction chemotherapy. OS was 28.71 months (interquartile range [IQR] 19.17, 51.19) from diagnosis, with no difference by IRE type (hazard ratio [HR] 1.05 for margin extension [p = 0.85]) or adjuvant chemotherapy (HR 1.14 [p = 0.639]). RFS was 8.51 months (IQR 4.95, 20.17) with no difference by IRE type (HR 0.90 for margin extension [p = 0.694]) or adjuvant chemotherapy (HR 0.90 [p = 0.711]). CONCLUSION These findings suggest that adjuvant therapy may have limited benefit for patients treated with induction chemotherapy followed by local control with IRE for unresectable pancreatic cancer. Further study of the duration and timing of systemic therapy is warranted to maximize benefit and limit toxicity.
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Affiliation(s)
- Alexander S Thomas
- Department of Surgery, Division of Gastrointestinal and Endocrine Surgery, Columbia University Irving Medical Center, New York, New York, USA
| | - Wooil Kwon
- Department of Surgery, Division of Gastrointestinal and Endocrine Surgery, Columbia University Irving Medical Center, New York, New York, USA.,Department of Surgery and Cancer Research Institute, Seoul National University College of Medicine, Seoul, South Korea
| | - David P Horowitz
- Department of Radiation Oncology, Herbert Irving Comprehensive Cancer Center, Columbia University Irving Medical New York, New York, New York, USA
| | - Susan E Bates
- Division of Hematology and Oncology, Columbia University Irving Medical Center, New York, New York, USA
| | - Antonio T Fojo
- Division of Hematology and Oncology, Columbia University Irving Medical Center, New York, New York, USA
| | - Gulam A Manji
- Division of Hematology and Oncology, Columbia University Irving Medical Center, New York, New York, USA
| | - Stephen Schreibman
- Division of Hematology and Oncology, Columbia University Irving Medical Center, New York, New York, USA
| | - Beth A Schrope
- Department of Surgery, Division of Gastrointestinal and Endocrine Surgery, Columbia University Irving Medical Center, New York, New York, USA
| | - John A Chabot
- Department of Surgery, Division of Gastrointestinal and Endocrine Surgery, Columbia University Irving Medical Center, New York, New York, USA
| | - Michael D Kluger
- Department of Surgery, Division of Gastrointestinal and Endocrine Surgery, Columbia University Irving Medical Center, New York, New York, USA
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Simultaneous Gemcitabine and Percutaneous CT-Guided Irreversible Electroporation for Locally Advanced Pancreatic Cancer. JOURNAL OF ONCOLOGY 2022; 2022:3523769. [PMID: 35747123 PMCID: PMC9213186 DOI: 10.1155/2022/3523769] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/05/2022] [Revised: 05/19/2022] [Accepted: 05/21/2022] [Indexed: 11/24/2022]
Abstract
Background Irreversible electroporation (IRE) is a new local ablation technique for pancreatic cancer. The aim of this study is to analyse the safety and effectiveness of simultaneous gemcitabine and percutaneous CT-guided IRE for locally advanced pancreatic cancer (LAPC). Materials and Methods From October 2016 to January 2018, 61 patients with LAPC who received simultaneous gemcitabine and IRE therapy (GEM-IRE group, n = 31) or IRE alone therapy (IRE group, n = 30). Routine intravenous gemcitabine chemotherapy was performed 2 weeks after IRE in both groups. Results Technical success rates were 90.0% (27/30) and 93.3% (28/30) in the GEM-IRE and IRE groups. Compared with the IRE group, the GEM-IRE group exhibited longer overall survival (OS), local tumor progression free survival (LTPFS), and distant disease free survival (DDFS) from IRE (OS, 17.1 vs. 14.2 months, p=0.031; LTPFS, 14.6 vs. 10.2 months, p=0.045; DDFS, 15.4 vs. 11.7 months, p=0.071). Multivariate Cox regression analysis results suggested that tumor volume ≤37 cm3 and simultaneous gemcitabine with IRE were significant independent prognostic factors of OS, LTPFS, and DDFS. Four major adverse reactions occurred; all of them were resolved after symptomatic treatment. Conclusions Simultaneous gemcitabine and percutaneous CT-guided IRE therapy model was effective and well-tolerated therapeutic strategy in LAPC patients.
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Gyftopoulos A, Ziogas IA, Barbas AS, Moris D. The Synergistic Role of Irreversible Electroporation and Chemotherapy for Locally Advanced Pancreatic Cancer. Front Oncol 2022; 12:843769. [PMID: 35692753 PMCID: PMC9174659 DOI: 10.3389/fonc.2022.843769] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2022] [Accepted: 04/26/2022] [Indexed: 12/11/2022] Open
Abstract
Irreversible electroporation (IRE) is a local ablative technique used in conjunction with chemotherapy to treat locally advanced pancreatic cancer (LAPC). The combination of IRE and chemotherapy has showed increased overall survival when compared to chemotherapy alone, pointing towards a possible facilitating effect of IRE on chemotherapeutic drug action and delivery. This review aims to present current chemotherapeutic regimens for LAPC and their co-implementation with IRE, with an emphasis on possible molecular augmentative mechanisms of drug delivery and action. Moreover, the potentiating mechanism of IRE on immunotherapy, M1 oncolytic virus and dendritic cell (DC)-based treatments is briefly explored. Investigating the synergistic effect of IRE on currently established treatment regimens as well as newer ones, may present exciting new possibilities for future studies seeking to improve current LAPC treatment algorithms.
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Affiliation(s)
| | - Ioannis A Ziogas
- Department of Surgery, Division of Hepatobiliary Surgery and Liver Transplantation, Vanderbilt University Medical Center, Nashville, TN, United States
| | - Andrew S Barbas
- Department of Surgery, Duke University Medical Center, Durham, NC, United States
| | - Dimitrios Moris
- Department of Surgery, Duke University Medical Center, Durham, NC, United States
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Sugumar K, Hurtado A, Naik I, Hue JJ, Rothermel LD, Ammori JB, Hardacre JM, Winter JM, Ocuin LM. Multimodal therapy with or without irreversible electroporation for unresectable locally advanced pancreatic adenocarcinoma: a systematic review and meta-analysis. HPB (Oxford) 2022; 24:586-595. [PMID: 35000842 DOI: 10.1016/j.hpb.2021.12.014] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2021] [Revised: 10/29/2021] [Accepted: 12/20/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND Irreversible electroporation (IRE) is used as a locoregional treatment modality for patients with locally advanced pancreatic cancer (LAPC), but is non-curative and is associated with postoperative morbidity and mortality. We performed a systematic review and meta-analysis comparing survival outcomes of multimodal therapy with or without IRE. METHODS Separate searches were performed for multimodal therapy + IRE and multimodal therapy alone given the lack of comparative literature using PubMed, SCOPUS, and Cochrane Library in 3/2021. We determined overall survival (OS) and progression-free survival (PFS) from diagnosis and time of IRE. Treatment-related morbidity and mortality was determined. RESULTS Of 585 published articles, 48 met inclusion criteria for IRE (n = 27) and without IRE (n = 21) with data for 1420 (IRE) and 1348 (without IRE) patients. The 6/12/24 months OS with IRE was 99%/84%/28%. The 6/12/24 months OS without IRE was 99%/80%/12%. At 12 months from IRE, OS was 55% and PFS was 12%. The mean major complication and 90-day mortality rates for IRE were 17.95% and 2.65%. CONCLUSION Multimodal therapy alone is associated with similar OS to multimodal therapy + IRE in patients with LAPC. Most patients progress and nearly half die within 1 year of the IRE procedure. Given the lack of quality prospective data, IRE should remain experimental and be used with caution in LAPC.
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Affiliation(s)
- Kavin Sugumar
- University Hospitals Seidman Cancer Center and the Department of Surgery, Cleveland, OH, USA
| | - Alex Hurtado
- Case Western Reserve University School of Medicine and the Case Comprehensive Cancer Center, Cleveland, OH, USA
| | - Ilora Naik
- Case Western Reserve University School of Medicine and the Case Comprehensive Cancer Center, Cleveland, OH, USA
| | - Jonathan J Hue
- University Hospitals Seidman Cancer Center and the Department of Surgery, Cleveland, OH, USA
| | - Luke D Rothermel
- University Hospitals Seidman Cancer Center and the Department of Surgery, Cleveland, OH, USA
| | - John B Ammori
- University Hospitals Seidman Cancer Center and the Department of Surgery, Cleveland, OH, USA
| | - Jeffrey M Hardacre
- University Hospitals Seidman Cancer Center and the Department of Surgery, Cleveland, OH, USA
| | - Jordan M Winter
- University Hospitals Seidman Cancer Center and the Department of Surgery, Cleveland, OH, USA
| | - Lee M Ocuin
- University Hospitals Seidman Cancer Center and the Department of Surgery, Cleveland, OH, USA.
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10
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Sugumar K, Hue JJ, Hardacre JM, Ammori JB, Rothermel LD, Dorth J, Saltzman J, Mohamed A, Selfridge JE, Bajor D, Winter JM, Ocuin LM. Combined multiagent chemotherapy and radiotherapy is associated with prolonged overall survival in patients with non-operatively managed stage II-III pancreatic adenocarcinoma. HPB (Oxford) 2022; 24:433-442. [PMID: 34465529 DOI: 10.1016/j.hpb.2021.08.938] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2021] [Revised: 07/25/2021] [Accepted: 08/06/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND Most patients with pancreatic adenocarcinoma (PDAC) do not undergo surgical resection. The role of radiotherapy (RT) in non-operatively managed localized pancreatic adenocarcinoma is unclear. METHODS The National Cancer Database (2010-2016) was queried for patients with clinical stage II-III PDAC treated with multiagent systemic chemotherapy (CT) +/- RT but not surgery. Factors associated with the receipt of RT and overall survival were compared after adjusting for patient demographics and clinical characteristics. RESULTS A total of 14,921 patients were included, of whom 9279 received CT and 5382 received CT + RT. Patients treated with CT + RT were more likely to be younger (65vs66yrs), treated at non-academic facilities (48.8%vs46.7%), have private insurance (40.3%vs36.5%), and have clinical T4 tumors (53.6%vs48.7%). Most patients who were treated with RT received external beam radiotherapy (89.3%), and the median dose was 5,000 cGy. Median time to start of RT was 129 days. CT + RT was associated with longer overall survival (15.9vs11.8mos,p < 0.001), and remained associated with survival on multivariable analysis (HR 0.74, 95%CI 0.70-0.78). On a 4-month conditional survival analysis, combined CT + RT remained associated with improved survival compared to CT alone (16.0vs13.1mos,p < 0.001). CONCLUSIONS In patients with non-operatively managed localized pancreatic adenocarcinoma, combined radiotherapy and multiagent systemic chemotherapy is associated with improved overall survival compared to chemotherapy alone.
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Affiliation(s)
- Kavin Sugumar
- Department of Surgery, Division of Surgical Oncology, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Jonathan J Hue
- Department of Surgery, Division of Surgical Oncology, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Jeffrey M Hardacre
- Department of Surgery, Division of Surgical Oncology, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - John B Ammori
- Department of Surgery, Division of Surgical Oncology, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Luke D Rothermel
- Department of Surgery, Division of Surgical Oncology, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Jennifer Dorth
- Department of Radiology, Division of Radiation Oncology, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Joel Saltzman
- Department of Medicine, Division of Hematology/Oncology, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Amr Mohamed
- Department of Medicine, Division of Hematology/Oncology, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Jennifer E Selfridge
- Department of Medicine, Division of Hematology/Oncology, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - David Bajor
- Department of Medicine, Division of Hematology/Oncology, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Jordan M Winter
- Department of Surgery, Division of Surgical Oncology, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Lee M Ocuin
- Department of Surgery, Division of Surgical Oncology, University Hospitals Cleveland Medical Center, Cleveland, OH, USA.
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11
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Heger U, Hackert T. Can local ablative techniques replace surgery for locally advanced pancreatic cancer? J Gastrointest Oncol 2021; 12:2536-2546. [PMID: 34790414 DOI: 10.21037/jgo-20-379] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2020] [Accepted: 11/04/2020] [Indexed: 12/25/2022] Open
Abstract
In the treatment of pancreatic ductal adenocarcinoma (PDAC) the best chance at long term survival or cure has to date always included the complete surgical removal of the tumor. However, locally advanced pancreatic cancer (LAPC), about 25% of all newly diagnosed PDAC, is defined by its primary technical unresectability due to infiltration of visceral arteries and absence of metastasis. Induction therapies, especially FOLFIRINOX treatment, together with technical surgical advancement have increased the numbers for conversion to secondary resectability. Recent data on resections after induction therapy show promising, almost doubled survival compared to palliative treatment. Yet, around 70% of LAPC remain unresectable after induction therapy, often due to persistent local invasion. As locally ablative techniques are becoming more widely available this review examines their possible applicability to substitute for surgery in these cases which we propose to group under the new term "Inconvertible LAPC". The need for defining this novel subgroup who might benefit from ablative treatment is based on the findings in our review that high-level evidence on ablative techniques for PDAC is largely lacking and the latest effective, harmonized treatment guidelines for LAPC are not often incorporated in these studies. The "inconvertible LAPC" label requires persistent unresectability after staging and induction therapy of LAPC according to current guidelines followed by liberal indication for aggressive surgical exploration at a center equipped for extended pancreatic resections. Ideally, this specification of a new, distinct patient group will also put it in the spotlight more, hopefully prompt more trials designed to generate robust evidence and optimize transferability of study results.
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Affiliation(s)
- Ulrike Heger
- Department of Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Thilo Hackert
- Department of Surgery, Heidelberg University Hospital, Heidelberg, Germany
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12
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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.
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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.
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13
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Frigerio I, Paiella S, Barbi E, Bianco R, Boz G, Butturini G, Cantore M, Cardarelli N, Mirko D, Fiorentini G, Giardino A, Lionetto G, Malleo G, Mambrini A, Milella M, Passardi A, Regi P, Salvia R, Scopelliti F, Viviani E, Bassi C, Girelli R. Open radiofrequency ablation as upfront treatment for locally advanced pancreatic cancer: Requiem from a randomized controlled trial. Pancreatology 2021; 21:1342-1348. [PMID: 34215498 DOI: 10.1016/j.pan.2021.06.005] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2021] [Revised: 06/04/2021] [Accepted: 06/17/2021] [Indexed: 12/11/2022]
Abstract
BACKGROUND Local ablation of pancreatic cancer has been suggested as an option to manage locally advanced pancreatic cancer (LAPC) although no robust evidence has been published to date to support its application. The aim of this study is to compare overall survival (OS) and progression-free survival (PFS) in patients receiving both radiofrequency ablation (RFA) and conventional chemoradiotherapy (CHRT) with patients receiving CHRT only. METHODS This is a multicentre prospective randomized controlled trial (RCT). Patients with LAPC diagnosed by the Pancreas-Ablation-Team-Verona were randomly assigned to open RFA (Group A) or CHRT (Group B). Survival analyses were performed using the Kaplan-Meier method and compared using the log-rank test. Statistical significance was set at p < 0.05. RESULTS One hundred LAPC patients were enrolled from January 2014 to August 2016. 33% of patients in Group A did not receive the designated procedure because of intraoperative findings of liver (18.7%) or peritoneal metastases (43.8%), or technical contraindications (37.5%). We did not observe any statistically significant survival benefit from RFA compared to CHRT, neither in terms of OS (medians of 14.2 months and 18.1 months, respectively, p = 0.639) nor PFS (medians of 8 months and 6 months respectively, p = 0.570). Mortality was nil and RFA-related morbidity was 15.6%. In 13% of subjects, conversion to surgery occurred (2 after RFA and 11 after CHRT). CONCLUSIONS This is the first RCT evaluating the impact of upfront RFA in the multimodal treatment of LAPC. Compared to CHRT, RFA alone did not provide any advantage in terms of OS or PFS. It could be considered as a therapeutic option for LAPC within a multimodal context and after neoadjuvant therapies.
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Affiliation(s)
- Isabella Frigerio
- Pancreatic Surgery Unit, Pederzoli Hospital, Peschiera del Garda, Italy.
| | - Salvatore Paiella
- General and Pancreatic Surgery Unit, of the Pancreas Institute of the Verona University Hospital Trust, Verona, Italy
| | - Emilio Barbi
- Department of Radiology, Pederzoli Hospital, Peschiera del Garda, Italy
| | - Roberto Bianco
- Department of Clinical Medicine and Surgery, University of Naples Federico II, Naples, Italy
| | - Gianni Boz
- Radiation Oncology Department, Centro di Riferimento Oncologico, 33081, Aviano, Italy
| | | | | | - Nadia Cardarelli
- Department of Oncology, San Bortolo General Hospital, Vicenza, Italy
| | - D'Onofrio Mirko
- Department of Radiology, Pancreas Institute, University of Verona, Verona, Italy
| | | | | | - Gabriella Lionetto
- General and Pancreatic Surgery Unit, of the Pancreas Institute of the Verona University Hospital Trust, Verona, Italy
| | - Giuseppe Malleo
- General and Pancreatic Surgery Unit, of the Pancreas Institute of the Verona University Hospital Trust, Verona, Italy
| | - Andrea Mambrini
- Oncological Department, Azienda USL Toscana Nord Ovest, Oncological Unit of Massa Carrara, Carrara, Italy
| | - Michele Milella
- De of Oncology, University of Verona School of Medicine, Verona University Hospital Trust, Verona, Italy
| | - Alessandro Passardi
- Department of Medical Oncology, Istituto Scientifico Romagnolo per lo Studio e la Cura dei Tumori (IRST) IRCCS, Meldola, Italy
| | - Paolo Regi
- Pancreatic Surgery Unit, Pederzoli Hospital, Peschiera del Garda, Italy
| | - Roberto Salvia
- General and Pancreatic Surgery Unit, of the Pancreas Institute of the Verona University Hospital Trust, Verona, Italy
| | | | - Elena Viviani
- General and Pancreatic Surgery Unit, of the Pancreas Institute of the Verona University Hospital Trust, Verona, Italy
| | - Claudio Bassi
- General and Pancreatic Surgery Unit, of the Pancreas Institute of the Verona University Hospital Trust, Verona, Italy.
| | - Roberto Girelli
- Pancreatic Surgery Unit, Pederzoli Hospital, Peschiera del Garda, Italy
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14
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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.
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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
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15
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Bibok A, Kim DW, Malafa M, Kis B. Minimally invasive image-guided therapy of primary and metastatic pancreatic cancer. World J Gastroenterol 2021; 27:4322-4341. [PMID: 34366607 PMCID: PMC8316906 DOI: 10.3748/wjg.v27.i27.4322] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Revised: 05/21/2021] [Accepted: 06/23/2021] [Indexed: 02/06/2023] Open
Abstract
Pancreatic cancer is a challenging malignancy with limited treatment options and poor life expectancy. The only curative option is surgical resection, but only 15%-20% of patients are resectable at presentation because more than 50% of patients has distant metastasis at diagnosis and the rest of them has locally advanced pancreatic cancer (LAPC). The standard of care first line treatment for LAPC patients is chemotherapy with or without radiation therapy. Recent developments in minimally invasive ablative techniques may add to the treatment armamentarium of LAPC. There are increasing number of studies evaluating these novel ablative techniques, including radiofrequency ablation, microwave ablation, cryoablation and irreversible electroporation. Most studies which included pancreatic tumor ablation, demonstrated improved overall survival in LAPC patients. However, the exact protocols are yet to set up to which stage of the treatment algorithm ablative techniques can be added and in what kind of treatment combinations. Patients with metastatic pancreatic cancer has dismal prognosis with 5-year survival is only 3%. The most common metastatic site is the liver as 90% of pancreatic cancer patients develop liver metastasis. Chemotherapy is the primary treatment option for patients with metastatic pancreatic cancer. However, when the tumor is not responding to chemotherapy or severe drug toxicity develops, locoregional liver-directed therapies can provide an opportunity to control intrahepatic disease progression and improve survival in selected patients. During the last decade new therapeutic options arose with the advancement of minimally invasive technologies to treat pancreatic cancer patients. These new therapies have been a topic of increasing interest due to the severe prognostic implications of locally advanced and metastatic pancreatic cancer and the low comorbid risk of these procedures. This review summarizes new ablative options for patients with LAPC and percutaneous liver-directed therapies for patients with liver-dominant metastatic disease.
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Affiliation(s)
- Andras Bibok
- Department of Diagnostic Imaging and Interventional Radiology, H. Lee Moffitt Cancer Center, Tampa, FL 33612, United States
- Department of Transplantation & Surgery, Radiology Unit, Semmelweis University, Budapest 1085, Hungary
| | - Dae Won Kim
- Department of Gastrointestinal Oncology, H. Lee Moffitt Cancer Center, Tampa, FL 33612, United States
| | - Mokenge Malafa
- Department of Gastrointestinal Oncology, H. Lee Moffitt Cancer Center, Tampa, FL 33612, United States
| | - Bela Kis
- Department of Diagnostic Imaging and Interventional Radiology, H. Lee Moffitt Cancer Center, Tampa, FL 33612, United States
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16
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Multicenter randomized controlled trial and registry study to assess the safety and efficacy of the NanoKnife® system for the ablation of stage 3 pancreatic adenocarcinoma: overview of study protocols. BMC Cancer 2021; 21:785. [PMID: 34233640 PMCID: PMC8261981 DOI: 10.1186/s12885-021-08474-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2020] [Accepted: 06/09/2021] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND Irreversible electroporation (IRE) is a local ablation technique utilizing high voltage, low energy direct current to create nanopores in cell membrane which disrupt homeostasis and leads to cell death. Previous reports have suggested IRE may have a role in treating borderline resectable and unresectable Stage 3 pancreatic tumors. METHODS Patients with Stage 3 pancreatic ductal adenocarcinoma (PDAC) will be enrolled in either a randomized, controlled, multicenter trial (RCT) or a multicenter registry study. Subjects enrolled in the RCT must have no evidence of disease progression after 3 months of modified FOLFIRINOX (mFOLFIRINOX) treatment prior to being randomization to either a control or IRE arm. Post-induction and post-IRE treatment for the control and IRE arms, respectively, will be left to the discretion of the treating physician. The RCT will enroll 528 subjects with 264 per arm and include up to 15 sites. All subjects will be followed for at least 24 months or until death. The registry study will include two cohorts of patients with Stage 3 PDAC, patients who received institutional standard of care (SOC) alone and those treated with IRE in addition to SOC. Both cohorts will be required to have undergone at least 3 months of SOC without progression prior to enrollment. The registry study will enroll 532 patients with 266 patients in each arm. All patients will be followed for at least 24 months or until death. The primary efficacy endpoint for both studies will be overall survival (OS). Co-primary safety endpoints will be 1) time from randomization or enrollment in the registry to death or new onset of Grade 4 adverse event (AE), and (2 high-grade complications defined as any AE or serious AE (SAE) with a CTCAE v5.0 grade of 3 or higher. Secondary endpoints will include progression-free survival, cancer-related pain, quality of life, and procedure-related pain for the IRE arm only. DISCUSSION These studies are intended to provide Level 1 clinical evidence and real-world data demonstrating the clinical utility and safety of the use of IRE in combination with chemotherapy in patients with Stage 3 PDAC. TRIAL REGISTRATION Clinicaltrials.gov NCT03899636 and NCT03899649. Registered April 2, 2019. Food and Drug Administration (FDA) Investigational Device Exemption (IDE) trial G180278 approved on May 3, 2019.
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17
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Oikonomou D, Karamouzis MV, Moris D, Dimitrokallis N, Papamichael D, Kountourakis P, Astras G, Davakis S, Papalampros A, Schizas D, Petrou AS, Felekouras E. Irreversible Electroporation (IRE) Combined With Chemotherapy Increases Survival in Locally Advanced Pancreatic Cancer (LAPC). Am J Clin Oncol 2021; 44:325-330. [PMID: 33979098 DOI: 10.1097/coc.0000000000000826] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVES Locally advanced pancreatic cancer (LAPC) is found in about 40% of patients with pancreatic cancer. Irreversible electroporation (IRE) is a nonthermal ablative technique that provides an alternative in patients with LAPC and can be safely combined with chemotherapy. MATERIALS AND METHODS From 2015 until October of 2019, we performed laparotomic IRE in a total of 40 patients with stage III LAPC. The median age of these patients was 65.2 years (range: 46 to 81 y), and the median tumor size was 3.8 cm (range: 2 to 5.2 cm). 33 of 40 patients were treated preoperatively with FOLFIRINOX or nab-paclitaxel plus gemcitabine and in case of disease control, IRE was performed, whereas in 7 patients, IRE was performed without previous chemotherapy. RESULTS All patients were treated successfully with IRE as the tumor evaluation showed no disease progression after the completion of induction chemotherapy. No IRE-related deaths occurred. Two major grade III complications were reported: pancreatic fistula grade A in 8 patients and 3 patients diagnosed with delayed gastric emptying. Up to October 31, 2019, the median overall survival (OS) of all patients was 24.2 months (range: 6 to 36 mo), and the median progression-free survival was 10.3 months (range: 3 to 24 mo). After the completion of IRE, 30 patients (75%) continued with adjuvant chemotherapy. Fifteen patients (37%) have >24 months OS and 3 patients (8%) have reached 36 months OS and are still alive. CONCLUSION The combination of chemotherapy with IRE, which is a safe and effective procedure, may result in a survival benefit for patients with LAPC.
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Affiliation(s)
- Dimitrios Oikonomou
- First Department of Surgery, Athens University School of Medicine, Laiko General Hospital
| | - Michalis V Karamouzis
- Department of Biological Chemistry, Division of Molecular Oncology, Athens University School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Dimitrios Moris
- First Department of Surgery, Athens University School of Medicine, Laiko General Hospital
| | - Nikolaos Dimitrokallis
- First Department of Surgery, Athens University School of Medicine, Laiko General Hospital
| | | | | | - Georgios Astras
- Department of Medical Oncology, American Oncology Center, American Medical Center
| | - Spyridon Davakis
- First Department of Surgery, Athens University School of Medicine, Laiko General Hospital
| | - Alexandros Papalampros
- First Department of Surgery, Athens University School of Medicine, Laiko General Hospital
| | - Dimitrios Schizas
- First Department of Surgery, Athens University School of Medicine, Laiko General Hospital
| | - Athanasios S Petrou
- Department of Surgery, American Medical Center (AMC), Division of HPB and Surgical Oncology, American Institute of Minimal Invasive Surgery (AIMIS), Nicosia, Cyprus
| | - Evangelos Felekouras
- First Department of Surgery, Athens University School of Medicine, Laiko General Hospital
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18
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Ratnayake B, Al-Leswas D, Mohammadi-Zaniani G, Littler P, Sen G, Manas D, Pandanaboyana S. Margin Accentuation Irreversible Electroporation in Stage III Pancreatic Cancer: A Systematic Review. Cancers (Basel) 2021; 13:cancers13133212. [PMID: 34199031 PMCID: PMC8268790 DOI: 10.3390/cancers13133212] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2021] [Revised: 06/14/2021] [Accepted: 06/24/2021] [Indexed: 11/17/2022] Open
Abstract
Simple Summary This literature review shows preliminary evidence to suggest that electroporation, the use of electricity to cause the death of cells around the tumour, may be associated with an improved survival and complete resection rates following pancreatic surgery for higher stage pancreatic cancer. However, one in five patients have a complication from the procedure that alters their normal course in hospital. Moreover, the number of patients who underwent this technique is small and further data is needed to support the preliminary evidence. The results therefore should be interpreted with caution. Abstract The present systematic review aimed to summarise the available evidence on indications and oncological outcomes after MA IRE for stage III pancreatic cancer (PC). A literature search was performed in the Pubmed, MEDLINE, EMBASE, SCOPUS databases using the PRISMA framework to identify all MA IRE studies. Nine studies with 235 locally advanced (LA) (82%, 192/235) or Borderline resectable (BR) PC (18%, 43/235) patients undergoing MA IRE pancreatic resection were included. Patients were mostly male (56%) with a weighted-mean age of 61 years (95% CI: 58–64). Pancreatoduodenectomy was performed in 51% (120/235) and distal pancreatectomy in 49% (115/235). R0 resection rate was 73% (77/105). Clavien Dindo grade 3–5 postoperative complications occurred in 19% (36/187). Follow-up intervals ranged from 3 to 29 months. Local and systematic recurrences were noted in 8 and 43 patients, respectively. The weighted-mean progression free survival was 11 months (95% CI: 7–15). The weighted-mean overall survival was 22 months (95% CI 20–23 months) and 8 months (95% CI 1–32 months) for MA IRE and IRE alone, respectively. Early non-randomised data suggest MA IRE during pancreatic surgery for stage III pancreatic cancer may result in increased R0 resection rates and improved OS with acceptable postoperative morbidity. Further, larger studies are warranted to corroborate this evidence.
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Affiliation(s)
- Bathiya Ratnayake
- Department of Surgery, Faculty of Medical and Health Sciences, University of Auckland, Auckland 1023, New Zealand;
| | - Dhya Al-Leswas
- Hepato-Pancreato-Biliary and Transplant Unit, Freeman Hospital, Newcastle upon Tyne NE7 7DN, UK; (D.A.-L.); (G.M.-Z.); (G.S.); (D.M.)
| | - Ghazaleh Mohammadi-Zaniani
- Hepato-Pancreato-Biliary and Transplant Unit, Freeman Hospital, Newcastle upon Tyne NE7 7DN, UK; (D.A.-L.); (G.M.-Z.); (G.S.); (D.M.)
| | - Peter Littler
- Department of Interventional Radiology, Freeman Hospital, Newcastle upon Tyne NE7 7DN, UK;
| | - Gourab Sen
- Hepato-Pancreato-Biliary and Transplant Unit, Freeman Hospital, Newcastle upon Tyne NE7 7DN, UK; (D.A.-L.); (G.M.-Z.); (G.S.); (D.M.)
| | - Derek Manas
- Hepato-Pancreato-Biliary and Transplant Unit, Freeman Hospital, Newcastle upon Tyne NE7 7DN, UK; (D.A.-L.); (G.M.-Z.); (G.S.); (D.M.)
| | - Sanjay Pandanaboyana
- Hepato-Pancreato-Biliary and Transplant Unit, Freeman Hospital, Newcastle upon Tyne NE7 7DN, UK; (D.A.-L.); (G.M.-Z.); (G.S.); (D.M.)
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne NE2 4AX, UK
- Correspondence:
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Kok HP, Cressman ENK, Ceelen W, Brace CL, Ivkov R, Grüll H, Ter Haar G, Wust P, Crezee J. Heating technology for malignant tumors: a review. Int J Hyperthermia 2021; 37:711-741. [PMID: 32579419 DOI: 10.1080/02656736.2020.1779357] [Citation(s) in RCA: 147] [Impact Index Per Article: 49.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
The therapeutic application of heat is very effective in cancer treatment. Both hyperthermia, i.e., heating to 39-45 °C to induce sensitization to radiotherapy and chemotherapy, and thermal ablation, where temperatures beyond 50 °C destroy tumor cells directly are frequently applied in the clinic. Achievement of an effective treatment requires high quality heating equipment, precise thermal dosimetry, and adequate quality assurance. Several types of devices, antennas and heating or power delivery systems have been proposed and developed in recent decades. These vary considerably in technique, heating depth, ability to focus, and in the size of the heating focus. Clinically used heating techniques involve electromagnetic and ultrasonic heating, hyperthermic perfusion and conductive heating. Depending on clinical objectives and available technology, thermal therapies can be subdivided into three broad categories: local, locoregional, or whole body heating. Clinically used local heating techniques include interstitial hyperthermia and ablation, high intensity focused ultrasound (HIFU), scanned focused ultrasound (SFUS), electroporation, nanoparticle heating, intraluminal heating and superficial heating. Locoregional heating techniques include phased array systems, capacitive systems and isolated perfusion. Whole body techniques focus on prevention of heat loss supplemented with energy deposition in the body, e.g., by infrared radiation. This review presents an overview of clinical hyperthermia and ablation devices used for local, locoregional, and whole body therapy. Proven and experimental clinical applications of thermal ablation and hyperthermia are listed. Methods for temperature measurement and the role of treatment planning to control treatments are discussed briefly, as well as future perspectives for heating technology for the treatment of tumors.
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Affiliation(s)
- H Petra Kok
- Department of Radiation Oncology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Erik N K Cressman
- Department of Interventional Radiology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Wim Ceelen
- Department of GI Surgery, Ghent University Hospital, Ghent, Belgium
| | - Christopher L Brace
- Department of Radiology and Biomedical Engineering, University of Wisconsin-Madison, Madison, WI, USA
| | - Robert Ivkov
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, USA.,Department of Oncology, Johns Hopkins University School of Medicine, Baltimore, MD, USA.,Department of Mechanical Engineering, Whiting School of Engineering, Johns Hopkins University, Baltimore, MD, USA.,Department of Materials Science and Engineering, Whiting School of Engineering, Johns Hopkins University, Baltimore, MD, USA
| | - Holger Grüll
- Department of Diagnostic and Interventional Radiology, Faculty of Medicine, University Hospital of Cologne, University of Cologne, Cologne, Germany
| | - Gail Ter Haar
- Department of Physics, The Institute of Cancer Research, London, UK
| | - Peter Wust
- Department of Radiation Oncology, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Johannes Crezee
- Department of Radiation Oncology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
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Timmer FE, Geboers B, Nieuwenhuizen S, Schouten EA, Dijkstra M, de Vries JJ, van den Tol MP, de Gruijl TD, Scheffer HJ, Meijerink MR. Locally Advanced Pancreatic Cancer: Percutaneous Management Using Ablation, Brachytherapy, Intra-arterial Chemotherapy, and Intra-tumoral Immunotherapy. Curr Oncol Rep 2021; 23:68. [PMID: 33864144 PMCID: PMC8052234 DOI: 10.1007/s11912-021-01057-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/11/2021] [Indexed: 02/07/2023]
Abstract
PURPOSE OF REVIEW Pancreatic ductal adenocarcinoma (PDAC) is one of the most aggressive neoplasms, bearing a terrible prognosis. Stage III tumors, also known as locally advanced pancreatic cancer (LAPC), are unresectable, and current palliative chemotherapy regimens have only modestly improved survival in these patients. At this stage of disease, interventional techniques may be of value and further prolong life. The aim of this review was to explore current literature on locoregional percutaneous management for LAPC. RECENT FINDINGS Locoregional percutaneous interventional techniques such as ablation, brachytherapy, and intra-arterial chemotherapy possess cytoreductive abilities and have the potential to increase survival. In addition, recent research demonstrates the immunomodulatory capacities of these treatments. This immune response may be leveraged by combining the interventional techniques with intra-tumoral immunotherapy, possibly creating a durable anti-tumor effect. This multimodality treatment approach is currently being examined in several ongoing clinical trials. The use of certain interventional techniques appears to improve survival in LAPC patients and may work synergistically when combined with immunotherapy. However, definitive conclusions can only be made when large prospective (randomized controlled) trials confirm these results.
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Affiliation(s)
- Florentine E.F. Timmer
- Department of Radiology and Nuclear Medicine, Amsterdam UMC (location VUmc), De Boelelaan 1117, 1081 HV Amsterdam, The Netherlands
| | - Bart Geboers
- Department of Radiology and Nuclear Medicine, Amsterdam UMC (location VUmc), De Boelelaan 1117, 1081 HV Amsterdam, The Netherlands
| | - Sanne Nieuwenhuizen
- Department of Radiology and Nuclear Medicine, Amsterdam UMC (location VUmc), De Boelelaan 1117, 1081 HV Amsterdam, The Netherlands
| | - Evelien A.C. Schouten
- Department of Radiology and Nuclear Medicine, Amsterdam UMC (location VUmc), De Boelelaan 1117, 1081 HV Amsterdam, The Netherlands
| | - Madelon Dijkstra
- Department of Radiology and Nuclear Medicine, Amsterdam UMC (location VUmc), De Boelelaan 1117, 1081 HV Amsterdam, The Netherlands
| | - Jan J.J. de Vries
- Department of Radiology and Nuclear Medicine, Amsterdam UMC (location VUmc), De Boelelaan 1117, 1081 HV Amsterdam, The Netherlands
| | - M. Petrousjka van den Tol
- Department of Surgical Oncology, Amsterdam UMC (location VUmc), De Boelelaan 1117, 1081 HV Amsterdam, The Netherlands
| | - Tanja D. de Gruijl
- Department of Medical Oncology, Amsterdam UMC (location VUmc)-Cancer Center Amsterdam, De Boelelaan 1117, 1081 HV Amsterdam, The Netherlands
| | - Hester J. Scheffer
- Department of Radiology and Nuclear Medicine, Amsterdam UMC (location VUmc), De Boelelaan 1117, 1081 HV Amsterdam, The Netherlands
| | - Martijn R. Meijerink
- Department of Radiology and Nuclear Medicine, Amsterdam UMC (location VUmc), De Boelelaan 1117, 1081 HV Amsterdam, The Netherlands
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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: 18] [Impact Index Per Article: 6.0] [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.
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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;
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22
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Latenstein AEJ, Mackay TM, van der Geest LGM, van Eijck CHJ, de Meijer VE, Stommel MWJ, Vissers PAJ, Besselink MG, de Hingh IHJT. Effect of centralization and regionalization of pancreatic surgery on resection rates and survival. Br J Surg 2021; 108:826-833. [PMID: 33738473 DOI: 10.1093/bjs/znaa146] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2020] [Revised: 10/20/2020] [Accepted: 11/25/2020] [Indexed: 01/25/2023]
Abstract
BACKGROUND Centralization of pancreatic surgery in the Netherlands has been ongoing since 2011. The aim of this study was to assess how centralization has affected the likelihood of resection and survival of patients with non-metastatic pancreatic head and periampullary cancer, diagnosed in hospitals with and without pancreatic surgery services. METHODS An observational cohort study was performed on nationwide data from the Netherlands Cancer Registry (2009-2017), including patients diagnosed with non-metastatic pancreatic head or periampullary cancer. The period of diagnosis was divided into three time intervals: 2009-2011, 2012-2014 and 2015-2017. Hospital of diagnosis was classified as a pancreatic or non-pancreatic surgery centre. Analyses were performed using multivariable logistic and Cox regression models. RESULTS In total, 10 079 patients were included, of whom 3114 (30.9 per cent) were diagnosed in pancreatic surgery centres. Between 2009-2011 and 2015-2017, the number of patients undergoing resection increased from 1267 of 3169 (40.0 per cent) to 1705 of 3566 (47.8 per cent) (P for trend < 0.001). In multivariable analysis, in 2015-2017, unlike the previous periods, patients diagnosed in pancreatic and non-pancreatic surgery centres had a similar likelihood of resection (odds ratio 1.08, 95 per cent c.i. 0.90 to 1.28; P = 0.422). In this period, however, overall survival was higher in patients diagnosed in pancreatic surgery than in those diagnosed in non-pancreatic surgery centres (hazard ratio 0.92, 95 per cent c.i. 0.85 to 0.99; P = 0.047). CONCLUSION After centralization of pancreatic surgery, the resection rate for patients with pancreatic head and periampullary cancer diagnosed in non-pancreatic surgery centres increased and became similar to that in pancreatic surgery centres. Overall survival remained higher in patients diagnosed in pancreatic surgery centres.
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Affiliation(s)
- A E J Latenstein
- Department of surgery, Cancer Centre Amsterdam, Amsterdam University Medical Centre, University of Amsterdam, Amsterdam, the Netherlands
| | - T M Mackay
- Department of surgery, Cancer Centre Amsterdam, Amsterdam University Medical Centre, University of Amsterdam, Amsterdam, the Netherlands
| | - L G M van der Geest
- Department of Research and Development, Netherlands Comprehensive Cancer Organization (IKNL), Utrecht, the Netherlands
| | - C H J van Eijck
- Department of Surgery, Erasmus Medical Centre, Rotterdam, the Netherlands
| | - V E de Meijer
- Department of Hepatobiliary Surgery and Liver Transplantation, University Medical Centre Groningen, University of Groningen, Groningen, the Netherlands
| | - M W J Stommel
- Department of Surgery, Radboud University Medical Centre, Nijmegen, the Netherlands
| | - P A J Vissers
- Department of Research and Development, Netherlands Comprehensive Cancer Organization (IKNL), Utrecht, the Netherlands
| | - M G Besselink
- Department of surgery, Cancer Centre Amsterdam, Amsterdam University Medical Centre, University of Amsterdam, Amsterdam, the Netherlands
| | - I H J T de Hingh
- Department of Surgery, Catharina Hospital, Eindhoven, the Netherlands
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Kwon W, Thomas A, Kluger MD. Irreversible electroporation of locally advanced pancreatic cancer. Semin Oncol 2021; 48:84-94. [PMID: 33648735 DOI: 10.1053/j.seminoncol.2021.02.004] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Revised: 01/18/2021] [Accepted: 02/02/2021] [Indexed: 12/14/2022]
Abstract
Locally advanced pancreatic cancer (LAPC) constitutes approximately one-third of all pancreatic cancer, with standard of care inconsistently defined and achieving modest outcomes at best. While resection after downstaging offers the chance for cure, only a fraction of patients with LAPC become candidates for resection. Chemotherapy remains the mainstay of treatment for the remainder. In these patients, ablative therapy may be given for local control of the tumor. Irreversible electroporation (IRE) is an attractive ablative technique. IRE changes the permeability of tumor cell membranes to induce apoptosis. Unlike other ablative therapies, IRE causes little thermal injury to the target area, making it ideal for LAPC involving major vessels. Compared to systemic chemotherapy alone, IRE seems to offer some survival benefit. Although early studies reported notable morbidity and mortality rates, IRE presents opportunities for those who cannot undergo resection and who otherwise have limited options. Another role of IRE is to extend the margins of resected tumors when there is a concern for R1 resection. Perhaps most exciting, IRE is thought to have effects beyond local ablation. IRE has immunomodulatory effects, which may induce in vivo vaccination and may potentially synergize with immunotherapy. Through electrochemotherapy, IRE may enhance drug delivery to residual tumor cells. Ultimately the role of IRE in the treatment of LAPC still needs to be validated through well designed randomized trials. Investigations of its future possibilities are in the early stages. IRE offers the potential to provide more options to LAPC patients.
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Affiliation(s)
- Wooil Kwon
- Division of GI/Endocrine Surgery, Department of Surgery, Columbia University Vagelos College of Physicians and Surgeons, New York, NY, USA; Division of Hepatobiliary & Pancreatic Surgery, Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Alexander Thomas
- Division of GI/Endocrine Surgery, Department of Surgery, Columbia University Vagelos College of Physicians and Surgeons, New York, NY, USA
| | - Michael D Kluger
- Division of GI/Endocrine Surgery, Department of Surgery, Columbia University Vagelos College of Physicians and Surgeons, New York, NY, USA.
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Groen JV, Stommel MWJ, Sarasqueta AF, Besselink MG, Brosens LAA, van Eijck CHJ, Molenaar IQ, Verheij J, de Vos-Geelen J, Wasser MN, Bonsing BA, Mieog JSD. Surgical management and pathological assessment of pancreatoduodenectomy with venous resection: an international survey among surgeons and pathologists. HPB (Oxford) 2021; 23:80-89. [PMID: 32444267 DOI: 10.1016/j.hpb.2020.04.015] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2019] [Revised: 02/06/2020] [Accepted: 04/23/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND The aim of this survey was to gain insights in the current surgical management and pathological assessment of pancreatoduodenectomy with portal-superior mesenteric vein resection (VR). METHODS A systematic literature search was performed to identify international expert surgeons (N = 150) and pathologists (N = 40) who published relevant studies between 2009 and 2019. These experts and Dutch surgeons (N = 17) and pathologists (N = 20) were approached to complete an online survey. RESULTS Overall, 76 (46%) surgeons and 37 (62%) pathologists completed the survey. Most surgeons (71%) estimated that preoperative imaging corresponded correctly with intraoperative findings of venous involvement in 50-75% of patients. An increased complication risk following VR was expected by 55% of surgeons, mainly after Type 4 (segmental resection-venous conduit anastomosis). Most surgeons (61%) preferred Type 3 (segmental resection-primary anastomosis). Most surgeons (75%) always perform the VR themselves. Standard postoperative imaging for patency control was performed by 54% of surgeons and 39% adjusted thromboprophylaxis following VR. Most pathologists (76%) always assessed tumor infiltration in the resected vein and only 54% of pathologists always assess the resection margins of the vein itself. Variation in assessment of tumor infiltration depth was observed. CONCLUSION This international survey showed variation in the surgical management and pathological assessment of pancreatoduodenectomy with venous involvement. This highlights the lack of evidence and emphasizes the need for research on imaging modalities to improve patient selection for VR, surgical techniques, postoperative management and standardization of the pathological assessment.
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Affiliation(s)
- Jesse V Groen
- Department of Surgery, Leiden University Medical Center, Leiden, the Netherlands
| | - Martijn W J Stommel
- Department of Surgery, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Arantza F Sarasqueta
- Department of Pathology, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, the Netherlands
| | - Marc G Besselink
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, the Netherlands
| | - Lodewijk A A Brosens
- Department of Pathology, University Medical Center Utrecht, Utrecht, the Netherlands; Department of Pathology, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Casper H J van Eijck
- Department of Surgery, Erasmus Medical Center, Rotterdam Department of Surgery, the Netherlands
| | - Isaac Q Molenaar
- Department of Surgery, University Medical Centre Utrecht, Utrecht, the Netherlands
| | - Joanne Verheij
- Department of Pathology, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, the Netherlands
| | - Judith de Vos-Geelen
- Department of Internal Medicine, Division of Medical Oncology, GROW - School for Oncology and Developmental Biology, Maastricht UMC+, Maastricht, the Netherlands
| | - Martin N Wasser
- Department of Radiology, Leiden University Medical Center, Leiden, Netherlands
| | - Bert A Bonsing
- Department of Surgery, Leiden University Medical Center, Leiden, the Netherlands
| | - J Sven D Mieog
- Department of Surgery, Leiden University Medical Center, Leiden, the Netherlands.
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Ma YY, Leng Y, Xing YL, Li HM, Chen JB, Niu LZ. Gemcitabine plus concurrent irreversible electroporation vs gemcitabine alone for locally advanced pancreatic cancer. World J Clin Cases 2020; 8:5564-5575. [PMID: 33344547 PMCID: PMC7716311 DOI: 10.12998/wjcc.v8.i22.5564] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2020] [Revised: 08/25/2020] [Accepted: 09/26/2020] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Locally advanced pancreatic cancer (LAPC) is a common malignant digestive system tumor that ranks as the fourth leading cause of cancer-related death in the world. The prognosis of LAPC is poor even after standard treatment. Irreversible electroporation (IRE) is a novel ablative strategy for LAPC. Several studies have confirmed the safety of IRE. To date, no prospective studies have been performed to investigate the therapeutic efficacy of conventional gemcitabine (GEM) plus concurrent IRE. AIM To compare the therapeutic efficacy between conventional GEM plus concurrent IRE and GEM alone for LAPC. METHODS From February 2016 to September 2017, a total of 68 LAPC patients were treated with GEM plus concurrent IRE n = 33) or GEM alone n = 35). Overall survival (OS), progression free survival (PFS), and procedure-related complications were compared between the two groups. Multivariate analyses were performed to identify any prognostic factors. RESULTS There were no treatment-related deaths. The technical success rate of IRE ablation was 100%. The GEM + IRE group had a significantly longer OS from the time of diagnosis of LAPC (19.8 mo vs 9.3 mo, P < 0.0001) than the GEM alone group. The GEM + IRE group had a significantly longer PFS (8.3 mo vs 4.7 mo, P < 0.0001) than the GEM alone group. Tumor volume less than 37 cm3 and GEM plus concurrent IRE were identified as significant favorable factors for both the OS and PFS. CONCLUSION Gemcitabine plus concurrent IRE is an effective treatment for patients with LAPC.
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Affiliation(s)
- Yang-Yang Ma
- Central Laboratory, Affiliated Fuda Cancer Hospital, Jinan University, Guangzhou 510665, Guangdong Province, China
| | - Yin Leng
- Department of Oncology, Affiliated Fuda Cancer Hospital, Jinan University, Guangzhou 510665, Guangdong Province, China
| | - Yan-Li Xing
- Department of Oncology, Affiliated Fuda Cancer Hospital, Jinan University, Guangzhou 510665, Guangdong Province, China
| | - Hong-Mei Li
- Department of Oncology, Affiliated Fuda Cancer Hospital, Jinan University, Guangzhou 510665, Guangdong Province, China
| | - Ji-Bing Chen
- Central Laboratory, Affiliated Fuda Cancer Hospital, Jinan University, Guangzhou 510665, Guangdong Province, China
| | - Li-Zhi Niu
- Department of Interventional Radiology, Affiliated Fuda Cancer Hospital, Jinan University, Guangzhou 510665, Guangdong Province, China
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Walma MS, Brada LJ, Patuleia SIS, Blomjous JG, Bollen TL, Bosscha K, Bruijnen RC, Busch OR, Creemers GJ, Daams F, van Dam R, Festen S, Jan de Groot D, Willem de Groot J, Mohammad NH, Hermans JJ, de Hingh IH, Kerver ED, van Leeuwen MS, van der Leij C, Liem MS, van Lienden KP, Los M, de Meijer VE, Meijerink MR, Mekenkamp LJ, Nederend J, Nio CY, Patijn GA, Polée MB, Pruijt JF, Renken NS, Rombouts SJ, Schouten TJ, Stommel MWJ, Verweij ME, de Vos-Geelen J, de Vries JJJ, Vulink A, Wessels FJ, Wilmink JW, van Santvoort HC, Besselink MG, Molenaar IQ. Treatment strategies and clinical outcomes in consecutive patients with locally advanced pancreatic cancer: A multicenter prospective cohort. Eur J Surg Oncol 2020; 47:699-707. [PMID: 33280952 DOI: 10.1016/j.ejso.2020.11.137] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2020] [Revised: 11/10/2020] [Accepted: 11/21/2020] [Indexed: 12/25/2022] Open
Abstract
INTRODUCTION Since current studies on locally advanced pancreatic cancer (LAPC) mainly report from single, high-volume centers, it is unclear if outcomes can be translated to daily clinical practice. This study provides treatment strategies and clinical outcomes within a multicenter cohort of unselected patients with LAPC. MATERIALS AND METHODS Consecutive patients with LAPC according to Dutch Pancreatic Cancer Group criteria, were prospectively included in 14 centers from April 2015 until December 2017. A centralized expert panel reviewed response according to RECIST v1.1 and potential surgical resectability. Primary outcome was median overall survival (mOS), stratified for primary treatment strategy. RESULTS Overall, 422 patients were included, of whom 77% (n = 326) received chemotherapy. The majority started with FOLFIRINOX (77%, 252/326) with a median of six cycles (IQR 4-10). Gemcitabine monotherapy was given to 13% (41/326) of patients and nab-paclitaxel/gemcitabine to 10% (33/326), with a median of two (IQR 3-5) and three (IQR 3-5) cycles respectively. The mOS of the entire cohort was 10 months (95%CI 9-11). In patients treated with FOLFIRINOX, gemcitabine monotherapy, or nab-paclitaxel/gemcitabine, mOS was 14 (95%CI 13-15), 9 (95%CI 8-10), and 9 months (95%CI 8-10), respectively. A resection was performed in 13% (32/252) of patients after FOLFIRINOX, resulting in a mOS of 23 months (95%CI 12-34). CONCLUSION This multicenter unselected cohort of patients with LAPC resulted in a 14 month mOS and a 13% resection rate after FOLFIRINOX. These data put previous results in perspective, enable us to inform patients with more accurate survival numbers and will support decision-making in clinical practice.
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Affiliation(s)
- Marieke S Walma
- Dept. of Surgery, UMC Utrecht Cancer Center and St Antonius Hospital Nieuwegein: Regional Academic Cancer Center Utrecht, Utrecht, the Netherlands; Dept. of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Lilly J Brada
- Dept. of Surgery, UMC Utrecht Cancer Center and St Antonius Hospital Nieuwegein: Regional Academic Cancer Center Utrecht, Utrecht, the Netherlands; Dept. of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Susana I S Patuleia
- Dept. of Surgery, UMC Utrecht Cancer Center and St Antonius Hospital Nieuwegein: Regional Academic Cancer Center Utrecht, Utrecht, the Netherlands
| | | | - Thomas L Bollen
- Dept. of Radiology, UMC Utrecht Cancer Center and St Antonius Hospital Nieuwegein: Regional Academic Cancer Center Utrecht, Utrecht, the Netherlands
| | - Koop Bosscha
- Dept. of Surgery, Jeroen Bosch Hospital, 's-Hertogenbosch, the Netherlands
| | - Rutger C Bruijnen
- Dept. of Radiology, UMC Utrecht Cancer Center and St Antonius Hospital Nieuwegein: Regional Academic Cancer Center Utrecht, Utrecht, the Netherlands
| | - Olivier R Busch
- Dept. of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Geert-Jan Creemers
- Dept. of Medical Oncology, Catharina Hospital, Eindhoven, the Netherlands
| | - Freek Daams
- Dept. of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Ronald van Dam
- Dept. of Surgery, Maastricht UMC+, Maastricht, the Netherlands
| | | | - Derk Jan de Groot
- Dept. of Medical Oncology, UMC Groningen, Groningen, the Netherlands
| | | | - Nadia Haj Mohammad
- Dept. of Medical Oncology, UMC Utrecht Cancer Center and St Antonius Hospital Nieuwegein: Regional Academic Cancer Center Utrecht, Utrecht, the Netherlands
| | - John J Hermans
- Dept. of Radiology, Radboud University Medical Center, Nijmegen, the Netherlands
| | | | - Emile D Kerver
- Dept. of Medical Oncology, OLVG, Amsterdam, the Netherlands
| | - Maarten S van Leeuwen
- Dept. of Radiology, UMC Utrecht Cancer Center and St Antonius Hospital Nieuwegein: Regional Academic Cancer Center Utrecht, Utrecht, the Netherlands
| | | | - Mike S Liem
- Dept. of Surgery, Medical Spectrum Twente, Enschede, the Netherlands
| | - Krijn P van Lienden
- Dept. of Radiology Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amstrdam, the Netherlands
| | - Maartje Los
- Dept. of Medical Oncology, UMC Utrecht Cancer Center and St Antonius Hospital Nieuwegein: Regional Academic Cancer Center Utrecht, Utrecht, the Netherlands
| | | | - Martijn R Meijerink
- Dept. of Radiology Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amstrdam, the Netherlands
| | - Leonie J Mekenkamp
- Dept. of Medical Oncology, Medical Spectrum Twente, Enschede, the Netherlands
| | - Joost Nederend
- Dept. of Radiology, Catharina Hospital, Eindhoven, the Netherlands
| | - C Yung Nio
- Dept. of Radiology Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amstrdam, the Netherlands
| | - Gijs A Patijn
- Dept. of Surgery, Isala Clinics, Zwolle, the Netherlands
| | - Marco B Polée
- Dept. of Medical Oncology, Medical Center Leeuwarden, Leeuwarden, the Netherlands
| | - Johannes F Pruijt
- Dept. of Medical Oncology, Jeroen Bosch Hospital, 's-Hertogenbosch, the Netherlands
| | - Nomdo S Renken
- Dept. of Radiology, Reinier de Graaf Hospital, Delft, the Netherlands
| | - Steffi J Rombouts
- Dept. of Surgery, UMC Utrecht Cancer Center and St Antonius Hospital Nieuwegein: Regional Academic Cancer Center Utrecht, Utrecht, the Netherlands; Dept. of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Thijs J Schouten
- Dept. of Surgery, UMC Utrecht Cancer Center and St Antonius Hospital Nieuwegein: Regional Academic Cancer Center Utrecht, Utrecht, the Netherlands
| | - Martijn W J Stommel
- Dept. of Surgery, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Maaike E Verweij
- Dept. of Surgery, UMC Utrecht Cancer Center and St Antonius Hospital Nieuwegein: Regional Academic Cancer Center Utrecht, Utrecht, the Netherlands
| | - Judith de Vos-Geelen
- Dept. of Medical Oncology, GROW - School for Oncology and Developmental Biology, Maastricht UMC+, Maastricht, the Netherlands
| | - Jan J J de Vries
- Dept. of Radiology Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amstrdam, the Netherlands
| | - Annelie Vulink
- Dept. of Medical Oncology, Reinier de Graaf Hospital, Delft, the Netherlands
| | - Frank J Wessels
- Dept. of Radiology, UMC Utrecht Cancer Center and St Antonius Hospital Nieuwegein: Regional Academic Cancer Center Utrecht, Utrecht, the Netherlands
| | - Johanna W Wilmink
- Dept. of Medical Oncology, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam; the Netherlands
| | - Hjalmar C van Santvoort
- Dept. of Surgery, UMC Utrecht Cancer Center and St Antonius Hospital Nieuwegein: Regional Academic Cancer Center Utrecht, Utrecht, the Netherlands
| | - Marc G Besselink
- Dept. of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands.
| | - I Quintus Molenaar
- Dept. of Surgery, UMC Utrecht Cancer Center and St Antonius Hospital Nieuwegein: Regional Academic Cancer Center Utrecht, Utrecht, the Netherlands
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Agnass P, Rodermond HM, Zweije R, Sijbrands J, Vogel JA, van Lienden KP, van Gulik TM, van Veldhuisen E, Franken NAP, Oei AL, Kok HP, Besselink MG, Crezee J. HyCHEED System for Maintaining Stable Temperature Control during Preclinical Irreversible Electroporation Experiments at Clinically Relevant Temperature and Pulse Settings. SENSORS 2020; 20:s20216227. [PMID: 33142821 PMCID: PMC7662544 DOI: 10.3390/s20216227] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/15/2020] [Revised: 10/21/2020] [Accepted: 10/28/2020] [Indexed: 12/11/2022]
Abstract
Electric permeabilization of cell membranes is the main mechanism of irreversible electroporation (IRE), an ablation technique for treatment of unresectable cancers, but the pulses also induce a significant temperature increase in the treated volume. To investigate the therapeutically thermal contribution, a preclinical setup is required to apply IRE at desired temperatures while maintaining stable temperatures. This study’s aim was to develop and test an electroporation device capable of maintaining a pre-specified stable and spatially homogeneous temperatures and electric field in a tumor cell suspension for several clinical-IRE-settings. A hydraulically controllable heat exchange electroporation device (HyCHEED) was developed and validated at 37 °C and 46 °C. Through plate electrodes, HyCHEED achieved both a homogeneous electric field and homogenous-stable temperatures; IRE heat was removed through hydraulic cooling. IRE was applied to 300 μL of pancreatic carcinoma cell suspension (Mia PaCa-2), after which cell viability and specific conductivity were determined. HyCHEED maintained stable temperatures within ±1.5 °C with respect to the target temperature for multiple IRE-settings at the selected temperature levels. An increase of cell death and specific conductivity, including post-treatment, was found to depend on electric-field strength and temperature. HyCHEED is capable of maintaining stable temperatures during IRE-experiments. This provides an excellent basis to assess the contribution of thermal effects to IRE and other bio-electromagnetic techniques.
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Affiliation(s)
- Pierre Agnass
- Department of Radiation Oncology, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, 1105 AZ Amsterdam, The Netherlands; (P.A.); (H.M.R.); (R.Z.); (J.S.); (N.A.P.F.); (A.L.O.); (H.P.K.)
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, 1105 AZ Amsterdam, The Netherlands; (T.M.v.G.); (E.v.V.); (M.G.B.)
- Laboratory of Experimental Oncology and Radiobiology, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, 1105 AZ Amsterdam, The Netherlands
| | - Hans M. Rodermond
- Department of Radiation Oncology, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, 1105 AZ Amsterdam, The Netherlands; (P.A.); (H.M.R.); (R.Z.); (J.S.); (N.A.P.F.); (A.L.O.); (H.P.K.)
- Laboratory of Experimental Oncology and Radiobiology, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, 1105 AZ Amsterdam, The Netherlands
- Center for Experimental Molecular Medicine, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, 1105 AZ Amsterdam, The Netherlands
| | - Remko Zweije
- Department of Radiation Oncology, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, 1105 AZ Amsterdam, The Netherlands; (P.A.); (H.M.R.); (R.Z.); (J.S.); (N.A.P.F.); (A.L.O.); (H.P.K.)
| | - Jan Sijbrands
- Department of Radiation Oncology, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, 1105 AZ Amsterdam, The Netherlands; (P.A.); (H.M.R.); (R.Z.); (J.S.); (N.A.P.F.); (A.L.O.); (H.P.K.)
| | - Jantien A. Vogel
- Department of Gastroenterology & Hepatology, Amsterdam Gastroenterology and Metabolism, Amsterdam UMC, University of Amsterdam, 1105 AZ Amsterdam, The Netherlands;
| | - Krijn P. van Lienden
- Department of Radiology, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, 1105 AZ Amsterdam, The Netherlands;
| | - Thomas M. van Gulik
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, 1105 AZ Amsterdam, The Netherlands; (T.M.v.G.); (E.v.V.); (M.G.B.)
| | - Eran van Veldhuisen
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, 1105 AZ Amsterdam, The Netherlands; (T.M.v.G.); (E.v.V.); (M.G.B.)
| | - Nicolaas A. P. Franken
- Department of Radiation Oncology, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, 1105 AZ Amsterdam, The Netherlands; (P.A.); (H.M.R.); (R.Z.); (J.S.); (N.A.P.F.); (A.L.O.); (H.P.K.)
- Laboratory of Experimental Oncology and Radiobiology, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, 1105 AZ Amsterdam, The Netherlands
- Center for Experimental Molecular Medicine, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, 1105 AZ Amsterdam, The Netherlands
| | - Arlene L. Oei
- Department of Radiation Oncology, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, 1105 AZ Amsterdam, The Netherlands; (P.A.); (H.M.R.); (R.Z.); (J.S.); (N.A.P.F.); (A.L.O.); (H.P.K.)
- Laboratory of Experimental Oncology and Radiobiology, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, 1105 AZ Amsterdam, The Netherlands
- Center for Experimental Molecular Medicine, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, 1105 AZ Amsterdam, The Netherlands
| | - H. Petra Kok
- Department of Radiation Oncology, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, 1105 AZ Amsterdam, The Netherlands; (P.A.); (H.M.R.); (R.Z.); (J.S.); (N.A.P.F.); (A.L.O.); (H.P.K.)
| | - Marc G. Besselink
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, 1105 AZ Amsterdam, The Netherlands; (T.M.v.G.); (E.v.V.); (M.G.B.)
| | - Johannes Crezee
- Department of Radiation Oncology, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, 1105 AZ Amsterdam, The Netherlands; (P.A.); (H.M.R.); (R.Z.); (J.S.); (N.A.P.F.); (A.L.O.); (H.P.K.)
- Correspondence: ; Tel.: +31-20-566-4231
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van Veldhuisen E, Vroomen LG, Ruarus AH, Derksen TC, Busch OR, de Jong MC, Kazemier G, Puijk RS, Sorgedrager NS, Vogel JA, Scheffer HJ, van Lienden KP, Wilmink JW, Besselink MG, Meijerink MR. Value of CT-Guided Percutaneous Irreversible Electroporation Added to FOLFIRINOX Chemotherapy in Locally Advanced Pancreatic Cancer: A Post Hoc Comparison. J Vasc Interv Radiol 2020; 31:1600-1608. [PMID: 32861569 DOI: 10.1016/j.jvir.2020.02.024] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2019] [Revised: 01/31/2020] [Accepted: 02/22/2020] [Indexed: 01/13/2023] Open
Abstract
PURPOSE To compare survival after CT-guided percutaneous irreversible electroporation (IRE) and folinic acid, fluorouracil, irinotecan, and oxaliplatin (FOLFIRINOX) chemotherapy versus FOLFIRINOX only in patients with locally advanced pancreatic cancer (LAPC). MATERIALS AND METHODS A post hoc comparison was performed of data derived from a prospective IRE-FOLFIRINOX cohort and a retrospective FOLFIRINOX-only cohort. All patients received a minimum of 3 cycles of FOLFIRINOX for LAPC and were considered eligible for CT-guided percutaneous IRE. Endpoints included overall survival (OS), local and distant progression-free survival, and time to progression (TTP) and were compared using stratified Kaplan-Meier analysis. Patients who received > 8 cycles of FOLFIRINOX before IRE and who had tumors > 6 cm in the FOLFIRINOX-only group were excluded. RESULTS Of 103 patients with a diagnosis of LAPC, 52 were deemed eligible (n = 30 IRE-FOLFIRINOX and n = 22 FOLFIRINOX-only). Patients in the FOLFIRINOX-only arm had larger tumors (53 mm ± 19 vs 38 mm ± 7, P = .340), had more locoregional lymph node metastases (23% vs 7%, P = .622), and more often received radiotherapy (7 patients vs 2 patients, P = .027); all other baseline characteristics were comparable. Median OS was 17.0 months (range, 5-35 mo; SD = 6) for IRE-FOLFIRINOX versus 12.4 months (range, 3-22 mo; SD = 6) for FOLFIRINOX-only (P = .038). After sensitivity analyses, median OS was 17.2 months (range, 6-27 mo; SD = 6) versus 12.4 months (range, 7-32 mo; SD = 10) (P = .05). Median TTP was longer in the IRE-FOLFIRINOX group: 14.2 months (range, 5-25 mo; SD = 4) versus 5.2 months (range, 2-22; SD = 6) (P = .0001). CONCLUSIONS In patients with LAPC after FOLFIRINOX chemotherapy, CT-guided percutaneous IRE may improve OS and TTP. This study may facilitate the design of randomized controlled trials to compare survival after IRE-FOLRINOX versus FOLFIRINOX-only.
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Affiliation(s)
- Eran van Veldhuisen
- Department of Surgery, Cancer Center Amsterdam, Amsterdam University Medical Center, University of Amsterdam, Amsterdam, the Netherlands; Department of Radiology and Nuclear Medicine, Cancer Center Amsterdam, Amsterdam University Medical Center, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Laurien G Vroomen
- Department of Radiology and Nuclear Medicine, Cancer Center Amsterdam, Amsterdam University Medical Center, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Alette H Ruarus
- Department of Radiology and Nuclear Medicine, Cancer Center Amsterdam, Amsterdam University Medical Center, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Tyche C Derksen
- Department of Surgery, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Olivier R Busch
- Department of Surgery, Cancer Center Amsterdam, Amsterdam University Medical Center, University of Amsterdam, Amsterdam, the Netherlands
| | - Marcus C de Jong
- Department of Radiology and Nuclear Medicine, Cancer Center Amsterdam, Amsterdam University Medical Center, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Geert Kazemier
- Department Surgery, Cancer Center Amsterdam, Amsterdam University Medical Center, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Robbert S Puijk
- Department of Radiology and Nuclear Medicine, Cancer Center Amsterdam, Amsterdam University Medical Center, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Natasha S Sorgedrager
- Department of Radiology and Nuclear Medicine, Cancer Center Amsterdam, Amsterdam University Medical Center, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Jantien A Vogel
- Department of Surgery, Cancer Center Amsterdam, Amsterdam University Medical Center, University of Amsterdam, Amsterdam, the Netherlands
| | - Hester J Scheffer
- Department of Radiology and Nuclear Medicine, Cancer Center Amsterdam, Amsterdam University Medical Center, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Krijn P van Lienden
- Department of Radiology, Cancer Center Amsterdam, Amsterdam University Medical Center, University of Amsterdam, Amsterdam, the Netherlands
| | - Johanna W Wilmink
- Department of Medical Oncology, Cancer Center Amsterdam, Amsterdam University Medical Center, University of Amsterdam, Amsterdam, the Netherlands
| | - Marc G Besselink
- Department of Surgery, Cancer Center Amsterdam, Amsterdam University Medical Center, University of Amsterdam, Amsterdam, the Netherlands
| | - Martijn R Meijerink
- Department of Radiology and Nuclear Medicine, Cancer Center Amsterdam, Amsterdam University Medical Center, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands.
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The efficacy and safety of the open approach irreversible electroporation in the treatment of pancreatic cancer: A systematic review. Eur J Surg Oncol 2020; 46:1565-1572. [PMID: 32536525 DOI: 10.1016/j.ejso.2020.05.017] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2020] [Revised: 05/04/2020] [Accepted: 05/19/2020] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Irreversible Electroporation (IRE) is a novel non-thermal ablation technique used in patients with locally advanced pancreatic cancer (LAPC), in the proximity of sensitive structures such as vessels, intestinal wall and the bile duct. Currently, it is only used in the setting of clinical trials. This systematic review aimed to tackle the knowledge gap in the literature, in relation to the safety and efficacy of the open approach IRE. METHODS MEDLINE, EMBASE and Cochrane libraries were searched for English language articles published from January 2000 to December 2019. Data related to safety and efficacy were extracted. RESULTS Nine studies involving 460 patients with LAPC were included. Open approach IRE was associated with high morbidity (29.4%) but with a survival benefit compared to traditional treatment. Median overall survival (OS) was at 17.15 months. Major morbidity was at 10.2% and mortality at 3.4%. CONCLUSIONS Despite the paucity of literature and the low quality of evidence, the results regarding safety and efficacy appear to be encouraging. The high morbidity seems to be mitigated by a demonstrated improvement in OS. The potential of this technique is more evident when mortality and major morbidity are considered, since they are at acceptable levels. The limitations of this review have made it difficult to extract definitive conclusions. Higher quality evidence is needed in the form of large-scale multicentre randomized controlled trials. It remains to be elucidated whether the rate of adverse events decreases as our experience with this technique increases.
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Timmer FEF, Geboers B, Ruarus AH, Schouten EAC, Nieuwenhuizen S, Puijk RS, de Vries JJJ, Meijerink MR, Scheffer HJ. Irreversible Electroporation for Locally Advanced Pancreatic Cancer. Tech Vasc Interv Radiol 2020; 23:100675. [PMID: 32591191 DOI: 10.1016/j.tvir.2020.100675] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Several minimally invasive image guided tumor ablation techniques have been added to the treatment spectrum for locally advanced pancreatic cancer (LAPC). Irreversible electroporation (IRE) might have a significant additive value in the management of this difficult-to-treat disease. As opposed to thermal ablative techniques, IRE induces cell death by the delivery of high-voltage electrical pulses. The electrical energy disrupts the cellular membrane integrity, causes loss of cellular homeostasis and ultimately results in cell death. The extracellular matrix of connective tissue in surrounding delicate structures such as bile ducts, bowel wall, and larger blood vessels is spared. The preservation of these structures makes IRE attractive for the treatment of pancreatic cancers that are unresectable due to their anatomical location (ie, LAPC and local recurrence after surgical resection). In addition to its cytoreductive abilities, evidence is emerging on IRE's capability to induce systemic immunomodulation through active in vivo vaccination against pancreatic cancer cells. These effects in combination with immunotherapy may offer a new treatment paradigm for tumors with low immunogenic potential like pancreatic ductal adenocarcinoma (PDAC). This review discusses several practical and technical issues of IRE for LAPC: clinical evaluation, indications, patient preparations, procedural steps, imaging characteristics, clinical results, and "tricks of the trade" used to improve the safety and efficacy of the treatment. Future directions such as the combination of IRE with immunotherapy will be shortly addressed.
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Affiliation(s)
- Florentine E F Timmer
- Department of Radiology and Nuclear Medicine at the Amsterdam University Medical Center, Vrije Universiteit-Cancer Center Amsterdam in Amsterdam, The Netherlands
| | - Bart Geboers
- Department of Radiology and Nuclear Medicine at the Amsterdam University Medical Center, Vrije Universiteit-Cancer Center Amsterdam in Amsterdam, The Netherlands.
| | - Alette H Ruarus
- Department of Radiology and Nuclear Medicine at the Amsterdam University Medical Center, Vrije Universiteit-Cancer Center Amsterdam in Amsterdam, The Netherlands
| | - Evelien A C Schouten
- Department of Radiology and Nuclear Medicine at the Amsterdam University Medical Center, Vrije Universiteit-Cancer Center Amsterdam in Amsterdam, The Netherlands
| | - Sanne Nieuwenhuizen
- Department of Radiology and Nuclear Medicine at the Amsterdam University Medical Center, Vrije Universiteit-Cancer Center Amsterdam in Amsterdam, The Netherlands
| | - Robbert S Puijk
- Department of Radiology and Nuclear Medicine at the Amsterdam University Medical Center, Vrije Universiteit-Cancer Center Amsterdam in Amsterdam, The Netherlands
| | - Jan J J de Vries
- Department of Radiology and Nuclear Medicine at the Amsterdam University Medical Center, Vrije Universiteit-Cancer Center Amsterdam in Amsterdam, The Netherlands
| | - Martijn R Meijerink
- Department of Radiology and Nuclear Medicine at the Amsterdam University Medical Center, Vrije Universiteit-Cancer Center Amsterdam in Amsterdam, The Netherlands
| | - Hester J Scheffer
- Department of Radiology and Nuclear Medicine at the Amsterdam University Medical Center, Vrije Universiteit-Cancer Center Amsterdam in Amsterdam, The Netherlands
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31
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Agnass P, van Veldhuisen E, van Gemert MJC, van der Geld CWM, van Lienden KP, van Gulik TM, Meijerink MR, Besselink MG, Kok HP, Crezee J. Mathematical modeling of the thermal effects of irreversible electroporation for in vitro, in vivo, and clinical use: a systematic review. Int J Hyperthermia 2020; 37:486-505. [DOI: 10.1080/02656736.2020.1753828] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Affiliation(s)
- Pierre Agnass
- Department of Radiation Oncology, Amsterdam UMC, University of Amsterdam, Cancer Center Amsterdam, Amsterdam, The Netherlands
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Eran van Veldhuisen
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Martin J. C. van Gemert
- Department of Biomedical Engineering and Physics, Amsterdam UMC, University of Amsterdam, Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Cees W. M. van der Geld
- Department of Chemical Engineering and Chemistry, Eindhoven University of Technology, Eindhoven, The Netherlands
| | - Krijn P. van Lienden
- Department of Radiology and Nuclear Medicine, Amsterdam UMC, University of Amsterdam, Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Thomas M. van Gulik
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Martijn R. Meijerink
- Department of Radiology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Marc G. Besselink
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - H. Petra Kok
- Department of Radiation Oncology, Amsterdam UMC, University of Amsterdam, Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Johannes Crezee
- Department of Radiation Oncology, Amsterdam UMC, University of Amsterdam, Cancer Center Amsterdam, Amsterdam, The Netherlands
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He C, Wang J, Zhang Y, Cai Z, Lin X, Li S. Comparison of combination therapies in the management of locally advanced pancreatic cancer: Induction chemotherapy followed by irreversible electroporation vs radiofrequency ablation. Cancer Med 2020; 9:4699-4710. [PMID: 32410380 PMCID: PMC7333834 DOI: 10.1002/cam4.3119] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2019] [Revised: 04/23/2020] [Accepted: 04/23/2020] [Indexed: 12/17/2022] Open
Abstract
Background Locally advanced pancreatic cancer (LAPC) remains a challenge for current treatments. Local destructive therapies, such as irreversible electroporation (IRE) and radiofrequency ablation (RFA), were used more and more frequently in the treatment of LAPC. Objective This study aimed to compare the efficacy of IRE with RFA in patients with LAPC. Methods From August 2015 to August 2017, 58 LAPC patients after IRE or RFA therapy, which was performed through open approach, were retrospectively reviewed. The survival outcomes after IRE (36 patients) and RFA (18 patients) were compared after propensity score matching (PSM) analysis. Results Before PSM analysis, IRE after the induction chemotherapy resulted in significant higher overall survival (OS) rates and progression‐free survival (PFS) rates to RFA (2‐year OS, 53.5% vs 30.8%, P = .013; 2‐year PFS, 28.4% vs 12.1%, P = .043). After PSM analysis, compared with RFA, the survival benefit of IRE was even more obvious, (2‐year OS, 53.5% vs 27.0%, P = .010; 2‐year PFS, 28.4% vs 6.4%, P = .018). For patients with tumor larger than 4 cm, IRE resulted in comparable OS and PFS between RFA and IRE while IRE also achieved better long‐term OS to RFA for those with tumor smaller than 4 cm. Multivariate analysis illustrated that IRE was a favorable prognostic factor in terms of OS and PFS in patients with LAPC. Conclusions IRE after induction chemotherapy is superior to RFA after induction chemotherapy for treating LAPC patients while these two therapies have comparable efficacy for tumors which were larger than 4 cm.
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Affiliation(s)
- Chaobin He
- Department of Pancreatobiliary Surgery, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Sun Yat-sen University Cancer Center, Guangzhou, China
| | - Jun Wang
- Department of Pancreatobiliary Surgery, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Sun Yat-sen University Cancer Center, Guangzhou, China
| | - Yu Zhang
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-sen University, Guangzhou, P.R. China
| | - Zhiyuan Cai
- Department of Pancreatobiliary Surgery, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Sun Yat-sen University Cancer Center, Guangzhou, China
| | - Xiaojun Lin
- Department of Pancreatobiliary Surgery, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Sun Yat-sen University Cancer Center, Guangzhou, China
| | - Shengping Li
- Department of Pancreatobiliary Surgery, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Sun Yat-sen University Cancer Center, Guangzhou, China
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Geboers B, Scheffer HJ, Graybill PM, Ruarus AH, Nieuwenhuizen S, Puijk RS, van den Tol PM, Davalos RV, Rubinsky B, de Gruijl TD, Miklavčič D, Meijerink MR. High-Voltage Electrical Pulses in Oncology: Irreversible Electroporation, Electrochemotherapy, Gene Electrotransfer, Electrofusion, and Electroimmunotherapy. Radiology 2020; 295:254-272. [PMID: 32208094 DOI: 10.1148/radiol.2020192190] [Citation(s) in RCA: 166] [Impact Index Per Article: 41.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
This review summarizes the use of high-voltage electrical pulses (HVEPs) in clinical oncology to treat solid tumors with irreversible electroporation (IRE) and electrochemotherapy (ECT). HVEPs increase the membrane permeability of cells, a phenomenon known as electroporation. Unlike alternative ablative therapies, electroporation does not affect the structural integrity of surrounding tissue, thereby enabling tumors in the vicinity of vital structures to be treated. IRE uses HVEPs to cause cell death by inducing membrane disruption, and it is primarily used as a radical ablative therapy in the treatment of soft-tissue tumors in the liver, kidney, prostate, and pancreas. ECT uses HVEPs to transiently increase membrane permeability, enhancing cellular cytotoxic drug uptake in tumors. IRE and ECT show immunogenic effects that could be augmented when combined with immunomodulatory drugs, a combination therapy the authors term electroimmunotherapy. Additional electroporation-based technologies that may reach clinical importance, such as gene electrotransfer, electrofusion, and electroimmunotherapy, are concisely reviewed. HVEPs represent a substantial advancement in cancer research, and continued improvement and implementation of these presented technologies will require close collaboration between engineers, interventional radiologists, medical oncologists, and immuno-oncologists.
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Affiliation(s)
- Bart Geboers
- From the Departments of Radiology and Nuclear Medicine (B.G., H.J.S., A.H.R., S.N., R.S.P., M.R.M.), Surgery (P.M.v.d.T.), and Medical Oncology (T.D.d.G.), Amsterdam University Medical Centers, De Boelelaan 1117, 1081 HV, Amsterdam, the Netherlands; Bioelectromechanical Systems Laboratory, Department of Biomedical Engineering and Mechanics, Virginia Tech-Wake Forest University, Blacksburg, Va (P.M.G., R.V.D.); Department of Bioengineering and Department of Mechanical Engineering, University of California, Berkeley, Berkeley, Calif (B.R.); and Faculty of Electrical Engineering, University of Ljubljana, Ljubljana, Slovenia (D.M.)
| | - Hester J Scheffer
- From the Departments of Radiology and Nuclear Medicine (B.G., H.J.S., A.H.R., S.N., R.S.P., M.R.M.), Surgery (P.M.v.d.T.), and Medical Oncology (T.D.d.G.), Amsterdam University Medical Centers, De Boelelaan 1117, 1081 HV, Amsterdam, the Netherlands; Bioelectromechanical Systems Laboratory, Department of Biomedical Engineering and Mechanics, Virginia Tech-Wake Forest University, Blacksburg, Va (P.M.G., R.V.D.); Department of Bioengineering and Department of Mechanical Engineering, University of California, Berkeley, Berkeley, Calif (B.R.); and Faculty of Electrical Engineering, University of Ljubljana, Ljubljana, Slovenia (D.M.)
| | - Philip M Graybill
- From the Departments of Radiology and Nuclear Medicine (B.G., H.J.S., A.H.R., S.N., R.S.P., M.R.M.), Surgery (P.M.v.d.T.), and Medical Oncology (T.D.d.G.), Amsterdam University Medical Centers, De Boelelaan 1117, 1081 HV, Amsterdam, the Netherlands; Bioelectromechanical Systems Laboratory, Department of Biomedical Engineering and Mechanics, Virginia Tech-Wake Forest University, Blacksburg, Va (P.M.G., R.V.D.); Department of Bioengineering and Department of Mechanical Engineering, University of California, Berkeley, Berkeley, Calif (B.R.); and Faculty of Electrical Engineering, University of Ljubljana, Ljubljana, Slovenia (D.M.)
| | - Alette H Ruarus
- From the Departments of Radiology and Nuclear Medicine (B.G., H.J.S., A.H.R., S.N., R.S.P., M.R.M.), Surgery (P.M.v.d.T.), and Medical Oncology (T.D.d.G.), Amsterdam University Medical Centers, De Boelelaan 1117, 1081 HV, Amsterdam, the Netherlands; Bioelectromechanical Systems Laboratory, Department of Biomedical Engineering and Mechanics, Virginia Tech-Wake Forest University, Blacksburg, Va (P.M.G., R.V.D.); Department of Bioengineering and Department of Mechanical Engineering, University of California, Berkeley, Berkeley, Calif (B.R.); and Faculty of Electrical Engineering, University of Ljubljana, Ljubljana, Slovenia (D.M.)
| | - Sanne Nieuwenhuizen
- From the Departments of Radiology and Nuclear Medicine (B.G., H.J.S., A.H.R., S.N., R.S.P., M.R.M.), Surgery (P.M.v.d.T.), and Medical Oncology (T.D.d.G.), Amsterdam University Medical Centers, De Boelelaan 1117, 1081 HV, Amsterdam, the Netherlands; Bioelectromechanical Systems Laboratory, Department of Biomedical Engineering and Mechanics, Virginia Tech-Wake Forest University, Blacksburg, Va (P.M.G., R.V.D.); Department of Bioengineering and Department of Mechanical Engineering, University of California, Berkeley, Berkeley, Calif (B.R.); and Faculty of Electrical Engineering, University of Ljubljana, Ljubljana, Slovenia (D.M.)
| | - Robbert S Puijk
- From the Departments of Radiology and Nuclear Medicine (B.G., H.J.S., A.H.R., S.N., R.S.P., M.R.M.), Surgery (P.M.v.d.T.), and Medical Oncology (T.D.d.G.), Amsterdam University Medical Centers, De Boelelaan 1117, 1081 HV, Amsterdam, the Netherlands; Bioelectromechanical Systems Laboratory, Department of Biomedical Engineering and Mechanics, Virginia Tech-Wake Forest University, Blacksburg, Va (P.M.G., R.V.D.); Department of Bioengineering and Department of Mechanical Engineering, University of California, Berkeley, Berkeley, Calif (B.R.); and Faculty of Electrical Engineering, University of Ljubljana, Ljubljana, Slovenia (D.M.)
| | - Petrousjka M van den Tol
- From the Departments of Radiology and Nuclear Medicine (B.G., H.J.S., A.H.R., S.N., R.S.P., M.R.M.), Surgery (P.M.v.d.T.), and Medical Oncology (T.D.d.G.), Amsterdam University Medical Centers, De Boelelaan 1117, 1081 HV, Amsterdam, the Netherlands; Bioelectromechanical Systems Laboratory, Department of Biomedical Engineering and Mechanics, Virginia Tech-Wake Forest University, Blacksburg, Va (P.M.G., R.V.D.); Department of Bioengineering and Department of Mechanical Engineering, University of California, Berkeley, Berkeley, Calif (B.R.); and Faculty of Electrical Engineering, University of Ljubljana, Ljubljana, Slovenia (D.M.)
| | - Rafael V Davalos
- From the Departments of Radiology and Nuclear Medicine (B.G., H.J.S., A.H.R., S.N., R.S.P., M.R.M.), Surgery (P.M.v.d.T.), and Medical Oncology (T.D.d.G.), Amsterdam University Medical Centers, De Boelelaan 1117, 1081 HV, Amsterdam, the Netherlands; Bioelectromechanical Systems Laboratory, Department of Biomedical Engineering and Mechanics, Virginia Tech-Wake Forest University, Blacksburg, Va (P.M.G., R.V.D.); Department of Bioengineering and Department of Mechanical Engineering, University of California, Berkeley, Berkeley, Calif (B.R.); and Faculty of Electrical Engineering, University of Ljubljana, Ljubljana, Slovenia (D.M.)
| | - Boris Rubinsky
- From the Departments of Radiology and Nuclear Medicine (B.G., H.J.S., A.H.R., S.N., R.S.P., M.R.M.), Surgery (P.M.v.d.T.), and Medical Oncology (T.D.d.G.), Amsterdam University Medical Centers, De Boelelaan 1117, 1081 HV, Amsterdam, the Netherlands; Bioelectromechanical Systems Laboratory, Department of Biomedical Engineering and Mechanics, Virginia Tech-Wake Forest University, Blacksburg, Va (P.M.G., R.V.D.); Department of Bioengineering and Department of Mechanical Engineering, University of California, Berkeley, Berkeley, Calif (B.R.); and Faculty of Electrical Engineering, University of Ljubljana, Ljubljana, Slovenia (D.M.)
| | - Tanja D de Gruijl
- From the Departments of Radiology and Nuclear Medicine (B.G., H.J.S., A.H.R., S.N., R.S.P., M.R.M.), Surgery (P.M.v.d.T.), and Medical Oncology (T.D.d.G.), Amsterdam University Medical Centers, De Boelelaan 1117, 1081 HV, Amsterdam, the Netherlands; Bioelectromechanical Systems Laboratory, Department of Biomedical Engineering and Mechanics, Virginia Tech-Wake Forest University, Blacksburg, Va (P.M.G., R.V.D.); Department of Bioengineering and Department of Mechanical Engineering, University of California, Berkeley, Berkeley, Calif (B.R.); and Faculty of Electrical Engineering, University of Ljubljana, Ljubljana, Slovenia (D.M.)
| | - Damijan Miklavčič
- From the Departments of Radiology and Nuclear Medicine (B.G., H.J.S., A.H.R., S.N., R.S.P., M.R.M.), Surgery (P.M.v.d.T.), and Medical Oncology (T.D.d.G.), Amsterdam University Medical Centers, De Boelelaan 1117, 1081 HV, Amsterdam, the Netherlands; Bioelectromechanical Systems Laboratory, Department of Biomedical Engineering and Mechanics, Virginia Tech-Wake Forest University, Blacksburg, Va (P.M.G., R.V.D.); Department of Bioengineering and Department of Mechanical Engineering, University of California, Berkeley, Berkeley, Calif (B.R.); and Faculty of Electrical Engineering, University of Ljubljana, Ljubljana, Slovenia (D.M.)
| | - Martijn R Meijerink
- From the Departments of Radiology and Nuclear Medicine (B.G., H.J.S., A.H.R., S.N., R.S.P., M.R.M.), Surgery (P.M.v.d.T.), and Medical Oncology (T.D.d.G.), Amsterdam University Medical Centers, De Boelelaan 1117, 1081 HV, Amsterdam, the Netherlands; Bioelectromechanical Systems Laboratory, Department of Biomedical Engineering and Mechanics, Virginia Tech-Wake Forest University, Blacksburg, Va (P.M.G., R.V.D.); Department of Bioengineering and Department of Mechanical Engineering, University of California, Berkeley, Berkeley, Calif (B.R.); and Faculty of Electrical Engineering, University of Ljubljana, Ljubljana, Slovenia (D.M.)
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Vogel JA, van Veldhuisen E, Alles LK, Busch OR, Dijk F, van Gulik TM, Huijzer GM, Besselink MG, van Lienden KP, Verheij J. Time-Dependent Impact of Irreversible Electroporation on Pathology and Ablation Size in the Porcine Liver: A 24-Hour Experimental Study. Technol Cancer Res Treat 2020; 18:1533033819876899. [PMID: 31533537 PMCID: PMC6753518 DOI: 10.1177/1533033819876899] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Irreversible electroporation causes cell death through low frequency, high voltage electrical pulses and is increasingly used to treat non-resectable cancers. A recent systematic review revealed that tissue damage through irreversible electroporation is time-dependent, but the impact of time on the ablation zone size remains unknown. Irreversible electroporation ablations were performed hourly during 24 consecutive hours in the peripheral liver of 2 anaesthetized domestic pigs using clinical treatment settings. Immediately after the 24th ablation, the livers were harvested and examined for tissue response in time based on macroscopic and microscopic pathology. The impact of time on these outcomes was assessed with Spearman rank correlation test. Ablation zones were sharply demarcated as early as 1 hour after treatment. During 24 hours, the ablation zones showed a significant increase in diameter (rs = 0.493, P = .014) and total surface (rs = 0.499, P = .013), whereas the impact of time on the homogeneous ablated area was not significant (rs = 0.172, P = .421). Therefore, the increase in size could mainly be attributed to an increase in the transition zone. Microscopically, the ablation zones showed progression in cell death and inflammation. This study assessed the dynamics of irreversible electroporation on the porcine liver during 24 consecutive hours and found that the pathological response (ie, cell death/inflammation), and ablation size continue to develop for at least 24 hours. Consequently, future studies on irreversible electroporation should prolong their observation period.
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Affiliation(s)
- Jantien A Vogel
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Eran van Veldhuisen
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Lindy K Alles
- Department of Experimental Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Olivier R Busch
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Frederike Dijk
- Department of Pathology, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Thomas M van Gulik
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands.,Department of Experimental Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Goos M Huijzer
- Department of Experimental Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Marc G Besselink
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Krijn P van Lienden
- Department of Interventional Radiology, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Joanne Verheij
- Department of Pathology, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
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35
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He C, Huang X, Zhang Y, Cai Z, Lin X, Li S. Comparison of Survival Between Irreversible Electroporation Followed by Chemotherapy and Chemotherapy Alone for Locally Advanced Pancreatic Cancer. Front Oncol 2020; 10:6. [PMID: 32038984 PMCID: PMC6987260 DOI: 10.3389/fonc.2020.00006] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2019] [Accepted: 01/06/2020] [Indexed: 12/27/2022] Open
Abstract
Locally advanced pancreatic cancer (LAPC) has a dismal prognosis even after standard chemotherapy, and local progression contributes to nearly one-third of the deaths of these patients. As a local destructive method, irreversible electroporation (IRE) can feasibly treat LAPC. The aim of this study was to evaluate IRE combined with chemotherapy as a new treatment and compare its efficacy with that of chemotherapy alone in patients with LAPC. The data of LAPC patients who received chemotherapy with or without IRE were extracted from Surveillance, Epidemiology, and End Results (SEER) database and medical records of Sun Yat-sen University Cancer Center (SYSUCC). The efficacy of these two treatments was compared using propensity score matching (PSM) analysis. LAPC patients treated with the combination therapy had better overall survival (OS). Significantly higher cancer-specific survival (CSS) and progression-free survival (PFS) rates were also observed in patients after IRE combined with chemotherapy, compared with chemotherapy alone. IRE combined with chemotherapy was established as a favorable factor for OS, CSS, and PFS in LAPC patients. This combination method may be a more suitable treatment for patients with LAPC.
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Affiliation(s)
- Chaobin He
- State Key Laboratory of Oncology in South China, Department of Pancreatobiliary Surgery, Collaborative Innovation Center for Cancer Medicine, Sun Yat-sen University Cancer Center, Guangzhou, China
| | - Xin Huang
- State Key Laboratory of Oncology in South China, Department of Pancreatobiliary Surgery, Collaborative Innovation Center for Cancer Medicine, Sun Yat-sen University Cancer Center, Guangzhou, China
| | - Yu Zhang
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-sen University, Guangzhou, China
| | - Zhiyuan Cai
- State Key Laboratory of Oncology in South China, Department of Pancreatobiliary Surgery, Collaborative Innovation Center for Cancer Medicine, Sun Yat-sen University Cancer Center, Guangzhou, China
| | - Xiaojun Lin
- State Key Laboratory of Oncology in South China, Department of Pancreatobiliary Surgery, Collaborative Innovation Center for Cancer Medicine, Sun Yat-sen University Cancer Center, Guangzhou, China
| | - Shengping Li
- State Key Laboratory of Oncology in South China, Department of Pancreatobiliary Surgery, Collaborative Innovation Center for Cancer Medicine, Sun Yat-sen University Cancer Center, Guangzhou, China
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Latenstein AEJ, van der Geest LGM, Bonsing BA, Groot Koerkamp B, Haj Mohammad N, de Hingh IHJT, de Meijer VE, Molenaar IQ, van Santvoort HC, van Tienhoven G, Verheij J, Vissers PAJ, de Vos-Geelen J, Busch OR, van Eijck CHJ, van Laarhoven HWM, Besselink MG, Wilmink JW. Nationwide trends in incidence, treatment and survival of pancreatic ductal adenocarcinoma. Eur J Cancer 2019; 125:83-93. [PMID: 31841792 DOI: 10.1016/j.ejca.2019.11.002] [Citation(s) in RCA: 91] [Impact Index Per Article: 18.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2019] [Revised: 10/24/2019] [Accepted: 11/01/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND In recent years, new treatment options have become available for pancreatic ductal adenocarcinoma (PDAC) including 5-fluorouracil, leucovorin, irinotecan and oxaliplatin. The impact hereof has not been assessed in nationwide cohort studies. This population-based study aimed to investigate nationwide trends in incidence, treatment and survival of PDAC. MATERIALS AND METHODS Patients with PDAC (1997-2016) were included from the Netherlands Cancer Registry. Results were categorised by treatment and by period of diagnosis (1997-2000, 2001-2004, 2005-2008, 2009-2012 and 2013-2016). Kaplan-Meier survival analysis was used to calculate overall survival. RESULTS In a national cohort of 36,453 patients with PDAC, the incidence increased from 12.1 (1997-2000) to 15.3 (2013-2016) per 100,000 (p < 0.001), whereas median overall survival increased from 3.1 to 3.8 months (p < 0.001). Over time, the resection rate doubled (8.3%-16.6%, p-trend<0.001), more patients received adjuvant chemotherapy (3.0%-56.2%, p-trend<0.001) and 3-year overall survival following resection increased (16.9%-25.4%, p < 0.001). Over time, the proportion of patients with metastatic disease who received palliative chemotherapy increased from 5.3% to 16.1% (p-trend<0.001), whereas 1-year survival improved from 13.3% to 21.2% (p < 0.001). The proportion of patients who only received supportive care decreased from 84% to 61% (p-trend<0.001). CONCLUSION The incidence of PDAC increased in the past two decades. Resection rates and use of adjuvant or palliative chemotherapy increased with improved survival in these patients. In all patients with PDAC, however, the survival benefit of 3 weeks is negligible because the majority of patients only received supportive care.
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Affiliation(s)
- Anouk E J Latenstein
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands.
| | - Lydia G M van der Geest
- Department of Research, Netherlands Comprehensive Cancer Organisation (IKNL), Utrecht, the Netherlands
| | - Bert A Bonsing
- Department of Surgery, Leiden University Medical Center, Leiden, the Netherlands
| | | | - Nadia Haj Mohammad
- Department of Medical Oncology, Regional Academic Cancer Center Utrecht, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | | | - Vincent E de Meijer
- Department of Hepatobiliary Surgery and Liver Transplantation, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Izaak Q Molenaar
- Department of Surgery, Regional Academic Cancer Center Utrecht, St Antonius Hospital Nieuwegein and University Medical Center Utrecht Cancer Center, Utrecht, the Netherlands
| | - Hjalmar C van Santvoort
- Department of Surgery, Regional Academic Cancer Center Utrecht, St Antonius Hospital Nieuwegein and University Medical Center Utrecht Cancer Center, Utrecht, the Netherlands
| | - Geertjan van Tienhoven
- Department of Radiation Oncology, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Joanne Verheij
- Department of Pathology, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Pauline A J Vissers
- Department of Research, Netherlands Comprehensive Cancer Organisation (IKNL), Utrecht, the Netherlands
| | - Judith de Vos-Geelen
- Department of Internal Medicine, Division of Medical Oncology, GROW - School for Oncology and Developmental Biology, Maastricht University Medical Center, Maastricht, the Netherlands
| | - Olivier R Busch
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | | | - Hanneke W M van Laarhoven
- Department of Medical Oncology, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Marc G Besselink
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Johanna W Wilmink
- Department of Medical Oncology, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands.
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Aycock KN, Davalos RV. Irreversible Electroporation: Background, Theory, and Review of Recent Developments in Clinical Oncology. Bioelectricity 2019; 1:214-234. [PMID: 34471825 PMCID: PMC8370296 DOI: 10.1089/bioe.2019.0029] [Citation(s) in RCA: 77] [Impact Index Per Article: 15.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
Irreversible electroporation (IRE) has established a clinical niche as an alternative to thermal ablation for the eradication of unresectable tumors, particularly those near critical vascular structures. IRE has been used in over 50 independent clinical trials and has shown clinical success when used as a standalone treatment and as a single component within combinatorial treatment paradigms. Recently, many studies evaluating IRE in larger patient cohorts and alongside other novel therapies have been reported. Here, we present the basic principles of reversible electroporation and IRE followed by a review of preclinical and clinical data with a focus on tumors in three organ systems in which IRE has shown great promise: the prostate, pancreas, and liver. Finally, we discuss alternative and future developments, which will likely further advance the use of IRE in the clinic.
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Affiliation(s)
- Kenneth N Aycock
- Department of Biomedical Engineering and Mechanics, Virginia Tech-Wake Forest University, Blacksburg, Virginia
| | - Rafael V Davalos
- Department of Biomedical Engineering and Mechanics, Virginia Tech-Wake Forest University, Blacksburg, Virginia
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38
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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.
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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
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39
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DeWitt MR, Latouche EL, Kaufman JD, Fesmire CC, Swet JH, Kirks RC, Baker EH, Vrochides D, Iannitti DA, McKillop IH, Davalos RV, Sano MB. Simplified Non-Thermal Tissue Ablation With a Single Insertion Device Enabled by Bipolar High-Frequency Pulses. IEEE Trans Biomed Eng 2019; 67:2043-2051. [PMID: 31751216 DOI: 10.1109/tbme.2019.2954122] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
OBJECTIVE To demonstrate the feasibility of a single electrode and grounding pad approach for delivering high frequency irreversible electroporation treatments (H-FIRE) in in-vivo hepatic tissue. METHODS Ablations were created in porcine liver under surgical anesthesia by adminstereing high frequency bursts of 0.5-5.0 μs pulses with amplitudes between 1.1-1.7 kV in the absence of cardiac synchronization or intraoperative paralytics. Finite element simulations were used to determine the electric field strength associated with the ablation margins (ELethal) and predict the ablations feasible with next generation electronics. RESULTS All animals survived the procedures for the protocol duration without adverse events. ELethal of 2550, 1650, and 875 V/cm were found for treatments consisting of 100x bursts containing 0.5 μs pulses and 25, 50, and 75 μs of energized-time per burst, respectively. Treatments with 1 μs pulses consisting of 100 bursts with 100 μs energized-time per burst resulted in ELethal of 650 V/cm. CONCLUSION A single electrode and grounding pad approach was successfully used to create ablations in hepatic tissue. This technique has the potential to reduce challenges associated with placing multiple electrodes in anatomically challenging environments. SIGNIFICANCE H-FIRE is an in situ tumor ablation approach in which electrodes are placed within or around a targeted region to deliver high voltage electrical pulses. Electric fields generated around the electrodes induce irrecoverable cell membrane damage leading to predictable cell death in the relative absence of thermal damage. The sparing of architectural integrity means H-FIRE offers potential advantages compared to thermal ablation modalities for ablating tumors near critical structures.
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40
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Lafranceschina S, Brunetti O, Delvecchio A, Conticchio M, Ammendola M, Currò G, Piardi T, de'Angelis N, Silvestris N, Memeo R. Systematic Review of Irreversible Electroporation Role in Management of Locally Advanced Pancreatic Cancer. Cancers (Basel) 2019; 11:E1718. [PMID: 31684186 PMCID: PMC6896066 DOI: 10.3390/cancers11111718] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2019] [Revised: 10/25/2019] [Accepted: 10/29/2019] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Ablative techniques provide in patients with locally advanced pancreatic cancer (LAPC) symptomatic relief, survival benefit and potential downsizing. Irreversible Electroporation (IRE) represents potentially an ideal solution as no thermal tissue damage occurs. The purpose of this review is to present an overview on safety, feasibility, oncological results, survival and quality of life improvement obtained by IRE. METHODS A systematic search was performed in PubMed, regarding the use of IRE on PC in humans for studies published in English up to March 2019. RESULTS 15 original studies embodying 691 patients with unresectable LAPC who underwent IRE were included. As emerged, IRE works better on tumour sizes between 3-4 cm. Oncological results are promising: median OS from diagnosis or treatment up to 27 months. Two groups investigated borderline resectable tumours treated with IRE before resection with margin attenuation, whereas IRE has proved to be effective in pain control. CONCLUSIONS Electroporation is bringing new hopes in LAPC management. The first aim of IRE is to offer a palliative treatment. Further efforts are needed for patient selection, as well as the use of IRE for 'margin accentuation' during surgical resection. Even if promising, IRE needs to be validated in large, randomized, prospective series.
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Affiliation(s)
- Stefano Lafranceschina
- Department of Emergency and Organ Transplantation, University "Aldo Moro" of Bary, 70124 Bary, Italy.
| | - Oronzo Brunetti
- Medical Oncology Unit, IRCCS Istituto Tumori "Giovanni Paolo II 2", 70124 Bari, Italy.
| | - Antonella Delvecchio
- Department of Emergency and Organ Transplantation, University "Aldo Moro" of Bary, 70124 Bary, Italy.
| | - Maria Conticchio
- Department of Emergency and Organ Transplantation, University "Aldo Moro" of Bary, 70124 Bary, Italy.
| | - Michele Ammendola
- Department of Health Science, General Surgery, Magna Graecia University, Medicine School of Germaneto, 88100 Catanzaro, Italy.
| | - Giuseppe Currò
- Department of Health Science, General Surgery, Magna Graecia University, Medicine School of Germaneto, 88100 Catanzaro, Italy.
| | - Tullio Piardi
- Department of Surgery, Hôpital Robert Debré, University of Champagne-Ardenne, 51100 Reims, France.
| | - Nicola de'Angelis
- Department of Digestive and Hepato-Pancreato-Biliary Surgery, Henri Mondor University Hospital, AP-HP, Université Paris-Est Créteil (UPEC), 51 Avenue du Maréchal de Lattre de Tassigny, 94010 Créteil, France.
| | - Nicola Silvestris
- Medical Oncology Unit, IRCCS Istituto Tumori "Giovanni Paolo II 2", 70124 Bari, Italy.
- Department of Biomedical Sciences and Human Oncology, University of Bari 'Aldo Moro', 70124 Bari, Italy.
| | - Riccardo Memeo
- Department of Emergency and Organ Transplantation, University "Aldo Moro" of Bary, 70124 Bary, Italy.
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van Veldhuisen E, Walma MS, van Rijssen LB, Busch OR, Bruijnen RCG, van Delden OM, Mohammad NH, de Hingh IH, Yo LS, van Laarhoven HW, van Leeuwen MS, Nio CY, van Santvoort HC, de Vries J, Wessels FJ, Wilmink JW, Molenaar IQ, Besselink MG, van Lienden KP. Added value of intra-operative ultrasound to determine the resectability of locally advanced pancreatic cancer following FOLFIRINOX chemotherapy (IMAGE): a prospective multicenter study. HPB (Oxford) 2019; 21:1385-1392. [PMID: 31010633 DOI: 10.1016/j.hpb.2019.02.017] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2018] [Revised: 02/11/2019] [Accepted: 02/25/2019] [Indexed: 12/12/2022]
Abstract
BACKGROUND Determining the resectability of locally advanced pancreatic cancer (LAPC) after FOLFIRINOX chemotherapy is challenging because CT-scans cannot reliably assess vascular involvement. This study evaluates the added value of intra-operative ultrasound (IOUS) in LAPC following FOLFIRINOX induction chemotherapy. METHODS Prospective multicenter study in patients with LAPC who underwent explorative laparotomy with IOUS after FOLFIRINOX chemotherapy. Resectability was defined according to the National Comprehensive Cancer Network guidelines. IOUS findings were compared with preoperative CT-scans and pathology results. RESULTS CT-staging in 38 patients with LAPC after FOLFIRINOX chemotherapy defined 22 patients LAPC, 15 borderline resectable and one resectable. IOUS defined 19 patients LAPC, 13 borderline resectable and six resectable. In 12/38 patients, IOUS changed the resectability status including five patients from borderline resectable to resectable and five patients from LAPC to borderline resectable. Two patients were upstaged from borderline resectable to LAPC. Tumor diameters were significantly smaller upon IOUS (31.7 ± 9.5 mm versus 37.1 ± 10.0 mm, p = 0.001) and resectability varied significantly (p = 0.043). Ultimately, 20 patients underwent resection of whom 14 were evaluated as (borderline) resectable on CT-scan, and 17 on IOUS. DISCUSSION This prospective study demonstrates that IOUS may change the resectability status up to a third of patients with LAPC following FOLFIRINOX chemotherapy.
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Affiliation(s)
- Eran van Veldhuisen
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, the Netherlands
| | - Marieke S Walma
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, the Netherlands; Department of Surgery, University Medical Center, Utrecht, the Netherlands
| | - L Bengt van Rijssen
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, the Netherlands
| | - Olivier R Busch
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, the Netherlands
| | - Rutger C G Bruijnen
- Department of Radiology, University Medical Center, Utrecht, the Netherlands
| | - Otto M van Delden
- Department of Radiology, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, the Netherlands
| | - Nadia Haj Mohammad
- Department of Medical Oncology, University Medical Center, Utrecht, the Netherlands
| | - Ignace H de Hingh
- Department of Surgery, Catharina Hospital, Eindhoven, the Netherlands
| | - Lonneke S Yo
- Department of Radiology, Catharina Hospital, Eindhoven, the Netherlands
| | - Hanneke W van Laarhoven
- Department of Medical Oncology, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, the Netherlands
| | | | - C Yung Nio
- Department of Radiology, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, the Netherlands
| | - Hjalmar C van Santvoort
- Department of Surgery, St Antonius Hospital Nieuwegein, University Medical Center Utrecht Cancer Center, Regional Academic Cancer Center Utrecht, the Netherlands
| | - Jan de Vries
- Department of Radiology and Nuclear Medicine, Cancer Center Amsterdam, Amsterdam UMC, VU University, Amsterdam, the Netherlands
| | - Frank J Wessels
- Department of Radiology, University Medical Center, Utrecht, the Netherlands
| | - Johanna W Wilmink
- Department of Medical Oncology, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, the Netherlands
| | - I Quintus Molenaar
- Department of Surgery, St Antonius Hospital Nieuwegein, University Medical Center Utrecht Cancer Center, Regional Academic Cancer Center Utrecht, the Netherlands
| | - Marc G Besselink
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, the Netherlands
| | - Krijn P van Lienden
- Department of Radiology, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, the Netherlands.
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Lyu C, Lopez-Ichikawa M, Rubinsky B, Chang TT. Normal and fibrotic liver parenchyma respond differently to irreversible electroporation. HPB (Oxford) 2019; 21:1344-1353. [PMID: 30879992 PMCID: PMC7170179 DOI: 10.1016/j.hpb.2019.01.019] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2018] [Revised: 11/30/2018] [Accepted: 01/31/2019] [Indexed: 12/12/2022]
Abstract
BACKGROUND The safety and efficacy of irreversible electroporation (IRE) in treating hepatic, biliary, and pancreatic malignancies are active areas of clinical investigation. In addition, recent studies have shown that IRE may enable regenerative surgery and in vivo tissue engineering. To use IRE effectively in these clinical applications, it is important to understand how different tissue microenvironments impact the response to IRE. In this study, we characterize the electrical and histological properties of non-fibrotic and fibrotic liver parenchyma before and after IRE treatment. METHODS Electrical resistivity and histology of fibrotic liver from C57BL/6 mice fed a 0.1% 3,5-diethylcarbonyl-1,4-dihydrocollidine (DDC) diet were compared to those of non-fibrotic liver from matched control mice before and after IRE treatment. RESULTS At baseline, the electrical resistivity of fibrotic liver was lower than that of non-fibrotic liver. Post-IRE, resistivity of non-fibrotic liver declined and then recovered back to baseline with time, correlating with hepatocyte repopulation of the ablated parenchyma without deposition of fibrotic scar. In contrast, resistivity of fibrotic liver remained depressed after IRE treatment, correlating with persistent inflammation. CONCLUSION Non-fibrotic and fibrotic liver respond to IRE differently. The underlying tissue microenvironment is an important modifying factor to consider when designing IRE protocols for tissue ablation.
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Affiliation(s)
- Chenang Lyu
- Department of Mechanical Engineering, University of California, Berkeley, CA 94720
| | | | - Boris Rubinsky
- Department of Mechanical Engineering, University of California, Berkeley, CA 94720
| | - Tammy T. Chang
- Department of Surgery, University of California, San Francisco, CA 94143
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Scholten L, Latenstein AEJ, van Eijck C, Erdmann J, van der Harst E, Mieog JSD, Molenaar IQ, van Santvoort HC, DeVries JH, Besselink MG. Outcome and long-term quality of life after total pancreatectomy (PANORAMA): a nationwide cohort study. Surgery 2019; 166:1017-1026. [PMID: 31500907 DOI: 10.1016/j.surg.2019.07.025] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2019] [Revised: 06/14/2019] [Accepted: 07/21/2019] [Indexed: 12/18/2022]
Abstract
BACKGROUND The threshold to perform total pancreatectomy is rather high, predominantly because of concerns for long-term consequences of brittle diabetes on patients' quality of life. Contemporary data on postoperative outcomes, diabetes management, and long-term quality of life after total pancreatectomy from large nationwide series are, however, lacking. METHODS We performed a nationwide, retrospective cohort study among adults who underwent total pancreatectomy in 17 Dutch centers (2006-2016). Morbidity and mortality were analyzed, and long-term quality of life was assessed cross-sectionally using the following generic and disease-specific questionnaires: the 5-level version European quality of life 5-dimension and the European Organization for Research and Treatment in Cancer Quality of Life Questionnaire Cancer. Several questionnaires specifically addressing diabetic quality of life included the Problem Areas in Diabetes Scale 20, the Diabetes Treatment Satisfaction Questionnaire-status version, and the Hypoglycemia Fear Survey-II. Results were compared with the general population and patients with type 1 diabetes. RESULTS Overall, 148 patients after total pancreatectomy were included. The annual nationwide volume of total pancreatectomy increased from 5 in 2006 to 32 in 2015 (P < .05). The 30-day and 90-day mortality were 5% and 8%, respectively. The major complication rate was 32%. Quality of life questionnaires were completed by 60 patients (85%, median follow-up of 36 months). Participants reported lower global (73 vs 78, P = .03) and daily health status (0.83 vs 0.87, P < .01) compared to the general population. Quality of life did not differ based on time after total pancreatectomy (<3, 3-5, or >5 years). In general, patients were satisfied with their diabetes therapy and experienced similar diabetes-related distress as patients with type 1 diabetes. CONCLUSION This nationwide study found increased use of total pancreatectomy with a relatively high 90-day mortality. Long-term quality of life was lower compared to the general population, although differences were small. Diabetes-related distress and treatment satisfaction were similar to patients with type 1 diabetes.
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Affiliation(s)
- Lianne Scholten
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, the Netherlands
| | - Anouk E J Latenstein
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, the Netherlands
| | - Casper van Eijck
- Department of Surgery, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Joris Erdmann
- Department of Surgery, University Medical Center Groningen, Groningen, the Netherlands
| | | | - J Sven D Mieog
- Department of Surgery, Leiden University Medical Center, Leiden, the Netherlands
| | - I Quintus Molenaar
- Department of Surgery, Regional Academic Cancer Center Utrecht, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Hjalmar C van Santvoort
- Department of Surgery, Regional Academic Cancer Center Utrecht, St Antonius Hospital Nieuwegein, Utrecht, the Netherlands
| | - J Hans DeVries
- Department of Endocrinology, Amsterdam UMC, University of Amsterdam, the Netherlands
| | - Marc G Besselink
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, the Netherlands.
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Parkin A, Man J, Timpson P, Pajic M. Targeting the complexity of Src signalling in the tumour microenvironment of pancreatic cancer: from mechanism to therapy. FEBS J 2019; 286:3510-3539. [PMID: 31330086 PMCID: PMC6771888 DOI: 10.1111/febs.15011] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2019] [Revised: 05/26/2019] [Accepted: 07/19/2019] [Indexed: 02/06/2023]
Abstract
Pancreatic cancer, a disease with extremely poor prognosis, has been notoriously resistant to virtually all forms of treatment. The dynamic crosstalk that occurs between tumour cells and the surrounding stroma, frequently mediated by intricate Src/FAK signalling, is increasingly recognised as a key player in pancreatic tumourigenesis, disease progression and therapeutic resistance. These important cues are fundamental for defining the invasive potential of pancreatic tumours, and several components of the Src and downstream effector signalling have been proposed as potent anticancer therapeutic targets. Consequently, numerous agents that block this complex network are being extensively investigated as potential antiinvasive and antimetastatic therapeutic agents for this disease. In this review, we will discuss the latest evidence of Src signalling in PDAC progression, fibrotic response and resistance to therapy. We will examine future opportunities for the development and implementation of more effective combination regimens, targeting key components of the oncogenic Src signalling axis, and in the context of a precision medicine-guided approach.
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Affiliation(s)
- Ashleigh Parkin
- The Kinghorn Cancer CentreThe Garvan Institute of Medical ResearchSydneyAustralia
| | - Jennifer Man
- The Kinghorn Cancer CentreThe Garvan Institute of Medical ResearchSydneyAustralia
| | - Paul Timpson
- The Kinghorn Cancer CentreThe Garvan Institute of Medical ResearchSydneyAustralia
- Faculty of MedicineSt Vincent's Clinical SchoolUniversity of NSWSydneyAustralia
| | - Marina Pajic
- The Kinghorn Cancer CentreThe Garvan Institute of Medical ResearchSydneyAustralia
- Faculty of MedicineSt Vincent's Clinical SchoolUniversity of NSWSydneyAustralia
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Hevert EAC, Howser CG, Gould ML, Brown DB. Ablative, Endovascular, and Biliary Interventions for Patients with Pancreatic Cancer. Semin Intervent Radiol 2019; 36:203-212. [PMID: 31435128 DOI: 10.1055/s-0039-1693118] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Interventional radiologists have multiple points of involvement in the treatment and management of patients with pancreatic adenocarcinoma. There is increasing interest in cytoreductive treatment of the primary tumor as well as metastatic disease via arterial and ablative techniques. The focus of this article is on the current evidence for pancreatic irreversible electroporation. For patients undergoing curative surgery or terminal palliation, interventional radiology can manage complications and symptoms. In this article, therapeutic and palliative options in this group of patients including postoperative embolization, biliary drainage, and stent placement are reviewed.
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Affiliation(s)
- Elizabeth Anne C Hevert
- Department of Radiology and Radiologic Sciences, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Collin G Howser
- Department of Radiology and Radiologic Sciences, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Michael L Gould
- Department of Radiology and Radiologic Sciences, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Daniel B Brown
- Department of Radiology and Radiologic Sciences, Vanderbilt University Medical Center, Nashville, Tennessee
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Janssen QP, Buettner S, Suker M, Beumer BR, Addeo P, Bachellier P, Bahary N, Bekaii-Saab T, Bali MA, Besselink MG, Boone BA, Chau I, Clarke S, Dillhoff M, El-Rayes BF, Frakes JM, Grose D, Hosein PJ, Jamieson NB, Javed AA, Khan K, Kim KP, Kim SC, Kim SS, Ko AH, Lacy J, Margonis GA, McCarter MD, McKay CJ, Mellon EA, Moorcraft SY, Okada KI, Paniccia A, Parikh PJ, Peters NA, Rabl H, Samra J, Tinchon C, van Tienhoven G, van Veldhuisen E, Wang-Gillam A, Weiss MJ, Wilmink JW, Yamaue H, Homs MYV, van Eijck CHJ, Katz MHG, Groot Koerkamp B. Neoadjuvant FOLFIRINOX in Patients With Borderline Resectable Pancreatic Cancer: A Systematic Review and Patient-Level Meta-Analysis. J Natl Cancer Inst 2019; 111:782-794. [PMID: 31086963 PMCID: PMC6695305 DOI: 10.1093/jnci/djz073] [Citation(s) in RCA: 200] [Impact Index Per Article: 40.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2018] [Revised: 12/19/2018] [Accepted: 04/22/2019] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND FOLFIRINOX is a standard treatment for metastatic pancreatic cancer patients. The effectiveness of neoadjuvant FOLFIRINOX in patients with borderline resectable pancreatic cancer (BRPC) remains debated. METHODS We performed a systematic review and patient-level meta-analysis on neoadjuvant FOLFIRINOX in patients with BRPC. Studies with BRPC patients who received FOLFIRINOX as first-line neoadjuvant treatment were included. The primary endpoint was overall survival (OS), and secondary endpoints were progression-free survival, resection rate, R0 resection rate, and grade III-IV adverse events. Patient-level survival outcomes were obtained from authors of the included studies and analyzed using the Kaplan-Meier method. RESULTS We included 24 studies (8 prospective, 16 retrospective), comprising 313 (38.1%) BRPC patients treated with FOLFIRINOX. Most studies (n = 20) presented intention-to-treat results. The median number of administered neoadjuvant FOLFIRINOX cycles ranged from 4 to 9. The resection rate was 67.8% (95% confidence interval [CI] = 60.1% to 74.6%), and the R0-resection rate was 83.9% (95% CI = 76.8% to 89.1%). The median OS varied from 11.0 to 34.2 months across studies. Patient-level survival data were obtained for 20 studies representing 283 BRPC patients. The patient-level median OS was 22.2 months (95% CI = 18.8 to 25.6 months), and patient-level median progression-free survival was 18.0 months (95% CI = 14.5 to 21.5 months). Pooled event rates for grade III-IV adverse events were highest for neutropenia (17.5 per 100 patients, 95% CI = 10.3% to 28.3%), diarrhea (11.1 per 100 patients, 95% CI = 8.6 to 14.3), and fatigue (10.8 per 100 patients, 95% CI = 8.1 to 14.2). No deaths were attributed to FOLFIRINOX. CONCLUSIONS This patient-level meta-analysis of BRPC patients treated with neoadjuvant FOLFIRINOX showed a favorable median OS, resection rate, and R0-resection rate. These results need to be assessed in a randomized trial.
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Affiliation(s)
| | - Stefan Buettner
- See the Notes section for the full list of authors’ affiliations
| | - Mustafa Suker
- See the Notes section for the full list of authors’ affiliations
| | - Berend R Beumer
- See the Notes section for the full list of authors’ affiliations
| | - Pietro Addeo
- See the Notes section for the full list of authors’ affiliations
| | | | - Nathan Bahary
- See the Notes section for the full list of authors’ affiliations
| | | | - Maria A Bali
- See the Notes section for the full list of authors’ affiliations
| | - Marc G Besselink
- See the Notes section for the full list of authors’ affiliations
| | - Brian A Boone
- See the Notes section for the full list of authors’ affiliations
| | - Ian Chau
- See the Notes section for the full list of authors’ affiliations
| | - Stephen Clarke
- See the Notes section for the full list of authors’ affiliations
| | - Mary Dillhoff
- See the Notes section for the full list of authors’ affiliations
| | | | - Jessica M Frakes
- See the Notes section for the full list of authors’ affiliations
| | - Derek Grose
- See the Notes section for the full list of authors’ affiliations
| | - Peter J Hosein
- See the Notes section for the full list of authors’ affiliations
| | - Nigel B Jamieson
- See the Notes section for the full list of authors’ affiliations
| | - Ammar A Javed
- See the Notes section for the full list of authors’ affiliations
| | - Khurum Khan
- See the Notes section for the full list of authors’ affiliations
| | - Kyu-Pyo Kim
- See the Notes section for the full list of authors’ affiliations
| | - Song Cheol Kim
- See the Notes section for the full list of authors’ affiliations
| | - Sunhee S Kim
- See the Notes section for the full list of authors’ affiliations
| | - Andrew H Ko
- See the Notes section for the full list of authors’ affiliations
| | - Jill Lacy
- See the Notes section for the full list of authors’ affiliations
| | | | | | - Colin J McKay
- See the Notes section for the full list of authors’ affiliations
| | - Eric A Mellon
- See the Notes section for the full list of authors’ affiliations
| | | | - Ken-Ichi Okada
- See the Notes section for the full list of authors’ affiliations
| | | | - Parag J Parikh
- See the Notes section for the full list of authors’ affiliations
| | - Niek A Peters
- See the Notes section for the full list of authors’ affiliations
| | - Hans Rabl
- See the Notes section for the full list of authors’ affiliations
| | - Jaswinder Samra
- See the Notes section for the full list of authors’ affiliations
| | | | | | | | | | - Matthew J Weiss
- See the Notes section for the full list of authors’ affiliations
| | | | - Hiroki Yamaue
- See the Notes section for the full list of authors’ affiliations
| | | | | | - Matthew H G Katz
- See the Notes section for the full list of authors’ affiliations
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Holland MM, Bhutiani N, Kruse EJ, Weiss MJ, Christein JD, White RR, Huang KW, Martin RCG. A prospective, multi-institution assessment of irreversible electroporation for treatment of locally advanced pancreatic adenocarcinoma: initial outcomes from the AHPBA pancreatic registry. HPB (Oxford) 2019; 21:1024-1031. [PMID: 30737097 DOI: 10.1016/j.hpb.2018.12.004] [Citation(s) in RCA: 43] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2018] [Revised: 12/11/2018] [Accepted: 12/28/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND The optimal treatment and management of locally advanced pancreatic cancer (LAPC) remains unclear and controversial. This study aimed to report the initial outcomes of the AHPBA Registry and evaluate the reproducibility of existing evidence that the addition of Irreversible Electroporation (IRE), a nonthermal ablative treatment, confers survival benefits beyond standard therapeutic options for patients with LAPC. METHODS From December 2015 to October 2017, patients with LAPC were treated with open-technique IRE following the AHPBA Registry Protocols. Patient demographics, long-term outcomes, and adverse events were recorded. Survival analyses were performed using Kaplan-Meier (KM) curves for overall survival (OS), progression free survival (PFS) and time to progression (TTP). RESULTS A total of 152 patients underwent successful IRE. Morbidity and mortality were 18% and 2% respectively, with 19 (13%) patients experiencing severe adverse events. Nine (6%) patients presented with local recurrence. Median TTP, PFS, and OS from diagnosis were 27.3 months, 22.8 months, and 30.7 months respectively. CONCLUSION The combination of IRE with established multiagent therapy is safe and demonstrates encouraging survival among patients with LAPC. IRE is associated with a low rate of serious adverse events and has been optimized for more widespread adoption through the standardized protocols available through the AHPBA registry.
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Affiliation(s)
- Michelle M Holland
- University of Louisville, Hiram C. Polk Jr, MD Department of Surgery, Division of Surgical Oncology, Louisville, KY, USA
| | - Neal Bhutiani
- University of Louisville, Hiram C. Polk Jr, MD Department of Surgery, Division of Surgical Oncology, Louisville, KY, USA
| | - Edward J Kruse
- Augusta University Medical Center, Department of Surgery, Section of Surgical Oncology, Augusta, GA, USA
| | - Matthew J Weiss
- Johns Hopkins University, Department of Surgery, Division of Surgical Oncology, Baltimore, MD, USA
| | - John D Christein
- University of Alabama, Department of Surgery, Division of Gastrointestinal Surgery, Birmingham, AL, USA
| | - Rebekah R White
- University of California San Diego Moores Cancer Center, Gastrointestinal Cancer Unit, San Diego, CA, USA
| | - Kai-Wen Huang
- National Taiwan University Hospital, Department of Surgery, Zhongzheng, Taipei, Taiwan
| | - Robert C G Martin
- University of Louisville, Hiram C. Polk Jr, MD Department of Surgery, Division of Surgical Oncology, Louisville, KY, USA.
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Napolitano F, Formisano L, Giardino A, Girelli R, Servetto A, Santaniello A, Foschini F, Marciano R, Mozzillo E, Carratù AC, Cascetta P, De Placido P, De Placido S, Bianco R. Neoadjuvant Treatment in Locally Advanced Pancreatic Cancer (LAPC) Patients with FOLFIRINOX or Gemcitabine NabPaclitaxel: A Single-Center Experience and a Literature Review. Cancers (Basel) 2019; 11:E981. [PMID: 31337045 PMCID: PMC6678351 DOI: 10.3390/cancers11070981] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2019] [Revised: 07/09/2019] [Accepted: 07/10/2019] [Indexed: 02/07/2023] Open
Abstract
The optimal therapeutic strategy for locally advanced pancreatic cancer patients (LAPC) has not yet been established. Our aim is to evaluate how surgery after neoadjuvant treatment with either FOLFIRINOX (FFN) or Gemcitabine-NabPaclitaxel (GemNab) affects the clinical outcome in these patients. LAPC patients treated at our institution were retrospectively analysed to reach this goal. The group characteristics were similar: 35 patients were treated with the FOLFIRINOX regimen and 21 patients with Gemcitabine Nab-Paclitaxel. The number of patients undergoing surgery was 14 in the FFN group (40%) and six in the GemNab group (28.6%). The median Disease-Free Survival (DFS) was 77.10 weeks in the FFN group and 58.65 weeks in the Gem Nab group (p = 0.625), while the median PFS in the unresected group was 49.4 weeks in the FFN group and 30.9 in the GemNab group (p = 0.0029, 95% CI 0.138-0.862, HR 0.345). The overall survival (OS) in the resected population needs a longer follow up to be completely assessed, while the median overall survival (mOS) in the FFN group was 72.10 weeks and 53.30 weeks for the GemNab group (p = 0.06) in the unresected population. Surgery is a valuable option for LAPC patients and it is able to induce a relevant survival advantage. FOLFIRINOX and Gem-NabPaclitaxel should be offered as first options to pancreatic cancer patients in the locally advanced setting.
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Affiliation(s)
- Fabiana Napolitano
- Department of Clinical Medicine and Surgery, University of Naples "Federico II", 80131 Naples, Italy
| | - Luigi Formisano
- Department of Clinical Medicine and Surgery, University of Naples "Federico II", 80131 Naples, Italy
| | - Alessandro Giardino
- Pancreatic Surgery Unit, Pederzoli Hospital, Peschiera del Garda, 37019 Verona, Italy
| | - Roberto Girelli
- Pancreatic Surgery Unit, Pederzoli Hospital, Peschiera del Garda, 37019 Verona, Italy
| | - Alberto Servetto
- Department of Clinical Medicine and Surgery, University of Naples "Federico II", 80131 Naples, Italy
| | - Antonio Santaniello
- Department of Clinical Medicine and Surgery, University of Naples "Federico II", 80131 Naples, Italy
| | - Francesca Foschini
- Department of Clinical Medicine and Surgery, University of Naples "Federico II", 80131 Naples, Italy
| | - Roberta Marciano
- Department of Clinical Medicine and Surgery, University of Naples "Federico II", 80131 Naples, Italy
| | - Eleonora Mozzillo
- Department of Clinical Medicine and Surgery, University of Naples "Federico II", 80131 Naples, Italy
| | - Anna Chiara Carratù
- Department of Clinical Medicine and Surgery, University of Naples "Federico II", 80131 Naples, Italy
| | - Priscilla Cascetta
- Department of Clinical Medicine and Surgery, University of Naples "Federico II", 80131 Naples, Italy
| | - Pietro De Placido
- Department of Clinical Medicine and Surgery, University of Naples "Federico II", 80131 Naples, Italy
| | - Sabino De Placido
- Department of Clinical Medicine and Surgery, University of Naples "Federico II", 80131 Naples, Italy
| | - Roberto Bianco
- Department of Clinical Medicine and Surgery, University of Naples "Federico II", 80131 Naples, Italy.
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Locally Advanced Pancreatic Cancer: Work-Up, Staging, and Local Intervention Strategies. Cancers (Basel) 2019; 11:cancers11070976. [PMID: 31336859 PMCID: PMC6679311 DOI: 10.3390/cancers11070976] [Citation(s) in RCA: 52] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2019] [Revised: 07/05/2019] [Accepted: 07/09/2019] [Indexed: 12/13/2022] Open
Abstract
Locally advanced pancreatic cancer (LAPC) has several definitions but essentially is a nonmetastasized pancreatic cancer, in which upfront resection is considered not beneficial due to extensive vascular involvement and consequent high chance of a nonradical resection. The introduction of FOLFIRINOX chemotherapy and gemcitabine-nab-paclitaxel (gem-nab) has had major implications for the management and outcome of patients with LAPC. After 4-6 months induction chemotherapy, the majority of patients have stable disease or even tumor-regression. Of these, 12 to 35% are successfully downstaged to resectable disease. Several studies have reported a 30-35 months overall survival after resection; although it currently remains unclear if this is a result of the resection or the good response to chemotherapy. Following chemotherapy, selection of patients for resection is difficult, as contrast-enhanced computed-tomography (CT) scan is unreliable in differentiating between viable tumor and fibrosis. In case a resection is not considered possible but stable disease is observed, local ablative techniques are being studied, such as irreversible electroporation, radiofrequency ablation, and stereotactic body radiation therapy. Pragmatic, multicenter, randomized studies will ultimately have to confirm the exact role of both surgical exploration and ablation in these patients. Since evidence-based guidelines for the management of LAPC are lacking, this review proposes a standardized approach for the treatment of LAPC based on the best available evidence.
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50
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Lee JM, Choi HS, Kim ES, Keum B, Seo YS, Jeen YT, Lee HS, Chun HJ, Um SH, Kim CD, Kim HB. Characterization of irreversible electroporation on the stomach: A feasibility study in rats. Sci Rep 2019; 9:9094. [PMID: 31235753 PMCID: PMC6591231 DOI: 10.1038/s41598-019-45659-1] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2018] [Accepted: 06/11/2019] [Indexed: 12/12/2022] Open
Abstract
Irreversible electroporation (IRE) is a newly developed non-thermal ablative therapy. During the IRE procedure, the permeability of the cell membrane is irreversibly changed by application of high-energy pulses across the tissue. This induces the breakdown of cell homeostasis, and thereby cell death. Here, we present an in vivo study to demonstrate IRE ablation of gastric tissue and characterize the changes that occur with time therein. No significant complications were observed in the test rats during the experiment. The electroporated tissues exhibited apoptosis at 10, 24 and 48 h after IRE ablation. The apoptosis peaked at 10 h after IRE and then declined, suggesting that the ablated tissue rapidly recovered owing to intense metabolic activity. In addition, the electroporated tissues exhibited morphological changes such as pyknosis and karyorrhexis, while histological analysis showed that the blood vessels were preserved. Interestingly, electroporation greatly affected the mucosa and muscularis propria, but not the submucosa and serosa. This study suggests that IRE could potentially be used as a minimally invasive treatment for early gastric cancer that does not exhibit lymph node metastasis or dysplasia.
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Affiliation(s)
- Jae Min Lee
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Korea University College of Medicine, Seoul, 02841, Republic of Korea
| | - Hyuk Soon Choi
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Korea University College of Medicine, Seoul, 02841, Republic of Korea.
| | - Eun Sun Kim
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Korea University College of Medicine, Seoul, 02841, Republic of Korea
| | - Bora Keum
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Korea University College of Medicine, Seoul, 02841, Republic of Korea
| | - Yeon Seok Seo
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Korea University College of Medicine, Seoul, 02841, Republic of Korea
| | - Yoon Tae Jeen
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Korea University College of Medicine, Seoul, 02841, Republic of Korea
| | - Hong Sik Lee
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Korea University College of Medicine, Seoul, 02841, Republic of Korea
| | - Hoon Jai Chun
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Korea University College of Medicine, Seoul, 02841, Republic of Korea
| | - Soon Ho Um
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Korea University College of Medicine, Seoul, 02841, Republic of Korea
| | - Chang Duck Kim
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Korea University College of Medicine, Seoul, 02841, Republic of Korea
| | - Hong Bae Kim
- Department of Biosystems & Biomaterials Science and Engineering, Seoul National University, Seoul, 08826, Republic of Korea
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