Open radiofrequency ablation as upfront treatment for locally advanced pancreatic cancer: Requiem from a randomized controlled trial

Endoscopic Ultrasound-Guided Radiofrequency Ablation for Pancreatic Adenocarcinoma: A Scoping Review with Meta-Analysis

Background: Endoscopic ultrasound-guided radiofrequency ablation (EUS-RFA) has recently been proposed as an alternative treatment option for patients with unresectable pancreatic adenocarcinoma (uPDAC) or metastatic pancreatic adenocarcinoma (mPDAC). This review aims to evaluate the technical feasibility, safety, and clinical outcomes of EUS-RFA in treating PDAC, based on the available literature. Methods: Following the PRISMA-DTA guidelines, a comprehensive search of databases, including PubMed, Scopus, and the Cochrane Library, was conducted, focusing on studies reporting on EUS-RFA for PDAC. Articles involving human subjects diagnosed with PDAC and treated with EUS-RFA, written in English, and published up to 30 June 2024, were included. Key outcome measures such as technical success rate, adverse events, tumor response, and patient survival were extracted and analyzed. The review process involved title and abstract screening, followed by full-text review. A meta-analysis was performed for adverse event rates using a random-effects model. Results: We identified 11 studies according to our inclusion criteria, with a total of 137 patients with PDAC. Except for the initial experience with a lower technical success rate due to tumor-related stiffness, all subsequent studies reported a pooled success rate of 100%. Most studies referred to locally advanced or metastatic PDAC, while one reported EUS-RFA in resectable PDAC. A meta-analysis for adverse events was performed, indicating a pooled adverse event rate of 22.6% (95% confidence interval: 0.16-0.30), with the most common adverse event being mild abdominal pain. Severe complications were rare. One study reported a median progression-free survival (PFS) of 16.3 months. Overall survival and PFS were scarcely reported, with median overall survival ranging from 12 to 24 months, inferior to that of the standard approach for uPDAC consisting of neoadjuvant chemoradiotherapy followed by surgery. Conclusions: EUS-RFA is a technically feasible and safe procedure for treating uPDAC or mPDAC and is under investigation for use in resectable PDAC. Even though the short-term outcomes are encouraging, larger cohort studies are necessary to understand long-term efficacy and survival benefits, including progression-free survival.

Reducing the incidence of pancreatic cancer through radiofrequency ablation of mucinous cystic neoplasms: What is the evidence?

Pancreatic cystic lesions are mostly discovered incidentally during cross-sectional imaging for other indications. They range from benign cysts to premalignant lesions, posing a risk for development of pancreatic cancer. Surveillance of cysts with low-risk features and surgical resection of high-risk ones has been the standard of care. However, the lack of consensus between national society guidelines results in discordant management and follow-up. One of the upcoming therapeutic modalities for pancreatic cysts, including mucinous cystic neoplasms (MCN), is endoscopic ultrasound (EUS)-guided interventions, including injection of chemotherapeutic agents or EUS-guided radiofrequency ablation (EUS-RFA). EUS-RFA is emerging as a promising minimally invasive tool with the need for further investigation to understand its clinical utility. This review discusses the physiology, clinical studies, adverse events, and future perspectives of RFA for various pancreatic lesions, with particular regard with MCN.

Local ablation disrupts immune evasion in pancreatic cancer

BACKGROUND

Pancreatic cancer (PC) is characterised by late diagnosis, tumour heterogeneity, and a peculiar immunosuppressive microenvironment, leading to poor clinical outcomes. Local ablative techniques have been proposed to treat unresectable PC patients, although their impact on activating the host immune system and overcoming resistance to immunotherapy remains elusive.

METHODS

We dissected the immune-modulatory abilities triggered by local ablation in mouse and human PC models and human specimens, integrating phenotypic and molecular technologies with functional assays.

RESULTS

Local ablation treatment performed in mice bearing orthotopic syngeneic PC tumours triggered tumour necrosis and a short-term inflammatory process characterised by the prompt increase of HMGB1 plasma levels, coupled with an enhanced amount of circulating and tumour infiltrating myeloid cells and increased MHCII expression in splenic myeloid antigen-presenting cells. Local ablation synergised with immunotherapy to restrict tumour progression and improved the survival of PC-bearing mice by evoking a T lymphocyte-dependent anti-tumour immune response. By integrating spatial transcriptomics with histological techniques, we pinpointed how combination therapy could reshape TME towards an anti-tumour milieu characterised by the preferential entrance and colocalization of activated T lymphocytes and myeloid cells endowed with antigen presentation features instead of T regulatory lymphocytes and CD206-expressing tumour-associated macrophages. In addition, treatment-dependent TME repolarization extended to neoplastic cells, promoting a shift from squamous to a more differentiated classical phenotype. Finally, we validated the immune regulatory properties induced by local ablation in PC patients and identified an association of the short-term treatment-dependent increase of neutrophils, NLR and HMGB1 with a longer time to progression.

CONCLUSION

Therefore, local ablation might overcome the current limitations of immunotherapy in PC.

Preoperative chemotherapy, radiotherapy and surgical decision-making in patients with borderline resectable and locally advanced pancreatic cancer

Surgical resection combined with systemic chemotherapy is the cornerstone of treatment for patients with localized pancreatic cancer. Upfront surgery is considered suboptimal in cases with extensive vascular involvement, which can be classified as either borderline resectable pancreatic cancer or locally advanced pancreatic cancer. In these patients, FOLFIRINOX or gemcitabine plus nab-paclitaxel chemotherapy is currently used as preoperative chemotherapy and is eventually combined with radiotherapy. Thus, more patients might reach 5-year overall survival. Patient selection for chemotherapy, radiotherapy and subsequent surgery is based on anatomical, biological and conditional parameters. Current guidelines and clinical practices vary considerably regarding preoperative chemotherapy and radiotherapy, response evaluation, and indications for surgery. In this Review, we provide an overview of the clinical evidence regarding disease staging, preoperative therapy, response evaluation and surgery in patients with borderline resectable pancreatic cancer or locally advanced pancreatic cancer. In addition, a clinical work-up is proposed based on the available evidence and guidelines. We identify knowledge gaps and outline a proposed research agenda.

Local ablative therapies and the effect on antitumor immune responses in pancreatic cancer - A review

Pancreatic ductal adenocarcinoma (PDAC) is a devastating disease, projected to rank as the second most prevalent cause of cancer-related mortality by 2030. Despite significant progress in advances in surgical techniques and chemotherapy protocols, the overall survival (OS) remains to be less than 10 % for all stages combined. In recent years, local ablative techniques have been introduced and utilized as additional therapeutic approaches for locally advanced pancreatic cancer (LAPC), with promising results with respect to local tumor control and OS. In addition to successful cytoreduction, there is emerging evidence that local ablation induces antitumor immune activity that could prevent or even treat distant metastatic tumors. The enhancement of antitumor immune responses could potentially make ablative therapy a therapeutic option for the treatment of metastatic PDAC. In this review, we summarize current ablative techniques used in the management of LAPC and their impact on systemic immune responses.

A novel nomogram and risk classification system based on inflammatory and immune indicators for predicting prognosis of pancreatic cancer patients with liver metastases

BACKGROUND

The study determined to construct a novel predictive nomogram to access the prognosis of pancreatic cancer patients with liver metastases (PCLM).

METHODS

Medical records included clinical and laboratory variables were collected. The patients were randomly divided into training and validation cohort. First, in the training cohort, the optimal cutoff value of SII, PNI, NLR, PLR were obtained. Then the survival analysis evaluated the effects of above indices on OS. Next, univariate and multivariate analyses were used to identify the independent factors of OS. Moreover, a nomogram was constructed based on LASSO cox analysis. Additionally, the predictive efficacy of the nomogram was evaluated by ROC curve and calibration curve in the training and validation cohort. Finally, a risk stratification system based on the nomogram was performed.

RESULTS

A total of 472 PCLM patients were enrolled in the study. The optimal cutoff values of SII, PNI, PLR and NLR were 372, 43.6, 285.7143 and 1.48, respectively. By combing SII and PNI, named coSII-PNI, we divided the patients into three groups. The Kaplan-Meier curves demonstrated above indices were correlated with OS. Univariate and multivariate analyses found the independent prognostic factors of OS. Through LASSO cox analysis, coSII-PNI, PNI, NLR, CA199, CEA, chemotherapy and gender were used to construct the nomogram. Lastly, the ROC curve and calibration curve demonstrated that the nomogram can predict prognosis of PCLM patients. Significant differences were observed between high and low groups.

CONCLUSIONS

The nomogram based on immune, inflammation, nutritional status and other clinical factors can accurately predict OS of PCLM patients.

State-of-the-Art and Upcoming Innovations in Pancreatic Cancer Care: A Step Forward to Precision Medicine

Pancreatic cancer remains a social and medical burden despite the tremendous advances that medicine has made in the last two decades. The incidence of pancreatic cancer is increasing, and it continues to be associated with high mortality and morbidity rates. The difficulty of early diagnosis (the lack of specific symptoms and biomarkers at early stages), the aggressiveness of the disease, and its resistance to systemic therapies are the main factors for the poor prognosis of pancreatic cancer. The only curative treatment for pancreatic cancer is surgery, but the vast majority of patients with pancreatic cancer have advanced disease at the time of diagnosis. Pancreatic surgery is among the most challenging surgical procedures, but recent improvements in surgical techniques, careful patient selection, and the availability of minimally invasive techniques (e.g., robotic surgery) have dramatically reduced the morbidity and mortality associated with pancreatic surgery. Patients who are not candidates for surgery may benefit from locoregional and systemic therapy. In some cases (e.g., patients for whom marginal resection is feasible), systemic therapy may be considered a bridge to surgery to allow downstaging of the cancer; in other cases (e.g., metastatic disease), systemic therapy is considered the standard approach with the goal of prolonging patient survival. The complexity of patients with pancreatic cancer requires a personalized and multidisciplinary approach to choose the best treatment for each clinical situation. The aim of this article is to provide a literature review of the available treatments for the different stages of pancreatic cancer.

Thermal ablation in pancreatic cancer: A scoping review of clinical studies

Background

Pancreatic cancer is a deadly cancer with a 5-year survival rate less than 10%. Only 20% of patients are eligible to receive surgery at diagnosis. Hence, new therapies are needed to improve outcomes for non-surgical candidates. Thermal ablation techniques can offer a non-invasive alternative to surgery.

Aim

The aim of this review is to map the literature for the use of thermal ablative techniques: Radiofrequency ablation (RFA), High-intensity focused ultrasound (HIFU), Microwave ablation (MWA), and Laser ablation (LA) in the management of patients with PC.

Methods

A search strategy was applied to PUBMED and EMBASE using keywords concerning pancreatic cancer, radiofrequency ablation, ultrasound ablation, laser ablation, and microwave ablation. The studies that fit this inclusion criteria were summarized in table format and results reviewed for interpretation.

Results

72 clinical studies were included. Most of the included studies related to RFA (n=35) and HIFU (n=27). The most common study design was retrospective (n=33). Only 3 randomized control trials (RCT) were included, all of which related to RFA. Safety outcomes were reported in 53 of the 72 studies, and survival outcomes were reported in 39. Statistically significant survival benefits were demonstrated in 11 studies.

Conclusion

The evidence for the benefit of MWA and LA in PC patients is limited. RFA and HIFU are safe and feasible therapies to be used in PC patients. Further RCTs where thermal techniques are standardized and reported are necessary in the future to elucidate thermal ablation's clinical utility, and before an evidence-based decision on its routine use in PC management can be considered.

Pancreatic Cancer: Challenges and Opportunities in Locoregional Therapies

Simple Summary

Pancreatic cancer is a serious ongoing global health burden, with an overall 5-year survival rate of less than 5%. One major hurdle in the treatment of this disease is the predominantly elderly patient population, leading to their ineligibility for curative surgery and a low rate of successful outcomes. Systemic administration introduces chemo-agents throughout the body via the blood, attacking not only tumours but also healthy organs. When localised interventions are employed, chemo-agents are retained specifically at tumour site, minimizing unwanted toxicity. As a result, there is a growing interest in finding novel localised interventions as alternatives to systemic therapy. Here, we present a detailed review of current locoregional therapies used in pancreatic cancer therapy. This work aims to present a thorough guide for researchers and clinicians intended to employ established and novel localised interventions in the treatment of pancreatic cancer. Furthermore, we present our insights and opinions on the potential ideals to improve these tools.

Abstract

Pancreatic cancer (PC) remains the seventh leading cause of cancer-related deaths worldwide and the third in the United States, making it one of the most lethal solid malignancies. Unfortunately, the symptoms of this disease are not very apparent despite an increasing incidence rate. Therefore, at the time of diagnosis, 45% of patients have already developed metastatic tumours. Due to the aggressive nature of the pancreatic tumours, local interventions are required in addition to first-line treatments. Locoregional interventions affect a specific area of the pancreas to minimize local tumour recurrence and reduce the side effects on surrounding healthy tissues. However, compared to the number of new studies on systemic therapy, very little research has been conducted on localised interventions for PC. To address this unbalanced focus and to shed light on the tremendous potentials of locoregional therapies, this work will provide a detailed discussion of various localised treatment strategies. Most importantly, to the best of our knowledge, the aspect of localised drug delivery systems used in PC was unprecedentedly discussed in this work. This review is meant for researchers and clinicians considering utilizing local therapy for the effective treatment of PC, providing a thorough guide on recent advancements in research and clinical trials toward locoregional interventions, together with the authors’ insight into their potential improvements.

Impact of Endoluminal Radiofrequency Ablation on Immunity in Pancreatic Cancer and Cholangiocarcinoma

Radiofrequency ablation (RFA) is a mini-invasive loco-regional ablation technique that is increasingly being used as a palliative treatment for pancreatic cancer and cholangiocarcinoma. Ablation-triggered immune system stimulation has been proposed as a mechanism behind the systemic effects of RFA. The aim of our study was to investigate the immune response to endoluminal biliary RFA. Peripheral blood samples were collected from patients with pancreatic cancer and cholangiocarcinoma randomised to receive endoluminal biliary radiofrequency ablation + stent (19 patients) or stent only (21 patients). We observed an early increase in IL-6 levels and a delayed increase in CXCL1, CXCL5, and CXCL11 levels as well as an increase in CD8+ and NK cells. However, these changes were not specific to RFA treatment. Explicitly in response to RFA, we observed a delayed increase in serum CXCL1 levels and an early decrease in the number of anti-inflammatory CD206+ blood monocytes. Our study provides the first evidence of endoluminal biliary RFA-based regulation of the systemic immune response in patients with pancreatic cancer and cholangiocarcinoma. These changes were characterised by a general inflammatory response. RFA-specific activation of the adaptive immune system was not confirmed.