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Wu HY, Li JW, Li JZ, Zhai QL, Ye JY, Zheng SY, Fang K. Comprehensive multimodal management of borderline resectable pancreatic cancer: Current status and progress. World J Gastrointest Surg 2023; 15:142-162. [PMID: 36896309 PMCID: PMC9988647 DOI: 10.4240/wjgs.v15.i2.142] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Revised: 11/23/2022] [Accepted: 01/12/2023] [Indexed: 02/27/2023] Open
Abstract
Borderline resectable pancreatic cancer (BRPC) is a complex clinical entity with specific biological features. Criteria for resectability need to be assessed in combination with tumor anatomy and oncology. Neoadjuvant therapy (NAT) for BRPC patients is associated with additional survival benefits. Research is currently focused on exploring the optimal NAT regimen and more reliable ways of assessing response to NAT. More attention to management standards during NAT, including biliary drainage and nutritional support, is needed. Surgery remains the cornerstone of BRPC treatment and multidisciplinary teams can help to evaluate whether patients are suitable for surgery and provide individualized management during the perioperative period, including NAT responsiveness and the selection of surgical timing.
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Affiliation(s)
- Hong-Yu Wu
- Department of Hepatobiliary Surgery, The Second Affiliated Hospital of Chongqing Medical University, Chongqing 400010, China
| | - Jin-Wei Li
- Department of Neurosurgery, The Fourth Affiliated Hospital of Guangxi Medical University, Liuzhou 545000, Guangxi Province, China
| | - Jin-Zheng Li
- Department of Hepatobiliary Surgery, The Second Affiliated Hospital of Chongqing Medical University, Chongqing 400010, China
| | - Qi-Long Zhai
- Department of Hepatobiliary Surgery, The Second Affiliated Hospital of Chongqing Medical University, Chongqing 400010, China
| | - Jing-Yuan Ye
- Department of Hepatobiliary Surgery, The Second Affiliated Hospital of Chongqing Medical University, Chongqing 400010, China
| | - Si-Yuan Zheng
- Department of Hepatobiliary Surgery, The Second Affiliated Hospital of Chongqing Medical University, Chongqing 400010, China
| | - Kun Fang
- Department of Surgery, Yinchuan Maternal and Child Health Hospital, Yinchuan 750000, Ningxia, China
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2
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Eresen A, Zhou K, Sun C, Shangguan J, Wang B, Pan L, Hu S, Pang Y, Zhang Z, Tran RMN, Bhatia AP, Nouizi F, Abi-Jaoudeh N, Yaghmai V, Zhang Z. Early assessment of irreversible electroporation ablation outcomes by analyzing MRI texture: preclinical study in an animal model of liver tumor. Am J Transl Res 2022; 14:5541-5551. [PMID: 36105031 PMCID: PMC9452330] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Accepted: 06/22/2022] [Indexed: 01/05/2023]
Abstract
OBJECTIVES Accurate differentiation of temporary vs. permanent changes occurring following irreversible electroporation (IRE) holds immense importance for the early assessment of ablative treatment outcomes. Here, we investigated the benefits of advanced statistical learning models for an immediate evaluation of therapeutic outcomes by interpreting quantitative characteristics captured with conventional MRI. METHODS The preclinical study integrated twenty-six rabbits with anatomical and perfusion MRI data acquired with a 3T clinical MRI scanner. T1w and T2w MRI data were quantitatively analyzed, and forty-six quantitative features were computed with four feature extraction methods. The candidate key features were determined by graph clustering following the filtering-based feature selection technique, RELIEFF algorithm. Kernel-based support vector machines (SVM) and random forest (RF) classifiers interpreting quantitative features of T1w, T2w, and combination (T1w+T2w) MRI were developed for replicating the underlying characteristics of the tissues to distinguish IRE ablation regions for immediate assessment of treatment response. Accuracy, sensitivity, specificity, and area under the receiver operating characteristics curve were used to evaluate classification performance. RESULTS Following the analysis of quantitative variables, three features were integrated to develop a SVM classification model, while five features were utilized for generating RF classifiers. SVM classifiers demonstrated detection accuracy of 91.06%, 96.15%, and 98.04% for individual and combination MRI data, respectively. Besides, RF classifiers obtained slightly lower accuracy compared to SVM which were 95.06%, 89.40%, and 94.38% respectively. CONCLUSIONS Quantitative models integrating structural characteristics of conventional T1w and T2w MRI data with statistical learning techniques identified IRE ablation regions allowing early assessment of treatment status.
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Affiliation(s)
- Aydin Eresen
- Department of Radiology, Feinberg School of Medicine, Northwestern UniversityChicago, IL, USA,Department of Radiological Sciences, University of California IrvineIrvine, CA, USA
| | - Kang Zhou
- Department of Radiology, Feinberg School of Medicine, Northwestern UniversityChicago, IL, USA,Department of Radiology, Peking Union Medical College HospitalBeijing 100000, China
| | - Chong Sun
- Department of Radiology, Feinberg School of Medicine, Northwestern UniversityChicago, IL, USA,Department of Orthopedics, Affiliated Hospital of Qingdao UniversityQingdao 266000, Shandong, China
| | - Junjie Shangguan
- Department of Radiology, Feinberg School of Medicine, Northwestern UniversityChicago, IL, USA
| | - Bin Wang
- Department of Radiology, Feinberg School of Medicine, Northwestern UniversityChicago, IL, USA,Department of General Surgery, Nanfang Hospital, Southern Medical UniversityGuangzhou 510000, Guangdong, China
| | - Liang Pan
- Department of Radiology, Feinberg School of Medicine, Northwestern UniversityChicago, IL, USA,Department of Radiology, Third Affiliated Hospital of Suzhou UniversityChangzhou 213000, Jiangsu, China
| | - Su Hu
- Department of Radiology, Feinberg School of Medicine, Northwestern UniversityChicago, IL, USA,Department of Radiology, First Affiliated Hospital of Soochow UniversitySuzhou 215000, Jiangsu, China
| | - Yongsheng Pang
- Department of Radiological Sciences, University of California IrvineIrvine, CA, USA
| | - Zigeng Zhang
- Department of Radiological Sciences, University of California IrvineIrvine, CA, USA
| | | | - Ajeet Pal Bhatia
- Department of Radiological Sciences, University of California IrvineIrvine, CA, USA
| | - Farouk Nouizi
- Department of Radiological Sciences, University of California IrvineIrvine, CA, USA,Chao Family Comprehensive Cancer Center, University of California IrvineIrvine, CA, USA
| | - Nadine Abi-Jaoudeh
- Department of Radiological Sciences, University of California IrvineIrvine, CA, USA,Chao Family Comprehensive Cancer Center, University of California IrvineIrvine, CA, USA
| | - Vahid Yaghmai
- Department of Radiological Sciences, University of California IrvineIrvine, CA, USA,Chao Family Comprehensive Cancer Center, University of California IrvineIrvine, CA, USA
| | - Zhuoli Zhang
- Department of Radiology, Feinberg School of Medicine, Northwestern UniversityChicago, IL, USA,Department of Radiological Sciences, University of California IrvineIrvine, CA, USA,Chao Family Comprehensive Cancer Center, University of California IrvineIrvine, CA, USA,Robert H. Lurie Comprehensive Cancer Center of Northwestern UniversityChicago, IL, USA,Department of Biomedical Engineering, University of California IrvineIrvine, CA, USA,Department of Pathology and Laboratory Medicine, University of California IrvineIrvine, CA, USA
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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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Rai ZL, Feakins R, Pallett LJ, Manas D, Davidson BR. Irreversible Electroporation (IRE) in Locally Advanced Pancreatic Cancer: A Review of Current Clinical Outcomes, Mechanism of Action and Opportunities for Synergistic Therapy. J Clin Med 2021; 10:1609. [PMID: 33920118 PMCID: PMC8068938 DOI: 10.3390/jcm10081609] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2021] [Revised: 04/04/2021] [Accepted: 04/07/2021] [Indexed: 12/11/2022] Open
Abstract
Locally advanced pancreatic cancer (LAPC) accounts for 30% of patients with pancreatic cancer. Irreversible electroporation (IRE) is a novel cancer treatment that may improve survival and quality of life in LAPC. This narrative review will provide a perspective on the clinical experience of pancreas IRE therapy, explore the evidence for the mode of action, assess treatment complications, and propose strategies for augmenting IRE response. A systematic search was performed using PubMed regarding the clinical use and safety profile of IRE on pancreatic cancer, post-IRE sequential histological changes, associated immune response, and synergistic therapies. Animal data demonstrate that IRE induces both apoptosis and necrosis followed by fibrosis. Major complications may result from IRE; procedure related mortality is up to 2%, with an average morbidity as high as 36%. Nevertheless, prospective and retrospective studies suggest that IRE treatment may increase median overall survival of LAPC to as much as 30 months and provide preliminary data justifying the well-designed trials currently underway, comparing IRE to the standard of care treatment. The mechanism of action of IRE remains unknown, and there is a lack of data on treatment variables and efficiency in humans. There is emerging data suggesting that IRE can be augmented with synergistic therapies such as immunotherapy.
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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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Shangguan AJ, Zhou K, Yang J, Eresen A, Wang B, Sun C, Pan L, Hu S, Khan AT, Mouli SK, Yaghmai V, Zhang Z. Intraprocedural Transcatheter Intraarterial Perfusion (TRIP)-MRI for Evaluation of Irreversible Electroporation Therapy Response in a Rabbit Liver Tumor Model. Clin Exp Gastroenterol 2020; 13:543-553. [PMID: 33192084 PMCID: PMC7654546 DOI: 10.2147/ceg.s269163] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2020] [Accepted: 09/24/2020] [Indexed: 12/22/2022] Open
Abstract
Purpose Irreversible electroporation (IRE) is a promising new ablation method for hepatocellular carcinoma (HCC) treatment with few side-effects; however, tissue perfusion and differentiation between treatment zones have not been sufficiently studied. In this project, we analyzed HCC tumor perfusion changes immediately after IRE treatment using transcatheter intraarterial perfusion (TRIP)-MRI to monitor treatment zone margins. Materials and Methods All protocols were approved by the institutional animal care and use committee. A total of 34 rabbits were used for this prospective study: tumor liver group (n=17), normal liver group (n=14), and 3 for growing VX2 tumors. All procedures and imaging were performed under anesthesia. VX2 tumors were grown by injection of VX2 cells into rabbit hindlimbs. Liver tumors were induced by percutaneous US-guided injection of VX2 tumor fragments into liver. For digital subtraction angiography (DSA), a 2F catheter was advanced through left hepatic artery via femoral artery access, followed by contrast injection. All rabbits underwent baseline anatomic MRI, then IRE procedure or IRE probe placement only, and lastly post-procedure anatomic and TRIP-MRI. Liver tissues were dissected immediately after imaging for histology. All statistical analyses were performed on GraphPad Prism, with P<0.05 considered significant. Results IRE generated central IRE zone and peripheral reversible electroporation (RE) zone on anatomic MRI for both normal liver and liver tumor tissues. The semiquantitative analysis showed that IRE zone had the lowest AUC, PE, WIS, Ktrans, ve , and vp as well as the highest TTP, followed by RE zone, then untreated tissues. Receiver operating characteristic analysis showed that WIS and AUC60 had the highest AUCROC. Histologic analysis showed a positive correlation in viable area fraction between MRI and histologic measurements. IRE zone had the highest %apoptosis and lowest CD31+ staining. Conclusion Our results demonstrated that intraprocedural TRIP-MRI can effectively differentiate IRE and RE zones after IRE ablation in normal liver and liver tumor tissues.
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Affiliation(s)
- Anna J Shangguan
- Department of Radiology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Kang Zhou
- Department of Radiology, Peking Union Medical College Hospital, Peking Union Medical College, Beijing, People's Republic of China
| | - Jia Yang
- Department of Radiology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Aydin Eresen
- Department of Radiology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Bin Wang
- Department of General Surgery, Nanfang Hospital, Southern Medical University, Guangdong Provincial Engineering Technology Research Center of Minimally Invasive Surgery, Guangzhou, People's Republic of China
| | - Chong Sun
- Department of Orthopedics, Affiliated Hospital of Qingdao University, Qingdao, Shandong, People's Republic of China
| | - Liang Pan
- Department of Radiology, Third Affiliated Hospital of Suzhou University, Changzhou, Jiangsu, People's Republic of China
| | - Su Hu
- Department of Radiology, First Affiliated Hospital of Soochow University, Suzhou, Jiangsu, People's Republic of China
| | - Ali T Khan
- Department of Radiology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Samdeep K Mouli
- Department of Radiology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Vahid Yaghmai
- Department of Radiological Sciences, School of Medicine, University of California Irvine, Irvine, CA, USA
| | - Zhuoli Zhang
- Department of Radiology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
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6
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Moris D, Machairas N, Tsilimigras DI, Prodromidou A, Ejaz A, Weiss M, Hasemaki N, Felekouras E, Pawlik TM. Systematic Review of Surgical and Percutaneous Irreversible Electroporation in the Treatment of Locally Advanced Pancreatic Cancer. Ann Surg Oncol 2019; 26:1657-1668. [PMID: 30843163 DOI: 10.1245/s10434-019-07261-7] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2018] [Indexed: 02/06/2023]
Abstract
OBJECTIVE The aim of the present systematic review was to collect, analyze, and critically evaluate the role of irreversible electroporation (IRE) in locally advanced pancreatic cancer (LAPC). Furthermore, we sought to analyze the different approaches of IRE (open, laparoscopic, and percutaneous) and assess the relative outcomes. METHODS A systematic review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Using the MEDLINE (1966-2018), Scopus (2004-2018), Google Scholar (2004-2018) and ClinicalTrials.gov databases, eligible articles published up to August 2018 were included. The following keywords were applied: 'irreversible electroporation', 'IRE', 'LAPC', 'unresectable pancreatic cancer', 'palliative treatment', 'locally advanced pancreatic cancer', 'ablation' and 'ablative treatment'. RESULTS IRE for LAPC was feasible and safe; however, it was associated with morbidity in approximately one in three patients, some of whom experienced serious complications, particularly after surgical IRE. In addition, while mortality following IRE was uncommon, it did occur in 2% of patients. While some studies suggested a survival benefit, others failed to note an improvement in long-term outcomes following IRE compared with other therapies. CONCLUSIONS Providers and patients need to be aware of the potential morbidity and mortality associated with IRE. In addition, based on the literature to date, the survival benefit of IRE for LAPC remains to be elucidated. Conclusive and definitive evidence to support a survival benefit of IRE does not currently exist. Future multicenter, randomized, prospective trials are needed to clarify the role of IRE in patients with LAPC.
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Affiliation(s)
- Dimitrios Moris
- Department of Surgery, The Urban Meyer III and Shelley Meyer Chair for Cancer Research, Wexner Medical Center, James Cancer Hospital and Solove Research Institute, The Ohio State University, Columbus, OH, USA.,Department of Surgery, Duke University Medical Center, Durham, NC, USA
| | - Nikolaos Machairas
- First Department of Surgery, Laikon General Hospital, University of Athens Medical School, Athens, Greece
| | - Diamantis I Tsilimigras
- Department of Surgery, The Urban Meyer III and Shelley Meyer Chair for Cancer Research, Wexner Medical Center, James Cancer Hospital and Solove Research Institute, The Ohio State University, Columbus, OH, USA.,First Department of Surgery, Laikon General Hospital, University of Athens Medical School, Athens, Greece
| | - Anastasia Prodromidou
- First Department of Surgery, Laikon General Hospital, University of Athens Medical School, Athens, Greece
| | - Aslam Ejaz
- Department of Surgery, The Urban Meyer III and Shelley Meyer Chair for Cancer Research, Wexner Medical Center, James Cancer Hospital and Solove Research Institute, The Ohio State University, Columbus, OH, USA
| | - Matthew Weiss
- Department of Surgery, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Natasha Hasemaki
- First Department of Surgery, Laikon General Hospital, University of Athens Medical School, Athens, Greece
| | - Evangelos Felekouras
- First Department of Surgery, Laikon General Hospital, University of Athens Medical School, Athens, Greece
| | - Timothy M Pawlik
- Department of Surgery, The Urban Meyer III and Shelley Meyer Chair for Cancer Research, Wexner Medical Center, James Cancer Hospital and Solove Research Institute, The Ohio State University, Columbus, OH, USA.
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