1
|
Черных ТМ, Малюгин ДА, Хачатуров МВ, Шефер АА, Золоедов ВИ. [Current views on the treatment of insulinoma]. PROBLEMY ENDOKRINOLOGII 2024; 70:46-55. [PMID: 38433541 PMCID: PMC10926244 DOI: 10.14341/probl13281] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/19/2023] [Revised: 07/06/2023] [Accepted: 07/20/2023] [Indexed: 03/05/2024]
Abstract
RELEVANCE Insulinoma is the most common hormonally active neuroendocrine tumor (NET) of the pancreas. In recent years, there has been a trend towards an increase in the incidence of NET especially insulinoma. AIM Summarizing and analyzing current data on various approaches to the treatment of insulinoma. Our review includes a comprehensive assessment of the advantages and disadvantages of currently available insulinoma treatment methods in comparison with past experience, as well as a review of promising methods that are not currently widely used. MATERIALS AND METHODS Analysis of literature from such databases as scientific electronic library elibrary.ru, Pubmed, Google Scholar, MedLine, Scopus and Web of Science. RESULTS The most common treatment for insulinoma is surgery. For patients with high operative risk, alternative methods such as alcohol ablation, radiofrequency ablation, and tumor embolization may be used. Medications include the use of somatostatin analogues, diazoxide. The literature describes the potential benefit of the use of beta-blockers, phenytoin, glucagon, however, in clinical trials, these drugs have not demonstrated a significant effect. For the treatment of malignant and metastatically advanced insulinoma, targeted therapy (primarily Everolimus), chemotherapy, as well as embolization (including chemoembolization, radioembolization), radiofrequency ablation (RFA), microwave ablation and cryoablation, ultrasound ablation (HIFU), laser ablation, brachytherapy, irreversible electroporation are used. CONCLUSION The study of new drugs is an important task for scientists, among medications the most promising are new generations of somatostatin analogues, targeted drugs and chemotherapy drugs. The rare frequency of insulinoma makes it difficult to conduct randomized controlled trials and prospective studies. That is why physicians and scientists need to maintain close contacts with each other and take into account the experience of treating each patient with such disease, which will help develop effective treatment algorithms in the future.
Collapse
Affiliation(s)
- Т. М. Черных
- Воронежский государственный медицинский университет им. Н.Н. Бурденко
| | - Д. А. Малюгин
- Воронежский государственный медицинский университет им. Н.Н. Бурденко
| | - М. В. Хачатуров
- Первый московский государственный медицинский университет им. И.М. Сеченова
| | - А. А. Шефер
- Воронежский государственный медицинский университет им. Н.Н. Бурденко
| | - В. И. Золоедов
- Воронежский государственный медицинский университет им. Н.Н. Бурденко
| |
Collapse
|
2
|
Dhar J, Samanta J, Nabi Z, Aggarwal M, Facciorusso A, Conti Bellocchi MC, Crinò SF. Endoscopic ultrasound-guided radiofrequency ablation of pancreatic insulinoma: a state of the art review. Expert Rev Gastroenterol Hepatol 2024; 18:37-53. [PMID: 38383965 DOI: 10.1080/17474124.2024.2321938] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2023] [Accepted: 02/19/2024] [Indexed: 02/23/2024]
Abstract
INTRODUCTION Insulinomas are the most common functional pancreatic neuroendocrine tumors (PNETs) that lead to incapacitating hypoglycemia. Guidelines recommend surgical resection as the mainstay of management. However, surgery is fraught with complications, causing significant peri/post-operative morbidity. Since insulinomas are usually benign, solitary, small (<2 cm), and do not need lymphadenectomy, hence, in this regard, endoscopic ultrasound-guided radiofrequency ablation (EUS-RFA) is now being increasingly performed, to circumvent these adverse events and impairment of pancreatic function. AREAS COVERED A comprehensive literature search was undertaken across various databases (PubMed/MEDLINE, Embase, Scopus), with no language restriction, for relevant articles (case series, reviews, case reports) pertaining to EUS-RFA for insulinoma and PNETs, till October 2023. In this review, we have explicated the role of EUS-RFA for insulinoma management, detailing thoroughly its mechanism of action, EUS-RFA devices with data on its safety and efficacy, and an algorithmic approach for its management. EXPERT OPINION EUS-RFA is being advocated as a 'mini-invasive' option with the potential to replace surgery as a first-line approach for benign, sporadic, solitary, and small (<2 cm) insulinomas. Under real-time guidance, EUS-RFA has immense precision, is safe, predictable, with acceptable safety profile. Presently, it is being frequently performed for high-risk or inoperable candidates. Current need-of-the-hour is a randomized controlled trial to substantiate its role in the therapeutic algorithm for insulinoma management.
Collapse
Affiliation(s)
- Jahnvi Dhar
- Department of Gastroenterology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Jayanta Samanta
- Department of Gastroenterology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Zaheer Nabi
- Department of Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, India
| | - Manik Aggarwal
- Department of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - Antonio Facciorusso
- Department Medical and Surgical Sciences, University of Foggia, Foggia, Italy
| | - Maria Cristina Conti Bellocchi
- Diagnostic and Interventional Endoscopy of the Pancreas, The Pancreas Institute, University Hospital of Verona, Verona, Italy
| | - Stefano Francesco Crinò
- Diagnostic and Interventional Endoscopy of the Pancreas, The Pancreas Institute, University Hospital of Verona, Verona, Italy
| |
Collapse
|
3
|
Punzi E, Carrubba C, Contegiacomo A, Posa A, Barbieri P, De Leoni D, Mazza G, Tanzilli A, Cina A, Natale L, Sala E, Iezzi R. Interventional Radiology in the Treatment of Pancreatic Adenocarcinoma: Present and Future Perspectives. Life (Basel) 2023; 13:life13030835. [PMID: 36983990 PMCID: PMC10059735 DOI: 10.3390/life13030835] [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: 02/12/2023] [Revised: 03/07/2023] [Accepted: 03/18/2023] [Indexed: 03/30/2023] Open
Abstract
Pancreatic ductal adenocarcinoma (PDAC) is a lethal disease; patients' long-term survival is strictly linked to the surgical resection of the tumor but only a minority of patients (2-3%) have a resectable disease at diagnosis. In patients with surgically unresectable disease, interventional radiology is taking on an increasing role in treatment with the application of loco-regional percutaneous therapies. The primary purposes of this narrative review are to analyze the safety and efficacy of ablative techniques in the management of borderline resectable and locally advanced diseases and to underline the role of the interventional radiologist in the management of patients with distant metastases. The secondary purpose is to focus on the synergy between immunotherapy and ablative therapies.
Collapse
Affiliation(s)
- Ernesto Punzi
- Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia-Istituto di Radiologia, Fondazione Policlinico Universitario A. Gemelli IRCCS, l.go A gemelli 8, 00168 Rome, Italy
| | - Claudio Carrubba
- Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia-Istituto di Radiologia, Fondazione Policlinico Universitario A. Gemelli IRCCS, l.go A gemelli 8, 00168 Rome, Italy
| | - Andrea Contegiacomo
- Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia-Istituto di Radiologia, Fondazione Policlinico Universitario A. Gemelli IRCCS, l.go A gemelli 8, 00168 Rome, Italy
| | - Alessandro Posa
- Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia-Istituto di Radiologia, Fondazione Policlinico Universitario A. Gemelli IRCCS, l.go A gemelli 8, 00168 Rome, Italy
| | - Pierluigi Barbieri
- Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia-Istituto di Radiologia, Fondazione Policlinico Universitario A. Gemelli IRCCS, l.go A gemelli 8, 00168 Rome, Italy
| | - Davide De Leoni
- Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia-Istituto di Radiologia, Fondazione Policlinico Universitario A. Gemelli IRCCS, l.go A gemelli 8, 00168 Rome, Italy
| | - Giulia Mazza
- Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia-Istituto di Radiologia, Fondazione Policlinico Universitario A. Gemelli IRCCS, l.go A gemelli 8, 00168 Rome, Italy
| | - Alessandro Tanzilli
- Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia-Istituto di Radiologia, Fondazione Policlinico Universitario A. Gemelli IRCCS, l.go A gemelli 8, 00168 Rome, Italy
| | - Alessandro Cina
- Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia-Istituto di Radiologia, Fondazione Policlinico Universitario A. Gemelli IRCCS, l.go A gemelli 8, 00168 Rome, Italy
| | - Luigi Natale
- Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia-Istituto di Radiologia, Fondazione Policlinico Universitario A. Gemelli IRCCS, l.go A gemelli 8, 00168 Rome, Italy
- Istituto di Radiodiagnostica, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
| | - Evis Sala
- Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia-Istituto di Radiologia, Fondazione Policlinico Universitario A. Gemelli IRCCS, l.go A gemelli 8, 00168 Rome, Italy
- Istituto di Radiodiagnostica, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
| | - Roberto Iezzi
- Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia-Istituto di Radiologia, Fondazione Policlinico Universitario A. Gemelli IRCCS, l.go A gemelli 8, 00168 Rome, Italy
- Istituto di Radiodiagnostica, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
| |
Collapse
|
4
|
Karaisz FG, Elkelany OO, Davies B, Lozanski G, Krishna SG. A Review on Endoscopic Ultrasound-Guided Radiofrequency Ablation (EUS-RFA) of Pancreatic Lesions. Diagnostics (Basel) 2023; 13:diagnostics13030536. [PMID: 36766643 PMCID: PMC9914142 DOI: 10.3390/diagnostics13030536] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2022] [Revised: 01/27/2023] [Accepted: 01/29/2023] [Indexed: 02/05/2023] Open
Abstract
The morbidity associated with pancreatectomies limits surgical options for high-risk patients with pancreatic neoplasms that warrant resection. Endoscopic ultrasound-guided radiofrequency ablation (EUS-RFA) offers a minimally invasive and potentially definitive means to treat pancreatic neuroendocrine tumors and precancerous pancreatic cystic lesions. In addition, EUS-RFA may play a role in the treatment and palliation of non-surgical cases of pancreatic adenocarcinoma. The efficacy of RFA appears to be further enhanced by systemic immunomodulatory effects. Here, we review current studies on the developing role of EUS-RFA in these pancreatic pathologies.
Collapse
Affiliation(s)
- Fred G. Karaisz
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, OH 43210, USA
| | - Osama O. Elkelany
- Department of Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, OH 43210, USA
| | - Benjamin Davies
- College of Medicine, The Ohio State University, Columbus, OH 43210, USA
| | - Gerard Lozanski
- Department of Pathology, The Ohio State University Wexner Medical Center, Columbus OH 43210, USA
| | - Somashekar G. Krishna
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, OH 43210, USA
- Correspondence:
| |
Collapse
|
5
|
Radiofrequency Hyperthermia Enhances Locally Delivered Oncolytic Immuno-Virotherapy for Pancreatic Adenocarcinoma. Cardiovasc Intervent Radiol 2022; 45:1812-1821. [PMID: 35902397 DOI: 10.1007/s00270-022-03210-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2022] [Accepted: 06/22/2022] [Indexed: 11/02/2022]
Abstract
PURPOSE To investigate the effect of radiofrequency hyperthermia (RFH)-enhanced oncolytic immuno-virotherapy on in vitro pancreatic adenocarcinoma cell line and in vivo rat pancreatic cancer model. MATERIALS AND METHODS Rat pancreatic adenocarcinoma cell line and 24 Lewis rats with orthotopic pancreatic adenocarcinomas underwent treatment with either (1) oncolytic virotherapy (talimogene laherparepvec [T-VEC]) plus RFH at 42 °C for 30 min; (2) oncolytic virotherapy-only; (3) RFH-only; or (4) saline (control). MTS assays and flow cytometry were used to analyze tumor cell viability and apoptosis levels 24 h after treatment. In the in vivo studies, bioluminescence optical/x-ray imaging and ultrasound imaging was used to assess tumor viability and size 7 and 14 days after treatment. Histopathologic analysis was performed after hematoxylin and eosin staining, TUNEL, Ki-67, and immunohistochemical staining with CD8 and ANK61. RESULTS Combination therapy (T-VEC + RFH) induced decreased cell viability and increased cell apoptosis compared to T-VEC alone, RFH alone, or control. Optical/x-ray imaging and ultrasound imaging demonstrated decreased tumor bioluminescent signal and tumor volume relative to baseline after combination therapy compared to T-VEC alone, RFH alone, or control. Histopathology demonstrated decreased tumor volume and cell proliferation, increased CD8+ T cell and NK cell infiltration in tumors treated with the combination therapy compared to other three groups. CONCLUSION RFH enhances locally delivered oncolytic immuno-virotherapy for pancreatic adenocarcinoma, with decreased cell viability and increased apoptosis observed after combination therapy in vitro, and decreased cell viability and tumor volume and increased immune cell infiltrate observed after combination therapy in vivo.
Collapse
|
6
|
Lim S, Truong VG, Choi J, Jeong HJ, Oh SJ, Park JS, Kang HW. Endoscopic Ultrasound-Guided Laser Ablation Using a Diffusing Applicator for Locally Advanced Pancreatic Cancer Treatment. Cancers (Basel) 2022; 14:cancers14092274. [PMID: 35565403 PMCID: PMC9102236 DOI: 10.3390/cancers14092274] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2022] [Accepted: 04/29/2022] [Indexed: 12/18/2022] Open
Abstract
Simple Summary Pancreatic cancer (PC) is one of the most lethal cancers; caused by family history, obesity, diabetes, and smoking, it has a 2–9% five-year survival rate. However, patients diagnosed by endoscopic ultrasound (EUS) already have an advanced stage of PC, indicating the difficulty of surgical resection. Recently, laser ablative treatment with a diffusing applicator has been proven to be feasible for treating advanced PC. Despite the potential application for treating PC, further evaluation of acute and chronic tissue responses are essential to determine the efficacy and safety of diffusing applicator under EUS guidance. In this study, EUS-guided diffusing applicator-assisted laser ablation was evaluated to quantify the extent of the tissue response after the delivery of various energy levels. Abstract Endoscopic ultrasound (EUS)-guided cylindrical interstitial laser ablation (CILA) procedures can be used to treat unresectable pancreatic cancer (PC). The aim of this study was to investigate the acute responses of pancreatic tissue after EUS-guided CILA in vivo in porcine models. Eight pigs were tested to compare the effects of different energy levels on pancreatic tissue ablation. A 1064 nm laser system was used to deliver 5 W through a diffusing applicator. The EUS-guided CILA was performed under four different energies: 200, 400, 600, and 800 J. Three days after the experiments, histological analysis was performed. The CILA consistently generated circular coagulated necrosis (CN) in the cross-sectioned pancreatic tissue. The ablation diameter was linearly dependent on the total energy delivery. The area of the CN initially increased with total energy delivery but became saturated at 600 J. The width of the degenerative parenchyma (DP) in the native tissue beyond the CN region increased with the total energy up to 600 J, and then decreased afterward. EUS-guided CILA can be a feasible approach for treating PC. Further animal studies will investigate the chronic responses of the pancreatic tissue to examine the efficacy and safety of the proposed method for clinical translation.
Collapse
Affiliation(s)
- Seonghee Lim
- Industry 4.0 Convergence Bionics Engineering, Pukyong National University, Busan 48513, Korea; (S.L.); (V.G.T.); (J.C.)
| | - Van Gia Truong
- Industry 4.0 Convergence Bionics Engineering, Pukyong National University, Busan 48513, Korea; (S.L.); (V.G.T.); (J.C.)
| | - Jongman Choi
- Industry 4.0 Convergence Bionics Engineering, Pukyong National University, Busan 48513, Korea; (S.L.); (V.G.T.); (J.C.)
| | - Hye Jung Jeong
- Digestive Disease Center, Department of Internal Medicine, Inha University School of Medicine, Incheon 22332, Korea;
| | - Sun-Ju Oh
- Department of Pathology, Kosin University College of Medicine, Busan 49267, Korea;
| | - Jin-Seok Park
- Digestive Disease Center, Department of Internal Medicine, Inha University School of Medicine, Incheon 22332, Korea;
- Correspondence: (J.-S.P.); (H.W.K.)
| | - Hyun Wook Kang
- Industry 4.0 Convergence Bionics Engineering, Pukyong National University, Busan 48513, Korea; (S.L.); (V.G.T.); (J.C.)
- Marine—Integrated Biomedical Technology Center and Department of Biomedical Engineering, Pukyong National University, Busan 48513, Korea
- Correspondence: (J.-S.P.); (H.W.K.)
| |
Collapse
|
7
|
Zhao L, Zhou Y, Bai Z, Zhang F, Yang X. The underlying molecular mechanism of intratumoral radiofrequency hyperthermia-enhanced chemotherapy of pancreatic cancer. J Interv Med 2022; 5:57-63. [PMID: 35936663 PMCID: PMC9349012 DOI: 10.1016/j.jimed.2022.02.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2022] [Revised: 02/22/2022] [Accepted: 02/28/2022] [Indexed: 02/07/2023] Open
Abstract
Background To investigate the underlying molecular mechanisms of radiofrequency hyperthermia (RFH)-enhanced direct chemotherapy of pancreatic cancers. Method Rat ductal PaCa cell line DSL-6A/C1 and orthotopic pancreatic cancers of Lewis rats were divided into four study groups with various treatments: i) phosphate-buffered saline (PBS) as a control; ii) RFH alone; iii) intratumoral chemotherapy alone (gemcitabine); and (iv) combination therapy of gemcitabine plus intratumoral RFH at 42 °C for 30 min. In the in-vitro confirmation experiments, the viability and apoptosis of DSL-6A/C1 cells in each treatment group were evaluated using cell live/dead staining, flow cytometry, and Western blot. In the in vivo validation experiments, related proteins were evaluated by immunohistochemistry (IHC) staining of tumors. Results Of the in-vitro experiments, the lowest cell viability and more apoptotic cells were shown in the group with combination therapy compared to other treatments. Western blot data showed elevated Bax/Bcl-2, Caspase-3, and HSP70 expressions in DSL cells with combination therapy, compared to other treatments. Of the in vivo experiments, IHC staining detected the significantly increased expressions of HSP70, IL-1β, TNF-ɑ, Bax, and Caspase-3 in pancreatic cancer tissues of the animal group treated by combination therapy of gemcitabine with RFH. Conclusion Molecular imaging-guided interventional RFH can significantly enhance the chemotherapeutic effect on pancreatic cancers via potential molecular mechanisms of up-regulating Bax/caspase-3-dependent apoptosis pathways.
Collapse
|
8
|
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.
Collapse
Affiliation(s)
- Ulrike Heger
- Department of Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Thilo Hackert
- Department of Surgery, Heidelberg University Hospital, Heidelberg, Germany
| |
Collapse
|
9
|
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.
Collapse
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
| |
Collapse
|
10
|
Granata V, Grassi R, Fusco R, Belli A, Palaia R, Carrafiello G, Miele V, Grassi R, Petrillo A, Izzo F. Local ablation of pancreatic tumors: State of the art and future perspectives. World J Gastroenterol 2021; 27:3413-3428. [PMID: 34163121 PMCID: PMC8218359 DOI: 10.3748/wjg.v27.i23.3413] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2021] [Revised: 03/28/2021] [Accepted: 05/08/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Currently, the technologies most commonly used to treat locally advanced pancreatic cancer are radiofrequency ablation (RFA), microwave ablation, and irreversible (IRE) or reversible electroporation combined with low doses of chemotherapeutic drugs.
AIM To report an overview and updates on ablative techniques in pancreatic cancer.
METHODS Several electronic databases were searched. The search covered the years from January 2000 to January 2021. Moreover, the reference lists of the found papers were analysed for papers not indexed in the electronic databases. All titles and abstracts were analysed.
RESULTS We found 30 studies (14 studies for RFA, 3 for microwave therapy, 10 for IRE, and 3 for electrochemotherapy), comprising 1047 patients, which were analysed further. Two randomized trials were found for IRE. Percutaneous and laparotomy approaches were performed. In the assessed patients, the median maximal diameter of the lesions was in the range of 2.8 to 4.5 cm. All series included patients unfit for surgical treatment, but Martin et al assessed a subgroup of patients with borderline resectable tumours who underwent resection with margin attenuation with IRE. Most studies administered chemotherapy prior to ablative therapies. However, several studies suggest that the key determinant of improved survival is attributable to ablative treatment alone. Nevertheless, the authors suggested chemotherapy before local therapies for several reasons. This strategy may not only downstage a subgroup of patients to curative-intent surgery but also support to recognize patients with biologically unfavourable tumours who would likely not benefit from ablation treatments. Ablation therapies seem safe based on the 1047 patients assessed in this review. The mortality rate ranged from 1.8% to 2%. However, despite the low mortality, the reported rates of severe post procedural complications ranged from 0%-42%. Most reported complications have been self-limiting and manageable. Median overall survival varied between 6.0 and 33 mo. Regarding the technical success rate, assessed papers reported an estimated rate in the range of 85% to 100%. However, the authors reported early recurrence after treatment. A distinct consideration should be made on whether local treatments induce an immune response in the ablated area. Preclinical and clinical studies have shown that RFA is a promising mechanism for inducing antigen-presenting cell infiltration and enhancing the systemic antitumour T-cell immune response and tumour regression.
CONCLUSION In the management of patients with pancreatic cancer, the possibility of a multimodal approach should be considered, and conceptually, the combination of RFA with immunotherapy represents a novel angle of attack against this tumour.
Collapse
Affiliation(s)
- Vincenza Granata
- Department of Radiology, Istituto Nazionale Tumori –IRCCS- Fondazione G. Pascale, Naples 80131, Italy
| | - Roberta Grassi
- Department of Radiology, Università degli Studi della Campania Luigi Vanvitelli, Naples 80127, Italy
| | - Roberta Fusco
- Department of Radiology, Istituto Nazionale Tumori –IRCCS- Fondazione G. Pascale, Naples 80131, Italy
| | - Andrea Belli
- Department of Surgery, Istituto Nazionale Tumori –IRCCS- Fondazione G. Pascale, Naples 80131, Italy
| | - Raffaele Palaia
- Department of Surgery, Istituto Nazionale Tumori –IRCCS- Fondazione G. Pascale, Naples 80131, Italy
| | | | - Vittorio Miele
- Italian Society of Medical and Interventional Radiology SIRM, SIRM Foundation Milan 20122, Italy
- Department of Emergency Radiology, San Camillo Hospital, Firenze 50139, Italy
| | - Roberto Grassi
- Department of Radiology, Università degli Studi della Campania Luigi Vanvitelli, Naples 80127, Italy
- Italian Society of Medical and Interventional Radiology SIRM, SIRM Foundation Milan 20122, Italy
| | - Antonella Petrillo
- Department of Radiology, Istituto Nazionale Tumori –IRCCS- Fondazione G. Pascale, Naples 80131, Italy
| | - Francesco Izzo
- Department of Surgery, Istituto Nazionale Tumori –IRCCS- Fondazione G. Pascale, Naples 80131, Italy
| |
Collapse
|
11
|
Iancu I, Bartoș A, Cioltean CL, Breazu C, Iancu C, Bartoș D. Role of radio-ablative technique for optimizing the survival of patients with locally advanced pancreatic adenocarcinoma (Review). Exp Ther Med 2021; 22:853. [PMID: 34178126 PMCID: PMC8220652 DOI: 10.3892/etm.2021.10285] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2021] [Accepted: 05/05/2021] [Indexed: 12/19/2022] Open
Abstract
Pancreatic ductal adenocarcinoma (PDAC) is one of the most common and frequently diagnosed malignant tumor of the pancreas with few treatment options and poor life expectancy. Despite the advances in the surgical field, 40% of the patients are diagnosed with locally advanced disease which is not suitable for surgery. Radio-frequency ablation (RFA) has been described as a new ‘weapon’ in the multimodal treatment of PDAC, representing a cytoreductive procedure which must be completed with radiotherapy or chemo-radiotherapy. A systematic research was carried out utilizing the PubMed database in regards to this subject, to evaluate the role of RFA in PDAC management. Abstracts, letters-to-the-editor and non-English language manuscripts were excluded. The literature showed that RFA can be used in open and laparoscopic surgery but it is also feasible for endoscopic ultrasound (EUS-guided RFA) or percutaneous approach. Even though we found optimistic and encouraging reports on overall survival (OS), randomized studies are still required to corroborate these findings. Our review research underline that surgical resection remains the only radical treatment option, RFA being a safe and feasible technique reserved for unresectable, non-metastatic pancreatic tumors. Its combination with oncological treatment can improve the OS of these patients.
Collapse
Affiliation(s)
- Ioana Iancu
- Department of Surgery, Regional Institute of Gastroenterology and Hepatology, 400162 Cluj-Napoca, Romania.,Anatomy and Embryology Department, 'Iuliu Hațieganu' University of Medicine and Pharmacy, 400006 Cluj-Napoca, Romania
| | - Adrian Bartoș
- Department of Surgery, Regional Institute of Gastroenterology and Hepatology, 400162 Cluj-Napoca, Romania.,Department of Surgery, 'Iuliu Hațieganu' University of Medicine and Pharmacy, 400162 Cluj-Napoca, Romania
| | - Cristian Liviu Cioltean
- Department of Surgery, Regional Institute of Gastroenterology and Hepatology, 400162 Cluj-Napoca, Romania
| | - Caius Breazu
- Department of Surgery, Regional Institute of Gastroenterology and Hepatology, 400162 Cluj-Napoca, Romania.,Department of Anesthesiology and Intensive Care, Regional Institute of Gastroenterology and Hepatology, 400162 Cluj-Napoca, Romania
| | - Cornel Iancu
- Department of Surgery, Regional Institute of Gastroenterology and Hepatology, 400162 Cluj-Napoca, Romania
| | - Dana Bartoș
- Department of Surgery, Regional Institute of Gastroenterology and Hepatology, 400162 Cluj-Napoca, Romania.,Anatomy and Embryology Department, 'Iuliu Hațieganu' University of Medicine and Pharmacy, 400006 Cluj-Napoca, Romania
| |
Collapse
|
12
|
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.
Collapse
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
| |
Collapse
|
13
|
Hu X, Xia F, Lee J, Li F, Lu X, Zhuo X, Nie G, Ling D. Tailor-Made Nanomaterials for Diagnosis and Therapy of Pancreatic Ductal Adenocarcinoma. ADVANCED SCIENCE (WEINHEIM, BADEN-WURTTEMBERG, GERMANY) 2021; 8:2002545. [PMID: 33854877 PMCID: PMC8025024 DOI: 10.1002/advs.202002545] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/05/2020] [Revised: 10/25/2020] [Indexed: 05/05/2023]
Abstract
Pancreatic ductal adenocarcinoma (PDAC) is one of the deadliest cancers worldwide due to its aggressiveness and the challenge to early diagnosis and treatment. In recent decades, nanomaterials have received increasing attention for diagnosis and therapy of PDAC. However, these designs are mainly focused on the macroscopic tumor therapeutic effect, while the crucial nano-bio interactions in the heterogeneous microenvironment of PDAC remain poorly understood. As a result, the majority of potent nanomedicines show limited performance in ameliorating PDAC in clinical translation. Therefore, exploiting the unique nature of the PDAC by detecting potential biomarkers together with a deep understanding of nano-bio interactions that occur in the tumor microenvironment is pivotal to the design of PDAC-tailored effective nanomedicine. This review will introduce tailor-made nanomaterials-enabled laboratory tests and advanced noninvasive imaging technologies for early and accurate diagnosis of PDAC. Moreover, the fabrication of a myriad of tailor-made nanomaterials for various PDAC therapeutic modalities will be reviewed. Furthermore, much preferred theranostic multifunctional nanomaterials for imaging-guided therapies of PDAC will be elaborated. Lastly, the prospects of these nanomaterials in terms of clinical translation and potential breakthroughs will be briefly discussed.
Collapse
Affiliation(s)
- Xi Hu
- Department of Clinical PharmacyZhejiang Provincial Key Laboratory for Drug Evaluation and Clinical Researchthe First Affiliated HospitalZhejiang University School of MedicineHangzhou310003China
| | - Fan Xia
- Institute of PharmaceuticsZhejiang Province Key Laboratory of Anti‐Cancer Drug ResearchHangzhou Institute of Innovative MedicineCollege of Pharmaceutical SciencesZhejiang UniversityHangzhou310058China
| | - Jiyoung Lee
- Institute of PharmaceuticsZhejiang Province Key Laboratory of Anti‐Cancer Drug ResearchHangzhou Institute of Innovative MedicineCollege of Pharmaceutical SciencesZhejiang UniversityHangzhou310058China
| | - Fangyuan Li
- Institute of PharmaceuticsZhejiang Province Key Laboratory of Anti‐Cancer Drug ResearchHangzhou Institute of Innovative MedicineCollege of Pharmaceutical SciencesZhejiang UniversityHangzhou310058China
- Key Laboratory of Biomedical Engineering of the Ministry of EducationCollege of Biomedical Engineering & Instrument ScienceZhejiang UniversityHangzhou310058China
| | - Xiaoyang Lu
- Department of Clinical PharmacyZhejiang Provincial Key Laboratory for Drug Evaluation and Clinical Researchthe First Affiliated HospitalZhejiang University School of MedicineHangzhou310003China
| | - Xiaozhen Zhuo
- Department of Cardiologythe First Affiliated HospitalXi'an Jiaotong UniversityXi'an710061China
| | - Guangjun Nie
- CAS Key Laboratory for Biomedical Effects of Nanomaterials and NanosafetyCAS Center for Excellence in NanoscienceNational Center for Nanoscience and TechnologyNo.11 Zhongguancun BeiyitiaoBeijing100190China
- GBA Research Innovation Institute for NanotechnologyGuangzhou510700China
| | - Daishun Ling
- Institute of PharmaceuticsZhejiang Province Key Laboratory of Anti‐Cancer Drug ResearchHangzhou Institute of Innovative MedicineCollege of Pharmaceutical SciencesZhejiang UniversityHangzhou310058China
- Key Laboratory of Biomedical Engineering of the Ministry of EducationCollege of Biomedical Engineering & Instrument ScienceZhejiang UniversityHangzhou310058China
| |
Collapse
|
14
|
Laser Treatment of Pancreatic Cancer with Immunostimulating Interstitial Laser Thermotherapy Protocol: Safety and Feasibility Results From Two Phase 2a Studies. J Surg Res 2020; 259:1-7. [PMID: 33278792 DOI: 10.1016/j.jss.2020.10.027] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Revised: 09/03/2020] [Accepted: 10/31/2020] [Indexed: 12/14/2022]
Abstract
PURPOSE Ablative techniques have emerged as new potential therapeutic options for patients with locally advanced pancreatic cancer (LAPC). We explored the safety and feasibility of using TRANBERG|Thermal Therapy System (Clinical Laserthermia Systems AB, Lund, Sweden) in feedback mode for immunostimulating Interstitial Laser Thermotherapy (imILT) protocol, the newest ablative technique introduced for the treatment of LAPC. METHODS The safety and feasibility results after the use of imILT protocol treatment in 15 patients of a prospective series of postsystemic therapy LAPC in two high-volume European institutions, the General and Pancreatic Unit of the Pancreas Institute, of the University of Verona, Italy, and the Department of Surgical Oncology of the Institut Paoli-Calmettes of Marseille, France, were assessed. RESULTS The mean age was 66 ± 5 years, with a mean tumor size of 34.6 (±8) mm. The median number of cycles of pre-imILT chemotherapy was 6 (6-12). The procedure was performed in 13 of 15 (86.6%) cases; indeed, in two cases, the procedure was not performed; in one, the procedure was considered technically demanding; in the other, liver metastases were found intraoperatively. In all treated cases, the procedure was completed. Three late pancreatic fistulas developed over four overall adverse events (26.6%) and were attributed to imILT. Mortality was nil. A learning curve is necessary to interpret and manage the laser parameters. CONCLUSIONS Safety, feasibility, and device handling outcomes of using TRANBERG|Thermal Therapy System with temperature probes in feedback mode and imILT protocol on LAPC were not satisfactory. The metastatic setting may be appropriate to evaluate the hypothetic abscopal effect.#NCT02702986 and #NCT02973217.
Collapse
|
15
|
Vanella G, Capurso G, Arcidiacono PG. Endosonography-guided Radiofrequency Ablation in Pancreatic Diseases: Time to Fill the Gap Between Evidence and Enthusiasm. J Clin Gastroenterol 2020; 54:591-601. [PMID: 32482951 DOI: 10.1097/mcg.0000000000001370] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Over the past 20 years, endoscopic ultrasound-guided radiofrequency ablation (EUS-RFA) has generated interest as a novel minimally invasive tool in the multimodal treatment of pancreatic malignant and premalignant lesions. However, although optimization of probes and settings has made EUS-RFA relatively safe, questions on the ideal positioning of this treatment in a multimodal strategy remain unanswered. This review will summarize the technical aspects of EUS-RFA and available clinical experiences for each pancreatic indication (pancreatic cancer, neuroendocrine neoplasms, cystic lesions, and celiac ganglia neurolysis). Established indications will be discussed along those requiring additional clinical data or even proof-of-concept studies. A dedicated session will further discuss evidence expected to emerge from ongoing registered trials, together with issues that must be addressed in future research, including the possible combination with immunotherapy, and the personalization of this treatment on the basis of genetic profiling. Despite the great clinical enthusiasm and scientific fervor, while evidence-based answers are produced, EUS-RFA must be centralized in high-volume centers of recognized expertise, where multidisciplinary discussions of indications and actively recruiting research protocols are available.
Collapse
Affiliation(s)
- Giuseppe Vanella
- Pancreato-Biliary Endoscopy and Endosonography Division, Pancreas Translational & Clinical Research Center, San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy
| | | | | |
Collapse
|
16
|
Moulla Y, Petersen TO, Maiwald B, Bailis N, Kreuser N, Lordick F, Seehofer D, Sucher R, Hecker M, Hoffmeister A, Jansen-Winkeln B, Gockel I. [Ablative treatment options for locally advanced unresectable and borderline resectable pancreatic carcinoma]. Chirurg 2020; 91:319-328. [PMID: 31828387 DOI: 10.1007/s00104-019-01072-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND Locally advanced unresectable (nonmetastatic) and borderline resectable pancreatic carcinomas represent a therapeutic challenge. Several minimally invasive local ablative techniques are available for local treatment in these situations. OBJECTIVE Which interventional techniques and application options are currently available for pancreatic carcinoma and which oncological results could be achieved so far? MATERIAL AND METHODS An analysis of reviews and studies was carried out. The selection of literature was based on searches in PubMed and the Cochrane library. The studies analyzed were reviews, meta-analyses and original articles mainly from the period between 2013 and 2018. Single case reports were not included in this review. RESULTS Local ablative techniques are performed with various forms of energy and are associated with specific advantages and disadvantages. They have to be individually tailored to the specific patient and situation. Noninvasive thermal ablation with high-intensity focused ultrasound (HIFU) is primarily used for palliative pain relief. Solid tumors are the main indication for thermal necrosis with microwave ablation (MWA) and radiofrequency ablation (RFA). The use of irreversible electroporation (IRE) enables a selective destruction of tumor cells and can be performed in the vicinity of sensitive structures. This technique is applied for primary tumor control and also for accentuation of tumor margins during resection. CONCLUSION With local ablative techniques an improvement in the quality of life and possibly the prognosis can be achieved in patients with unresectable pancreatic cancer; however, the latter aspect has to be viewed with caution due to a current lack of well-founded data.
Collapse
Affiliation(s)
- Yusef Moulla
- Klinik und Poliklinik für Viszeral‑, Transplantations‑, Thorax- und Gefäßchirurgie, Department für Operative Medizin (DOPM), Universitätsklinikum Leipzig, AöR, Liebigstr. 20, 04103, Leipzig, Deutschland
| | - Tim-Ole Petersen
- Klinik und Poliklinik für Diagnostische und Interventionelle Radiologie, Universitätsklinikum Leipzig, AöR, Leipzig, Deutschland
| | - Bettina Maiwald
- Klinik und Poliklinik für Diagnostische und Interventionelle Radiologie, Universitätsklinikum Leipzig, AöR, Leipzig, Deutschland
| | - Nikolaos Bailis
- Klinik und Poliklinik für Diagnostische und Interventionelle Radiologie, Universitätsklinikum Leipzig, AöR, Leipzig, Deutschland
| | - Nicole Kreuser
- Klinik und Poliklinik für Viszeral‑, Transplantations‑, Thorax- und Gefäßchirurgie, Department für Operative Medizin (DOPM), Universitätsklinikum Leipzig, AöR, Liebigstr. 20, 04103, Leipzig, Deutschland
| | - Florian Lordick
- Universitäres Krebszentrum Leipzig (UCCL), Universitätsklinikum Leipzig, AöR, Leipzig, Deutschland
| | - Daniel Seehofer
- Klinik und Poliklinik für Viszeral‑, Transplantations‑, Thorax- und Gefäßchirurgie, Department für Operative Medizin (DOPM), Universitätsklinikum Leipzig, AöR, Liebigstr. 20, 04103, Leipzig, Deutschland
| | - Robert Sucher
- Klinik und Poliklinik für Viszeral‑, Transplantations‑, Thorax- und Gefäßchirurgie, Department für Operative Medizin (DOPM), Universitätsklinikum Leipzig, AöR, Liebigstr. 20, 04103, Leipzig, Deutschland
| | - Martin Hecker
- Klinik und Poliklinik für Gastroenterologie, Universitätsklinikum Leipzig, AöR, Leipzig, Deutschland
| | - Albrecht Hoffmeister
- Klinik und Poliklinik für Gastroenterologie, Universitätsklinikum Leipzig, AöR, Leipzig, Deutschland
| | - Boris Jansen-Winkeln
- Klinik und Poliklinik für Viszeral‑, Transplantations‑, Thorax- und Gefäßchirurgie, Department für Operative Medizin (DOPM), Universitätsklinikum Leipzig, AöR, Liebigstr. 20, 04103, Leipzig, Deutschland
| | - Ines Gockel
- Klinik und Poliklinik für Viszeral‑, Transplantations‑, Thorax- und Gefäßchirurgie, Department für Operative Medizin (DOPM), Universitätsklinikum Leipzig, AöR, Liebigstr. 20, 04103, Leipzig, Deutschland.
| |
Collapse
|
17
|
Li W, Wang X, Wang Z, Zhang T, Cai F, Tang P, Meng J, Du H, Wang H, Li M, Li S. The role of seed implantation in patients with unresectable pancreatic carcinoma after relief of obstructive jaundice using ERCP. Brachytherapy 2020; 19:97-103. [PMID: 31564517 DOI: 10.1016/j.brachy.2019.08.010] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2019] [Revised: 07/27/2019] [Accepted: 08/21/2019] [Indexed: 12/17/2022]
Abstract
PURPOSE The purpose of the study was to investigate the role of iodine-125 seed implantation, guided by endoscopic ultrasound (EUS) and/or percutanous ultrasound, in patients with unresectable pancreatic carcinoma after relief of obstructive jaundice using endoscopic retrograde cholangiopancreatography (ERCP). METHODS AND MATERIALS A total of 101 patients with obstructive jaundice due to unresectable pancreatic carcinoma were enrolled between January 2010 and December 2017 in this retrospective study. Of these patients, 50 underwent implantation of iodine-125 seeds under EUS and/or percutaneous ultrasound guidance after receiving a stent via ERCP (treatment group), and 51 received a stent via ERCP without undergoing seed implantation (control group). The clinical data and therapeutic outcomes of these patients were analyzed. RESULTS Compared with the control group, the treatment group obtained significant relief of abdominal pain at the 1-week, 1-month, and 3-month followup (p < 0.05), with a significantly lower visual analog scale pain score (p < 0.05). The treatment group obtained a longer median survival (8.8 vs. 6.5 months, p = 0.02), longer median duration of stent patency (10.8 ± 1.4 vs. 6.9 ± 0.8 months, p = 0.02), and prolonged average time to gastric outlet obstruction (6.8 ± 1.6 vs. 5.3 ± 1.3 months, p = 0.02). Differences between liver function and appetite for the two groups were not significant (p > 0.05 and p = 0.59, respectively). CONCLUSIONS Iodine-125 seed implantation after relief of obstructive jaundice via ERCP prolongs survival, biliary stent patency, and time to gastric outlet obstruction and improves patient quality of life by relieving pancreatic pain in patients with unresectable pancreatic carcinoma.
Collapse
Affiliation(s)
- Wen Li
- Department of Gastroenterology and Hepatology, The Chinese PLA General Hospital, Beijing, China
| | - Xiangdong Wang
- Department of Gastroenterology and Hepatology, The Chinese PLA General Hospital, Beijing, China
| | - Zikai Wang
- Department of Gastroenterology and Hepatology, The Chinese PLA General Hospital, Beijing, China
| | - Tiantian Zhang
- Department of Gastroenterology and Hepatology, The Chinese PLA General Hospital, Beijing, China
| | - Fengchun Cai
- Department of Gastroenterology and Hepatology, The Chinese PLA General Hospital, Beijing, China
| | - Ping Tang
- Department of Gastroenterology and Hepatology, The Chinese PLA General Hospital, Beijing, China
| | - Jiangyun Meng
- Department of Gastroenterology and Hepatology, The Chinese PLA General Hospital, Beijing, China
| | - Hong Du
- Department of Gastroenterology and Hepatology, The Chinese PLA General Hospital, Beijing, China
| | - Hongbin Wang
- Department of Gastroenterology and Hepatology, The Chinese PLA General Hospital, Beijing, China
| | - Mingyang Li
- Department of Gastroenterology and Hepatology, The Chinese PLA General Hospital, Beijing, China
| | - Shuling Li
- Department of Gastroenterology and Hepatology, The Chinese PLA General Hospital, Beijing, China.
| |
Collapse
|
18
|
Das SK, Wang JL, Li B, Zhang C, Yang HF. Clinical effectiveness of combined interventional therapy as a salvage modality for unresectable pancreatic carcinoma. Oncol Lett 2019; 18:375-385. [PMID: 31289509 PMCID: PMC6539718 DOI: 10.3892/ol.2019.10323] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2018] [Accepted: 03/21/2019] [Indexed: 12/13/2022] Open
Abstract
Although different treatment methods have been introduced to treat advanced pancreatic carcinoma, the median overall survival rate remains unsatisfactory. Theoretically, combining different treatment methods should work in synergy to enhance locoregional disease control and improve survival. Therefore, the aim of the present retrospective study was to analyze the effectiveness of combined interventional therapy compared with trans-arterial chemoembolization (TACE) or chemotherapy alone for the treatment of unresectable pancreatic carcinoma. A total of 266 patients who were undergoing treatment for unresectable pancreatic carcinoma between July 2012 and November 2015 were included in the current study. The tumor responses and 3-year overall survival rates of patients treated with combined interventional therapy (TACE combined with iodine-125 seed implantation and/or radiofrequency ablation; CIT group; n=84) were compared with those of patients treated with TACE alone (TACE group; n=59), as well as patients treated with systemic chemotherapy alone (control group; n=123). Patients in the CIT group exhibited significantly improved tumor responses compared with patients in the TACE group (51.89 vs. 30.61%; P=0.028) or control group (51.89 vs. 17.20%; P<0.001). The 3-year overall survival rate of the CIT group was also significantly higher compared with that of the TACE and control groups (P=0.0116 and P=0.0001, respectively). Furthermore, the CIT group exhibited a significantly higher overall survival rate for patients with unresectable metastatic pancreatic cancer compared with the TACE and control groups (P=0.0088 and P<0.0001, respectively), which suggests that a combination of different interventional techniques increases the survival of patients with unresectable pancreatic cancer. No life-threatening complications were observed in any treatment group. In conclusion, combined interventional therapy exhibits a good efficacy and an improved survival rate for unresectable pancreatic cancer compared with TACE alone.
Collapse
Affiliation(s)
- Sushant Kumar Das
- Department of Interventional Radiology, Affiliated Hospital of North Sichuan Medical College, Nanchong, Sichuan 637000, P.R. China
| | - Jin Liang Wang
- Department of Radiology, Pingdingshan Fifth People's Hospital, Pingdingshan, Henan 467000, P.R. China
| | - Bing Li
- Department of Interventional Radiology, Affiliated Hospital of North Sichuan Medical College, Nanchong, Sichuan 637000, P.R. China
| | - Chuan Zhang
- Department of Interventional Radiology, Affiliated Hospital of North Sichuan Medical College, Nanchong, Sichuan 637000, P.R. China
| | - Han Feng Yang
- Department of Interventional Radiology, Affiliated Hospital of North Sichuan Medical College, Nanchong, Sichuan 637000, P.R. China
| |
Collapse
|
19
|
Fegrachi S, Walma MS, de Vries JJJ, van Santvoort HC, Besselink MG, von Asmuth EG, van Leeuwen MS, Borel Rinkes IH, Bruijnen RC, de Hingh IH, Klaase JM, Molenaar IQ, van Hillegersberg R. Safety of radiofrequency ablation in patients with locally advanced, unresectable pancreatic cancer: A phase II study. Eur J Surg Oncol 2019; 45:2166-2172. [PMID: 31227340 DOI: 10.1016/j.ejso.2019.06.008] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2019] [Revised: 05/02/2019] [Accepted: 06/06/2019] [Indexed: 12/17/2022] Open
Abstract
INTRODUCTION Radiofrequency ablation (RFA) has been proposed as a new treatment option for locally advanced, unresectable pancreatic cancer (LAPC). In preparation of a randomized controlled trial (RCT), the aim of this phase II study was to assess the safety of RFA for patients with LAPC. MATERIALS AND METHODS Patients diagnosed with LAPC confirmed during surgical exploration between November 2012 and April 2014 were eligible for inclusion. RFA probes were placed under ultrasound guidance with a safety margin of at least 10 mm from the duodenum and 15 mm from the portomesenteric vessels. During RFA, the duodenum was continuously perfused with cold saline to reduce risk for thermal damage. Primary outcome was defined as the amount of major complications (Clavien-Dindo grade ≥III). RFA-related complications were predefined as: pancreatic fistula, pancreatitis, thermal damage to the portomesenteric vessels and duodenal perforation. RESULTS In total, 17 patients underwent RFA. Delayed gastric emptying (DGE) requiring endoscopic feeding tube placement occurred in 4 patients (24%) as only major complication. Five patients (29%) had a major complication other than DGE. One (6%) RFA-related major complications occurred. One patient (6%) died due to complications from a biliary leak following hepaticojejunostomy. After evaluation of the first 5 patients, gastrojejunostomy was no longer performed routinely. Since then severe DGE seemed to occur less (3/5 vs. 3/12 grade C DGE). CONCLUSION RFA is a major, but safe procedure for patients with LAPC if performed with strict predefined safety criteria. A RCT is currently investigating the true effectiveness of RFA in patients with LAPC.
Collapse
Affiliation(s)
- Samira Fegrachi
- Departments of Surgery, University Medical Center Utrecht Cancer Center, St Antonius Hospital Nieuwegein, Regional Academic Cancer Center Utrecht, PO Box 85500, 3508 GA, Utrecht, the Netherlands
| | - Marieke S Walma
- Departments of Surgery, University Medical Center Utrecht Cancer Center, St Antonius Hospital Nieuwegein, Regional Academic Cancer Center Utrecht, PO Box 85500, 3508 GA, Utrecht, the Netherlands
| | - Jan J J de Vries
- Department of Radiology, Cancer Center Amsterdam, Amsterdam UMC, VU University, De Boelelaan 1117, 1081 HV, Amsterdam, the Netherlands
| | - Hjalmar C van Santvoort
- Departments of Surgery, University Medical Center Utrecht Cancer Center, St Antonius Hospital Nieuwegein, Regional Academic Cancer Center Utrecht, PO Box 85500, 3508 GA, Utrecht, the Netherlands
| | - Marc G Besselink
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, 1100 DD, Amsterdam, the Netherlands
| | - Erik G von Asmuth
- Departments of Surgery, University Medical Center Utrecht Cancer Center, St Antonius Hospital Nieuwegein, Regional Academic Cancer Center Utrecht, PO Box 85500, 3508 GA, Utrecht, the Netherlands
| | - Maarten S van Leeuwen
- Department of Radiology, University Medical Center Utrecht Cancer Center, University of Utrecht, PO Box 85500, 3508 GA, Utrecht, the Netherlands
| | - Inne H Borel Rinkes
- Departments of Surgery, University Medical Center Utrecht Cancer Center, St Antonius Hospital Nieuwegein, Regional Academic Cancer Center Utrecht, PO Box 85500, 3508 GA, Utrecht, the Netherlands
| | - Rutger C Bruijnen
- Department of Radiology, University Medical Center Utrecht Cancer Center, University of Utrecht, PO Box 85500, 3508 GA, Utrecht, the Netherlands
| | - Ignace H de Hingh
- Department of Surgery, Catharina Hospital Eindhoven, Michelangelolaan 2, 5623 EJ, Eindhoven, the Netherlands
| | - Joost M Klaase
- Department of Surgery, University Medical Center Groningen, Hanzeplein 1, 9713 GZ, Groningen, the Netherlands
| | - I Quintus Molenaar
- Departments of Surgery, University Medical Center Utrecht Cancer Center, St Antonius Hospital Nieuwegein, Regional Academic Cancer Center Utrecht, PO Box 85500, 3508 GA, Utrecht, the Netherlands
| | - Richard van Hillegersberg
- Departments of Surgery, University Medical Center Utrecht Cancer Center, St Antonius Hospital Nieuwegein, Regional Academic Cancer Center Utrecht, PO Box 85500, 3508 GA, Utrecht, the Netherlands.
| |
Collapse
|
20
|
Suker M, Koerkamp BG, Coene PP, van der Harst E, Bonsing BA, Vahrmeijer AL, Mieog JSD, Swijnenburg RJ, Dwarkasing RS, Roos D, van Eijck CHJ. Yield of staging laparoscopy before treatment of locally advanced pancreatic cancer to detect occult metastases. Eur J Surg Oncol 2019; 45:1906-1911. [PMID: 31186205 DOI: 10.1016/j.ejso.2019.06.004] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2019] [Revised: 05/16/2019] [Accepted: 06/01/2019] [Indexed: 02/07/2023] Open
Abstract
INTRODUCTION Locally advanced pancreatic cancer (LAPC) is found in 35% of patients with pancreatic cancer. However, these patients often have occult metastatic disease. Patients with occult metastases are unlikely to benefit from locoregional treatments. This study evaluated the yield of occult metastases during staging laparoscopy in patients with LAPC. METHODS Between January 2013 and January 2017 all patients with LAPC underwent a staging laparoscopy after a recent tri-phasic CT-scan of the chest and abdomen. Data were retrospectively reviewed from a prospectively maintained database. Univariate and multivariable logistic regression analysis was conducted to predict metastasis found at laparoscopy. RESULTS A total of 91 (41% male, median age 64 years) LAPC patients were included. The median time between CT-scan and staging laparoscopy was 21 days. During staging laparoscopy metastases were found in 17 patients (19%, 95% CI: 12%-28%). Seven (8%) patients had liver-only, 9 (10%) patients peritoneal-only, and 1 (1%) patient both liver and peritoneal metastases. Univariate logistic regression analysis showed that CEA (OR 1.056, 95% CI 1.007-1.107, p = 0.02) was the only preoperative predictor for occult metastases. In a multivariable logistic regression analysis of the preoperative risk factors again only CEA was an independent predictor for occult metastatic disease (p = 0.03). Patients with a CEA above 5 μg/L had a risk of occult metastasis of 91%. FOLFIRINOX was given to 69 (76%) of the patients with a median number of cycles of 8. Subsequent radiotherapy was given to 44 (48%) patients after the FOLFIRINOX treatment. Six (14%) patients underwent a resection after FOLFIRINOX and radiotherapy. The overall 1-year survival was 53% in patients without occult metastasis versus 29% with occult metastasis (p = 0.11). The 1-year OS for patients that completed FOLFIRINOX and radiotherapy was 84%. CONCLUSION The yield of staging laparoscopy for occult intrahepatic or peritoneal metastases in patients with locally advanced pancreatic cancer was 19%. Staging laparoscopy is recomended for patients with LAPC for accurate staging to determine optimal treatment.
Collapse
Affiliation(s)
- M Suker
- Department of Surgery, Erasmus MC University Medical Centre, Rotterdam, the Netherlands.
| | - B Groot Koerkamp
- Department of Surgery, Erasmus MC University Medical Centre, Rotterdam, the Netherlands
| | - P P Coene
- Department of Surgery, Maasstad Hospital, Rotterdam, the Netherlands
| | - E van der Harst
- Department of Surgery, Maasstad Hospital, Rotterdam, the Netherlands
| | - B A Bonsing
- Department of Surgery, Leiden University Medical Center, Leiden, the Netherlands
| | - A L Vahrmeijer
- Department of Surgery, Leiden University Medical Center, Leiden, the Netherlands
| | - J S D Mieog
- Department of Surgery, Leiden University Medical Center, Leiden, the Netherlands
| | - R J Swijnenburg
- Department of Surgery, Leiden University Medical Center, Leiden, the Netherlands
| | - R S Dwarkasing
- Department of Radiology, Erasmus MC University Medical Centre, Rotterdam, the Netherlands
| | - D Roos
- Department of Surgery, Reinier de Graaf Group, Delft, the Netherlands
| | - C H J van Eijck
- Department of Surgery, Erasmus MC University Medical Centre, Rotterdam, the Netherlands
| |
Collapse
|
21
|
Wu J, Li Z, Li Y, Pettitt A, Zhou F. Photothermal Effects of Reduced Graphene Oxide on Pancreatic Cancer. Technol Cancer Res Treat 2019; 17:1533034618768637. [PMID: 29665743 PMCID: PMC5912281 DOI: 10.1177/1533034618768637] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Pancreatic cancer is a malignant tumor model with high mortality. Many patients are ineligible for surgical resection once diagnosed; therefore, it is important to explore more safe and effective treatment options. This study was designed to determine the therapeutic effect of reduced graphene oxide combined with the near-infrared laser in animal pancreatic cancer. The results showed that reduced graphene oxide has strong light absorption ability between 600 and 1100 nm detected by spectrophotometer. Experimental results of different concentrations of reduced graphene oxide solution under 980-nm laser irradiation at different powers showed that the enhancement of the photothermal conversion effect of reduced graphene oxide depends on reduced graphene oxide concentration and light dose. In vivo experiments showed that higher laser dose (0.75 W/cm2) combined with higher reduced graphene oxide concentration (2 mg/kg) can achieve higher treatment temperature and slower tumor growth. These results suggest that reduced graphene oxide combined with the 980-nm laser in the treatment of mouse pancreatic cancer can get an ideal thermal killing effect, with the clinical potential of pancreatic cancer treatment.
Collapse
Affiliation(s)
- Jie Wu
- 1 Department of Biotechnology, College of Engineering and Technology, Beijing Normal University, Zhuhai, Guangdong, China
| | - Zhifang Li
- 2 College of Photonic and Electronic Engineering, Fujian Normal University, Fujian Provincial Key Laboratory of Photonic Technology, Key Laboratory of Optoelectronic Science and Technology for Medicine, Ministry of Education, Fuzhou, China
| | - Yong Li
- 3 Biophotonics Research Laboratory, Center for Interdisciplinary Biomedical Education and Research, University of Central Oklahoma, Edmond, OK, USA.,4 Department of Interventional Therapy, Tianjin Key Laboratory of Cancer Prevention and Therapy, Tianjin Medical University Cancer Institute and Hospital, Tianjin, China
| | - Alex Pettitt
- 3 Biophotonics Research Laboratory, Center for Interdisciplinary Biomedical Education and Research, University of Central Oklahoma, Edmond, OK, USA
| | - Feifan Zhou
- 2 College of Photonic and Electronic Engineering, Fujian Normal University, Fujian Provincial Key Laboratory of Photonic Technology, Key Laboratory of Optoelectronic Science and Technology for Medicine, Ministry of Education, Fuzhou, China.,3 Biophotonics Research Laboratory, Center for Interdisciplinary Biomedical Education and Research, University of Central Oklahoma, Edmond, OK, USA
| |
Collapse
|
22
|
Paiella S, De Pastena M, Romeo F, D'onofrio M, Fontana M, Pea A, De Marchi G, Crinò SF, Bassi C, Salvia R. Ablation treatments in unresectable pancreatic cancer. MINERVA CHIR 2019; 74:263-269. [PMID: 30600963 DOI: 10.23736/s0026-4733.18.07881-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Ablation treatments have been increasingly applied as an alternative treatment for unresectable locally advanced pancreatic cancer (LAPC). The goal of LAPC therapy is surgical resection with negative margins (R0); however, that can be achieved only in a minority of patients and only following neoadjuvant treatment. Ablation might be useful for those patients with unresectable LAPC that do not progress towards metastatic stage and do not experience a true downstaging. Indeed, some LAPC that tend to grow locally, might be the subgroup of tumors that could benefit from ablation. Experience is necessary to select patients and the technique to adopt, since serious or fatal complications can occur. This review aims to discuss the role of ablation treatments in LAPC, with a unique focus on radiofrequency ablation and irreversible electroporation.
Collapse
Affiliation(s)
- Salvatore Paiella
- Unit of General and Pancreatic Surgery, Pancreas Institute, Policlinico GB Rossi, University of Verona, Verona, Italy -
| | - Matteo De Pastena
- Unit of General and Pancreatic Surgery, Pancreas Institute, Policlinico GB Rossi, University of Verona, Verona, Italy
| | - Francesco Romeo
- Unit of General and Pancreatic Surgery, Pancreas Institute, Policlinico GB Rossi, University of Verona, Verona, Italy
| | - Mirko D'onofrio
- Unit of Radiology, Pancreas Institute, Policlinico GB Rossi, University of Verona, Verona, Italy
| | - Martina Fontana
- Unit of General and Pancreatic Surgery, Pancreas Institute, Policlinico GB Rossi, University of Verona, Verona, Italy
| | - Antonio Pea
- Unit of General and Pancreatic Surgery, Pancreas Institute, Policlinico GB Rossi, University of Verona, Verona, Italy
| | - Giulia De Marchi
- Unit of Gastroenterology B, Pancreas Institute, Policliclino GB Rossi, University of Verona, Verona, Italy
| | - Stefano F Crinò
- Unit of Gastroenterology and Digestive Endoscopy, Pancreas Institute, Policliclino GB Rossi, University of Verona, Verona, Italy
| | - Claudio Bassi
- Unit of General and Pancreatic Surgery, Pancreas Institute, Policlinico GB Rossi, University of Verona, Verona, Italy
| | - Roberto Salvia
- Unit of General and Pancreatic Surgery, Pancreas Institute, Policlinico GB Rossi, University of Verona, Verona, Italy
| |
Collapse
|
23
|
Saccomandi P, Lapergola A, Longo F, Schena E, Quero G. Thermal ablation of pancreatic cancer: A systematic literature review of clinical practice and pre-clinical studies. Int J Hyperthermia 2018; 35:398-418. [PMID: 30428728 DOI: 10.1080/02656736.2018.1506165] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
PURPOSE Pancreatic cancer is a challenging malignancy with low treatment option and poor life expectancy. Thermal ablation techniques were proposed as alternative treatment options, especially in advanced stages and for unfit-for-surgery patients. This systematic review describes the thermal ablative techniques -i.e., Laser (LA), Radiofrequency (RFA), Microwave (MWA) Ablation, High-Intensity Focused Ultrasound (HIFU) and cryoablation- available for pancreatic cancer treatment. Additionally, an analysis of the efficacy, complication rate and overall survival for each technique is conducted. MATERIAL AND METHODS This review collects the ex vivo, preclinical and clinical studies presenting the use of thermal techniques in the pancreatic cancer treatment, searched up to March 2018 in PubMed and Medline. Abstracts, letters-to-the-editor, expert opinions, reviews and non-English language manuscripts were excluded. RESULTS Sixty-five papers were included. For the ex vivo and preclinical studies, there are: 12 records for LA, 8 for RFA, 0 for MWA, 6 for HIFU, 1 for cryoablation and 3 for hybrid techniques. For clinical studies, 1 paper for LA, 14 for RFA, 1 for MWA, 17 for HIFU, 1 for cryoablation and 1 for hybrid techniques. CONCLUSIONS Important technological advances are presented in ex vivo and preclinical studies, as the real-time thermometry, nanotechnology and hybrid techniques to enhance the thermal outcome. Conversely, a lack of standardization in the clinical employment of the procedures emerged, leading to contrasting results on the safety and feasibility of some analyzed techniques. Uniform conclusions on the safety and feasibility of these techniques for pancreatic cancer will require further structured investigation.
Collapse
Affiliation(s)
- Paola Saccomandi
- a IHU-Strasbourg Institute of Image-Guided Surgery , Strasbourg , France.,b Departement of Mechanical Engineering, Politecnico di Milano , Milan , Italy
| | - Alfonso Lapergola
- a IHU-Strasbourg Institute of Image-Guided Surgery , Strasbourg , France.,c Università G. D'Annunzio , Chieti , Italy
| | - Fabio Longo
- a IHU-Strasbourg Institute of Image-Guided Surgery , Strasbourg , France.,d Fondazione Policlinico Universitario Agostino Gemelli IRCCS , Rome , Italy
| | | | - Giuseppe Quero
- d Fondazione Policlinico Universitario Agostino Gemelli IRCCS , Rome , Italy
| |
Collapse
|
24
|
Reccia I, Kumar J, Habib N, Sodergren M. The use of radiofrequency ablation in pancreatic cancer in the midst of the dawn of immuno-oncology. Med Oncol 2018; 35:151. [DOI: 10.1007/s12032-018-1209-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2018] [Accepted: 09/26/2018] [Indexed: 02/06/2023]
|
25
|
Dugarova RS, Berelavichus SV, Kaldarov AR, Gorin DS. [Physical minimally invasive treatment of pancreatic insulinoma]. Khirurgiia (Mosk) 2018:94-97. [PMID: 29697692 DOI: 10.17116/hirurgia2018494-97] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Affiliation(s)
- R S Dugarova
- Vishnevsky Institute of Surgery of Healthcare Ministry of the Russian Federation, Moscow, Russia
| | - S V Berelavichus
- Vishnevsky Institute of Surgery of Healthcare Ministry of the Russian Federation, Moscow, Russia
| | - A R Kaldarov
- Vishnevsky Institute of Surgery of Healthcare Ministry of the Russian Federation, Moscow, Russia
| | - D S Gorin
- Vishnevsky Institute of Surgery of Healthcare Ministry of the Russian Federation, Moscow, Russia
| |
Collapse
|
26
|
Mo Z, Lu H, Mo S, Fu X, Chang S, Yue J. Ultrasound-guided radiofrequency ablation enhances natural killer-mediated antitumor immunity against liver cancer. Oncol Lett 2018; 15:7014-7020. [PMID: 29725428 PMCID: PMC5920230 DOI: 10.3892/ol.2018.8231] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2017] [Accepted: 11/29/2017] [Indexed: 12/15/2022] Open
Abstract
For patients with liver cancer who are not sufficiently fit for surgical resection, radiofrequency ablation (RFA) is an effective and low risk treatment modality; however, the mechanism underlying this procedure is not fully understood. In the present study, a series of experiments were conducted, which demonstrated that RFA therapy stimulates innate antitumor immunity via directly enhancing natural killer (NK) cell cytotoxicity, thus achieving a favorable outcome for patients with liver tumors. It was determined that the percentage of NK cells within the peripheral blood of the rabbits in the RFA treatment groups were significantly higher, compared with the control groups. The levels of interferon-γ and tumor necrosis factor-α in NK cells were also significantly upregulated following thermal coagulation induced via RFA. In addition, RFA enhanced the NK cell receptor, NK group 2D (NKG2D), expression and NK cell antitumor cytotoxicity in hepatic cancer cells. The results indicated that the RFA treatment could effectively eliminate liver tumors via enhancing NK-mediated antitumor activity and NKG2D expression.
Collapse
Affiliation(s)
- Zelai Mo
- Department of Ultrasound, The Maternal and Child Health Hospital of Hainan, Haikou, Hainan 570206, P.R. China
| | - Hailan Lu
- Department of Respiratory Medicine, The Hainan General Hospital, Haikou, Hainan 570311, P.R. China
| | - Shaowei Mo
- Department of Science and Education, The Hainan General Hospital, Haikou, Hainan 570311, P.R. China
| | - Xiangmin Fu
- Department of Medical Records, The Hainan General Hospital, Haikou, Hainan 570311, P.R. China
| | - Shunwu Chang
- Department of General Surgery, The Hainan General Hospital, Haikou, Hainan 570311, P.R. China
| | - Jie Yue
- Department of Vascular Surgery, The Hainan General Hospital, Haikou, Hainan 570311, P.R. China
| |
Collapse
|
27
|
Kumar J, Reccia I, Sodergren MH, Kusano T, Zanellato A, Pai M, Spalding D, Zacharoulis D, Habib N. Radiofrequency assisted pancreaticoduodenectomy for palliative surgical resection of locally advanced pancreatic adenocarcinoma. Oncotarget 2018; 9:15732-15739. [PMID: 29644005 PMCID: PMC5884660 DOI: 10.18632/oncotarget.24596] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2017] [Accepted: 02/21/2018] [Indexed: 02/07/2023] Open
Abstract
Background Despite careful patient selection and preoperative investigations curative resection rate (R0) in pancreaticoduodenectomy ranges from 15% to 87%. Here we describe a new palliative approach for pancreaticoduodenectomy using a radiofrequency energy device to ablate tumor in situ in patients undergoing R1/R2 resections for locally advanced pancreatic ductal adenocarcinoma where vascular reconstruction was not feasible. Results There was neither postoperative mortality nor significant morbidity. Each time the ablation lasted less than 15 minutes. Following radiofrequency ablation it was observed that the tumor remnant attached to the vessel had shrunk significantly. In four patients this allowed easier separation and dissection of the ablated tumor from the adherent vessel leading to R1 resection. In the other two patients, the ablated tumor did not separate from vessel due to true tumor invasion and patients had an R2 resection. The ablated remnant part of the tumor was left in situ. Conclusion Whenever pancreaticoduodenectomy with R0 resection cannot be achieved, this new palliative procedure could be considered in order to facilitate resection and enable maximum destruction in remnant tumors. Method Six patients with suspected tumor infiltration and where vascular reconstruction was not warranted underwent radiofrequency-assisted pancreaticoduodenectomy for locally advanced pancreatic ductal adenocarcinoma. Radiofrequency was applied across the tumor vertically 5–10 mm from the edge of the mesenteric and portal veins. Following ablation, the duodenum and the head of pancreas were removed after knife excision along the ablated line. The remaining ablated tissue was left in situ attached to the vessel.
Collapse
Affiliation(s)
- Jayant Kumar
- Department of Surgery and Cancer, Hammersmith Campus, Imperial College London, London, UK
| | - Isabella Reccia
- Department of Surgery and Cancer, Hammersmith Campus, Imperial College London, London, UK
| | - Mikael H Sodergren
- Department of Surgery and Cancer, Hammersmith Campus, Imperial College London, London, UK
| | - Tomokazu Kusano
- Department of Surgery and Cancer, Hammersmith Campus, Imperial College London, London, UK
| | - Artur Zanellato
- Department of Surgery and Cancer, Hammersmith Campus, Imperial College London, London, UK
| | - Madhava Pai
- Department of Surgery and Cancer, Hammersmith Campus, Imperial College London, London, UK
| | - Duncan Spalding
- Department of Surgery and Cancer, Hammersmith Campus, Imperial College London, London, UK
| | | | - Nagy Habib
- Department of Surgery and Cancer, Hammersmith Campus, Imperial College London, London, UK
| |
Collapse
|
28
|
Vogl TJ, Panahi B, Albrecht MH, Naguib NNN, Nour-Eldin NEA, Gruber-Rouh T, Thompson ZM, Basten LM. Microwave ablation of pancreatic tumors. MINIM INVASIV THER 2017; 27:33-40. [PMID: 29278340 DOI: 10.1080/13645706.2017.1420664] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
OBJECTIVES To evaluate the clinical performance of percutaneous microwave ablation (MWA) for treatment of locally-advanced-pancreatic-cancer (LAPC). MATERIAL AND METHODS Twenty-two MWA sessions (August 2015-March 2017) in 20 patients with primary pancreatic cancer (13 men, 7 women, mean-age: 59.9 ± 8.6 years, range: 46-73 years), who had given informed consent, were retrospectively evaluated. All procedures were performed percutaneously under CT-guidance using the same high-frequency (2.45-GHz) MWA device. Tumor location and diameter, ablation diameter and volume, roundness, duration, technical success and efficacy, output energy, complications, and local tumor progression defined as a tumor focus connected to the edge of a previously technically efficient ablation zone were collected. RESULTS Seventeen pancreatic malignant tumors (77.3%) were located in the pancreatic head and five (22.7%) in the pancreatic tail. Initial Mean Tumor Diameter was 30 ± 6 mm. Technical success and efficacy were idem (100%). No major complications occurred. Two patients (9.1%) showed minor complications of severe local pain related to MWA. Post-ablation diameter was on average 34.4 ± 5.8 mm. Mean ablation volume was 7.8 ± 3.8 cm³. The mean transverse roundness index was 0.74 ± 0.14. Mean ablation time was 2.6 ± 0.96 min. The mean applied energy per treatment was 9627 ± 3953 J. Local tumor progression was documented in one case (10%) of the 10/22 available three-month follow-up imaging studies. CONCLUSION High-frequency (2.45 GHz) microwave ablation (MWA) for treatment of unresectable and non-metastatic locally-advanced-pancreatic-cancer (LAPC) shows promising results regarding feasibility and safety of percutaneous approach after short-term follow-up and should be further evaluated.
Collapse
Affiliation(s)
- Thomas J Vogl
- a Department of Diagnostic and Interventional Radiology , Frankfurt-University Hospital , Frankfurt am Main , Germany
| | - Bita Panahi
- a Department of Diagnostic and Interventional Radiology , Frankfurt-University Hospital , Frankfurt am Main , Germany
| | - Moritz H Albrecht
- a Department of Diagnostic and Interventional Radiology , Frankfurt-University Hospital , Frankfurt am Main , Germany
| | - Nagy Naguib Naeem Naguib
- a Department of Diagnostic and Interventional Radiology , Frankfurt-University Hospital , Frankfurt am Main , Germany
| | - Nour-Eldin A Nour-Eldin
- a Department of Diagnostic and Interventional Radiology , Frankfurt-University Hospital , Frankfurt am Main , Germany
| | - Tatjana Gruber-Rouh
- a Department of Diagnostic and Interventional Radiology , Frankfurt-University Hospital , Frankfurt am Main , Germany
| | - Zachary M Thompson
- b Department of Radiology and Radiological Science , Medical University of South Carolina , Charleston , SC , USA
| | - Lajos M Basten
- a Department of Diagnostic and Interventional Radiology , Frankfurt-University Hospital , Frankfurt am Main , Germany
| |
Collapse
|
29
|
O Kane GM, Knox JJ. Locally advanced pancreatic cancer: An emerging entity. Curr Probl Cancer 2017; 42:12-25. [PMID: 29153290 DOI: 10.1016/j.currproblcancer.2017.10.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2017] [Revised: 10/29/2017] [Accepted: 10/30/2017] [Indexed: 12/23/2022]
Abstract
Pancreatic adenocarcinoma (PDAC) remains a highly fatal disease that is increasing in incidence. PDAC can be classified according to resectability status with 3 nonmetastatic groups defined: resectable, borderline resectable, and locally advanced PDAC (LAPC). Delineating these subtypes is important with the optimal treatment approach dictated by high-quality CT imaging and multidisciplinary team discussion. Patients with LAPC are thought unresectable and are therefore rarely cured. In these patients, chemotherapy remains the mainstay of treatment. Aggressive approaches in this cohort are increasingly employed. Local therapies after induction chemotherapy including standard fractionation radiation, stereotactic body radiotherapy (SBRT), and irreversible electroporation (IRE) are being investigated in an attempt to improve long-term control. In some cases, responses to neoadjuvant therapy may facilitate surgical resection. Biomarkers that can select patients most likely to benefit from these options are urgently needed. This review aims to highlight the emerging treatment of patients with LAPC and to discuss current trials.
Collapse
|
30
|
Giardino A, Innamorati G, Ugel S, Perbellini O, Girelli R, Frigerio I, Regi P, Scopelliti F, Butturini G, Paiella S, Bacchion M, Bassi C. Immunomodulation after radiofrequency ablation of locally advanced pancreatic cancer by monitoring the immune response in 10 patients. Pancreatology 2017; 17:962-966. [PMID: 29037917 DOI: 10.1016/j.pan.2017.09.008] [Citation(s) in RCA: 47] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2017] [Revised: 08/29/2017] [Accepted: 09/25/2017] [Indexed: 02/06/2023]
Abstract
OBJECTIVE/BACKGROUND RFA of pancreatic cancer has been demonstrated to be feasible and safe with a positive impact on survival. The aim was to investigate whether an immune reaction is activated after locally advanced pancreatic cancer (LAPC) ablation. METHODS Peripheral Blood samples were obtained preoperatively and on post-operative days 3-30. Evaluated parameters were: cells [CD4+, CD8+ and activated subsets, T-Reg, Monocytes, myeloid and plasmocytoid Dendritic cells (mDC and pDC)] and cytokines [Interleukin (IL)-6, Stromal-cells derived factor (SDF)-1, IL-1β, Tumour-Necrosis Factor (TNF)-α, Interferon (IFN)-γ, Vascular Endothelial Growth Factor (VEGF), chemokine (C-C motif) ligand 5 (CCL-5), Transforming-Growth Factor (TGF)-β]. RESULTS Ten patients were enrolled. CD4+, CD8+ and TEM increased from day 3 suggesting the activation of the adaptive response. Immunosuppressive T-Reg cells were stable despite the possibility that laparotomy and heating might favour their expansion. Myeloid DCs, that present tumour-associated antigens, increased at day 30. RFA dramatically increased circulating IL-6 at day 3 but this decreased to baseline by day 30, consistent with the supposed anti-tumour effect. RFA did not significantly modulate essential chemokines, such as CCL-5 and SDF1, VEGF, TGF-β and TNF-α, that favour tumour-growth by sustaining cancer angiogenesis and fuelling tumour-associated inflammation. CONCLUSIONS This study provides the first evidence of RFA-based immunomodulation in LAPC. We observed a general activation of adaptive response along with a decrease of immunosuppression. Furthermore, most cells showed prolonged activation some weeks after the procedure, suggesting true immunomodulation rather than a normal inflammatory response.
Collapse
Affiliation(s)
- Alessandro Giardino
- Hepato-Biliary and Pancreatic Unit, Ospedale Dott. Pederzoli, Peschiera del Garda, VR, Italy.
| | | | | | | | - Roberto Girelli
- Hepato-Biliary and Pancreatic Unit, Ospedale Dott. Pederzoli, Peschiera del Garda, VR, Italy
| | - Isabella Frigerio
- Hepato-Biliary and Pancreatic Unit, Ospedale Dott. Pederzoli, Peschiera del Garda, VR, Italy
| | - Paolo Regi
- Hepato-Biliary and Pancreatic Unit, Ospedale Dott. Pederzoli, Peschiera del Garda, VR, Italy
| | - Filippo Scopelliti
- Hepato-Biliary and Pancreatic Unit, Ospedale Dott. Pederzoli, Peschiera del Garda, VR, Italy
| | - Giovanni Butturini
- Hepato-Biliary and Pancreatic Unit, Ospedale Dott. Pederzoli, Peschiera del Garda, VR, Italy
| | | | - Matilde Bacchion
- General Surgery Department, Pederzoli Hospital, Peschiera del Garda, VR, Italy
| | | |
Collapse
|
31
|
Thermal Ablation of the Pancreas With Intraoperative High-Intensity Focused Ultrasound: Safety and Efficacy in a Porcine Model. Pancreas 2017; 46:219-224. [PMID: 27841792 DOI: 10.1097/mpa.0000000000000720] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
OBJECTIVE New focal destruction technologies such as high-intensity focused ultrasound (HIFU) may improve the prognosis of pancreatic ductal adenocarcinoma. Our objectives were to demonstrate the safety and efficacy of intraoperative pancreatic HIFU ablation in a porcine model. METHODS In a porcine model (N = 12), a single HIFU ablation was performed in either the body or tail of the pancreas, distant to superior mesenteric vessels. All animals were sacrificed on the eighth day. The primary objective was to obtain an HIFU ablation measuring at least 1 cm without premature death. RESULTS In total, 12 HIFU ablations were carried out. These ablations were performed within 160 seconds and on average measured 20 (15-27) × 16 (8-26) mm. The primary objective was fulfilled in all but 1 pig. There were no premature deaths or severe complications. High-intensity focused ultrasound treatment was associated with a transitory increase in amylase and lipase levels, and pseudocysts were observed in half of the pigs without being clinically apparent. All ablations were well delimited at both gross and histological examinations. CONCLUSIONS Intraoperative thermal destruction of porcine pancreas with HIFU is feasible. Reproducibility and safety have to be confirmed when applied close to mesenteric vessels and in long-term preclinical studies.
Collapse
|
32
|
An update on the role of irreversible electroporation in locally advanced pancreatic adenocarcinoma. HPB (Oxford) 2016; 18:791-792. [PMID: 27542589 PMCID: PMC5061020 DOI: 10.1016/j.hpb.2016.07.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2016] [Revised: 06/22/2016] [Accepted: 07/08/2016] [Indexed: 12/12/2022]
|
33
|
Yılmaz S, Özdoğan M, Cevener M, Ozluk A, Kargi A, Kendiroglu F, Ogretmen I, Yildiz A. Use of cryoablation beyond the prostate. Insights Imaging 2016; 7:223-32. [PMID: 26762141 PMCID: PMC4805614 DOI: 10.1007/s13244-015-0460-7] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2015] [Revised: 12/04/2015] [Accepted: 12/11/2015] [Indexed: 12/19/2022] Open
Abstract
UNLABELLED Cryoablation has been used for many years as a surgical ablation technique in the prostate and kidney. However, since the introduction of high-intensity focused ultrasound (HIFU) and robotic surgery for prostate tumours, its popularity in the urologic community has declined. In the early 2000s, innovations in cryoablation technology allowed the use of thinner probes, which were suitable for percutaneous application. As a result, radiologists began using cryoablation, first in the liver, and then in other organs or tissues such as the kidney, lung, breast, pancreas, bone, and soft tissue. In most of these locations, cryoablation has great potential given its inherent advantages, including the use of local anaesthesia, little or no pain during and after the procedure, real-time monitoring of the ablation area on US, CT or MRI, the potential for ablation of large tumours with multiple probes, and the ability to change the shape of the ablation in non-spherical tumours. Yet despite these advantages, the use of percutaneous cryoablation among radiologists appears to be far lower than that of heat-based ablation techniques. The aim of this article is to outline specific aspects of cryoablation and to illustrate its potential clinical applications with case presentations. KEY POINTS • Recent advances have made cryoablation suitable for percutaneous use by radiologists with image guidance. • Cryoablation has distinct advantages over heat-based ablation techniques. • Cryoablation is becoming increasingly popular for lung, breast, kidney, bone, and soft tissue tumours.
Collapse
Affiliation(s)
- Saim Yılmaz
- MIIO Group, Radiology Division, Memorial-MedStar Hospitals, Antalya, Turkey.
- MIIO: Mediterranean Integrative and Innovative Oncology, Antalya, Turkey.
| | - Mustafa Özdoğan
- MIIO Group, Medical Oncology Division, Memorial-MedStar Hospitals, Antalya, Turkey
| | - Metin Cevener
- MIIO Group, Radiology Division, Memorial-MedStar Hospitals, Antalya, Turkey
| | - Ali Ozluk
- MIIO Group, General Surgery Division, Memorial-MedStar Hospitals, Antalya, Turkey
| | - Aysegul Kargi
- MIIO Group, Medical Oncology Division, Memorial-MedStar Hospitals, Antalya, Turkey
| | - Feride Kendiroglu
- MIIO Group, Radiology Division, Memorial-MedStar Hospitals, Antalya, Turkey
| | - Irfan Ogretmen
- MIIO Group, Medical Oncology Division, Memorial-MedStar Hospitals, Antalya, Turkey
| | - Akin Yildiz
- MIIO Group, Nuclear Medicine Division, Memorial-MedStar Hospitals, Antalya, Turkey
| |
Collapse
|
34
|
D'Onofrio M, Barbi E, Girelli R, Tinazzi Martini P, De Robertis R, Ciaravino V, Salvia R, Butturini G, Frigerio I, Milazzo T, Crosara S, Paiella S, Pederzoli P, Bassi C. Variation of tumoral marker after radiofrequency ablation of pancreatic adenocarcinoma. J Gastrointest Oncol 2016; 7:213-20. [PMID: 27034788 DOI: 10.3978/j.issn.2078-6891.2015.085] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND To evaluate the correlation between variations of CA 19.9 blood levels and the entity of necrosis at CT after radiofrequency ablation (RFA) of unresectable pancreatic adenocarcinoma. METHODS In this study, from June 2010 to February 2014, patients with diagnosis of unresectable and not metastatic pancreatic ductal adenocarcinoma, expressing tumor marker CA 19.9, treated with RFA procedure were included. All these patients underwent RFA. CT study was performed 1 week after RFA. The dosage of CA 19.9 levels was performed 1 month after RFA. Features of necrosis at CT, as mean entity, density and necrosis percentages compared to the original lesion, were evaluated and compared by using t-test with CA 19.9 blood levels variations after RFA procedure. RESULTS In this study were included 51 patients with diagnosis of unresectable and not metastatic pancreatic ductal adenocarcinoma, expressing tumor marker CA 19.9, treated with RFA procedure and with CT study and CA 19.9 available for analysis. After the procedure, CA 19.9 blood levels reduced in 24/51 (47%), remained stable in 10/51 (20%) and increased in 17/51 (33%). In patients with CA 19.9 levels reduced, the tumor marker were reduced less than 20% in 4/24 (17%) and more than 20% in 20/24 (83%); instead the tumor marker were reduced less than 30% in 8/24 (33%) and more than 30% in 16/24 (67%). At CT scan necrotic area density difference was not statistically significant. Also there was no statistically significant difference among the mean area, the mean volume and the mean ablation volume in percentage related to the treated tumor among the three different groups of patients divided depending on the CA 19.9 blood levels. But a tendency to a statistically significant difference was found in comparing the mean percentage of ablation volume between two subgroups of patients with a decrease of CA 19.9 levels with less or more than 20% reduction of tumor markers and between two subgroups with less or more than 30% reduction of CA 19.9 levels. CONCLUSIONS RFA of unresectable pancreatic adenocarcinoma induces reduction of CA 19.9 blood levels in about half of the cases.
Collapse
Affiliation(s)
- Mirko D'Onofrio
- 1 Department of Radiology, G.B. Rossi Hospital, University of Verona, Verona, Italy ; 2 Department of Radiology, 3 Department of Surgery, Casa di Cura Dott. Pederzoli, Peschiera del Garda, Verona, Italy ; 4 Department of Surgery, G.B. Rossi Hospital, University of Verona, Verona, Italy
| | - Emilio Barbi
- 1 Department of Radiology, G.B. Rossi Hospital, University of Verona, Verona, Italy ; 2 Department of Radiology, 3 Department of Surgery, Casa di Cura Dott. Pederzoli, Peschiera del Garda, Verona, Italy ; 4 Department of Surgery, G.B. Rossi Hospital, University of Verona, Verona, Italy
| | - Roberto Girelli
- 1 Department of Radiology, G.B. Rossi Hospital, University of Verona, Verona, Italy ; 2 Department of Radiology, 3 Department of Surgery, Casa di Cura Dott. Pederzoli, Peschiera del Garda, Verona, Italy ; 4 Department of Surgery, G.B. Rossi Hospital, University of Verona, Verona, Italy
| | - Paolo Tinazzi Martini
- 1 Department of Radiology, G.B. Rossi Hospital, University of Verona, Verona, Italy ; 2 Department of Radiology, 3 Department of Surgery, Casa di Cura Dott. Pederzoli, Peschiera del Garda, Verona, Italy ; 4 Department of Surgery, G.B. Rossi Hospital, University of Verona, Verona, Italy
| | - Riccardo De Robertis
- 1 Department of Radiology, G.B. Rossi Hospital, University of Verona, Verona, Italy ; 2 Department of Radiology, 3 Department of Surgery, Casa di Cura Dott. Pederzoli, Peschiera del Garda, Verona, Italy ; 4 Department of Surgery, G.B. Rossi Hospital, University of Verona, Verona, Italy
| | - Valentina Ciaravino
- 1 Department of Radiology, G.B. Rossi Hospital, University of Verona, Verona, Italy ; 2 Department of Radiology, 3 Department of Surgery, Casa di Cura Dott. Pederzoli, Peschiera del Garda, Verona, Italy ; 4 Department of Surgery, G.B. Rossi Hospital, University of Verona, Verona, Italy
| | - Roberto Salvia
- 1 Department of Radiology, G.B. Rossi Hospital, University of Verona, Verona, Italy ; 2 Department of Radiology, 3 Department of Surgery, Casa di Cura Dott. Pederzoli, Peschiera del Garda, Verona, Italy ; 4 Department of Surgery, G.B. Rossi Hospital, University of Verona, Verona, Italy
| | - Giovanni Butturini
- 1 Department of Radiology, G.B. Rossi Hospital, University of Verona, Verona, Italy ; 2 Department of Radiology, 3 Department of Surgery, Casa di Cura Dott. Pederzoli, Peschiera del Garda, Verona, Italy ; 4 Department of Surgery, G.B. Rossi Hospital, University of Verona, Verona, Italy
| | - Isabella Frigerio
- 1 Department of Radiology, G.B. Rossi Hospital, University of Verona, Verona, Italy ; 2 Department of Radiology, 3 Department of Surgery, Casa di Cura Dott. Pederzoli, Peschiera del Garda, Verona, Italy ; 4 Department of Surgery, G.B. Rossi Hospital, University of Verona, Verona, Italy
| | - Teresa Milazzo
- 1 Department of Radiology, G.B. Rossi Hospital, University of Verona, Verona, Italy ; 2 Department of Radiology, 3 Department of Surgery, Casa di Cura Dott. Pederzoli, Peschiera del Garda, Verona, Italy ; 4 Department of Surgery, G.B. Rossi Hospital, University of Verona, Verona, Italy
| | - Stefano Crosara
- 1 Department of Radiology, G.B. Rossi Hospital, University of Verona, Verona, Italy ; 2 Department of Radiology, 3 Department of Surgery, Casa di Cura Dott. Pederzoli, Peschiera del Garda, Verona, Italy ; 4 Department of Surgery, G.B. Rossi Hospital, University of Verona, Verona, Italy
| | - Salvatore Paiella
- 1 Department of Radiology, G.B. Rossi Hospital, University of Verona, Verona, Italy ; 2 Department of Radiology, 3 Department of Surgery, Casa di Cura Dott. Pederzoli, Peschiera del Garda, Verona, Italy ; 4 Department of Surgery, G.B. Rossi Hospital, University of Verona, Verona, Italy
| | - Paolo Pederzoli
- 1 Department of Radiology, G.B. Rossi Hospital, University of Verona, Verona, Italy ; 2 Department of Radiology, 3 Department of Surgery, Casa di Cura Dott. Pederzoli, Peschiera del Garda, Verona, Italy ; 4 Department of Surgery, G.B. Rossi Hospital, University of Verona, Verona, Italy
| | - Claudio Bassi
- 1 Department of Radiology, G.B. Rossi Hospital, University of Verona, Verona, Italy ; 2 Department of Radiology, 3 Department of Surgery, Casa di Cura Dott. Pederzoli, Peschiera del Garda, Verona, Italy ; 4 Department of Surgery, G.B. Rossi Hospital, University of Verona, Verona, Italy
| |
Collapse
|
35
|
Spadi R, Brusa F, Ponzetti A, Chiappino I, Birocco N, Ciuffreda L, Satolli MA. Current therapeutic strategies for advanced pancreatic cancer: A review for clinicians. World J Clin Oncol 2016; 7:27-43. [PMID: 26862489 PMCID: PMC4734936 DOI: 10.5306/wjco.v7.i1.27] [Citation(s) in RCA: 61] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2015] [Revised: 09/22/2015] [Accepted: 11/23/2015] [Indexed: 02/06/2023] Open
Abstract
Pancreatic cancer (PC) would become the second leading cause of cancer death in the near future, despite representing only 3% of new cancer diagnosis. Survival improvement will come from a better knowledge of risk factors, earlier diagnosis, better integration of locoregional and systemic therapies, as well as the development of more efficacious drugs rising from a deeper understanding of disease biology. For patients with unresectable, non-metastatic disease, combined strategies encompassing primary chemotherapy and radiation seems to be promising. In fit patients, new polychemotherapy regimens can lead to better outcomes in terms of slight but significant survival improvement associated with a positive impact on quality of life. The upfront use of these regimes can also increase the rate of radical resections in borderline resectable and locally advanced PC. Second line treatments showed to positively affect both overall survival and quality of life in fit patients affected by metastatic disease. At present, oxaliplatin-based regimens are the most extensively studied. Nonetheless, other promising drugs are currently under evaluation. Presently, in addition to surgery and conventional radiation therapy, new locoregional treatment techniques are emerging as alternative options in the multimodal approach to patients or diseases not suitable for radical surgery. As of today, in contrast with other types of cancer, targeted therapies failed to show relevant activity either alone or in combination with chemotherapy and, thus, current clinical practice does not include them. Up to now, despite the fact of extremely promising results in different tumors, also immunotherapy is not in the actual therapeutic armamentarium for PC. In the present paper, we provide a comprehensive review of the current state of the art of clinical practice and research in PC aiming to offer a guide for clinicians on the most relevant topics in the management of this disease.
Collapse
|
36
|
Al-Hawary MM, Francis IR, Anderson MA. Pancreatic Solid and Cystic Neoplasms: Diagnostic Evaluation and Intervention. Radiol Clin North Am 2015; 53:1037-48. [PMID: 26321452 DOI: 10.1016/j.rcl.2015.05.005] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
High-resolution imaging modalities, such as multi-detector computed tomography, MR imaging, and endoscopic ultrasound, are frequently used alone or in combination to characterize focal solid and cystic pancreatic neoplasms. Imaging in solid pancreatic neoplasms, typically adenocarcinoma and neuroendocrine tumors, is primarily used to detect and stage the extent of the tumor and to determine if complete surgical resection for cure is feasible. In cystic pancreatic masses, imaging aims to differentiate benign nonmucinous cystic lesions from potentially or frankly malignant mucin-producing cysts. Several noninvasive and invasive treatment options can be performed if surgical resection is not possible or contraindicated.
Collapse
Affiliation(s)
- Mahmoud M Al-Hawary
- Division of Abdominal Imaging, Department of Radiology, University of Michigan Hospitals, 1500 East Medical Center Drive, Room B1 D502, Ann Arbor, MI 48109, USA.
| | - Isaac R Francis
- Division of Abdominal Imaging, Department of Radiology, University of Michigan Hospitals, 1500 East Medical Center Drive, Room B1 D540, Ann Arbor, MI 48109, USA
| | - Michelle A Anderson
- Division of Gastroenterology, Department of Internal Medicine, University of Michigan Hospitals, 1500 East Medical Center Drive, Ann Arbor, MI 48109, USA
| |
Collapse
|
37
|
Pancreatic metastasis from clear cell renal cell carcinoma: outcome of an aggressive approach. Urology 2015; 85:135-40. [PMID: 25530375 DOI: 10.1016/j.urology.2014.09.034] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2014] [Revised: 08/25/2014] [Accepted: 09/23/2014] [Indexed: 12/19/2022]
Abstract
OBJECTIVE To evaluate the long-term results of patients surgically treated for metastatic clear cell renal cell carcinoma (CCRCC) with a unique pancreatic secondary localization to assess the importance of radical treatment in this rare group of patients. PATIENTS AND METHODS This is a retrospective monocentric study including 20 surgically treated patients between 1997 and 2012 for a unique pancreatic metastasis of a CCRCC. The main objective was to evaluate the outcome after surgical resection. RESULTS Twenty patients were followed up for a CCRCC. The M/F ratio was 1.2. The average age of onset of kidney cancer was 57.05 ± 7.78 years. Two patients who had synchronous pancreatic metastasis and 18 patients who had metachronous metastasis appeared after an average of 130 ± 59 months (24-240 months). The average size of the metastases was 20 ± 11.6 mm. Pancreatic metastasis was unique in all patients, with 35% of patients having multiple lesions of the pancreas. All patients underwent a pancreatic resection of metastasis. Histologic examination confirmed the location of a secondary CCRCC in all patients. Median follow-up after pancreatectomy was 69 months (1-150 months). Disease-free survival at 2 years was 60%. Overall survival rates at 2 and 4 years were 79% and 72%, respectively. There was no difference found between patients with multiple and unique pancreatic metastases in overall survival. CONCLUSION Unique pancreatic metastasis of CCRCC is rare. The literature on this subject is limited. Surgical resection might be an option and can be associated with long-term disease-free intervals in highly selected patients.
Collapse
|
38
|
Current status of Interventional Radiology in the management of Gastro-Entero-Pancreatic Neuroendocrine Tumours (GEP-NETs). Cardiovasc Intervent Radiol 2014; 38:13-24. [PMID: 25366087 DOI: 10.1007/s00270-014-1005-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2014] [Accepted: 08/18/2014] [Indexed: 12/18/2022]
Abstract
Within the group of Gastro-Entero-Pancreatic Neuroendocrine tumours (GEP-NETs), several heterogeneous malignancies are included with a variety of clinical manifestations and imaging characteristics. Often these cases are inoperable and minimal invasive treatment offered by image-guided procedures appears to be the only option. Interventional radiology offers a valid solution in the management of primary and metastatic GEP-NETs. The purpose of this review article is to describe the current status of the role of Interventional Radiology in the management of GEP-NETs.
Collapse
|
39
|
Radiofrequency ablation of small breast tumours: Evaluation of a novel bipolar cool-tip application. Eur J Surg Oncol 2014; 40:1222-9. [DOI: 10.1016/j.ejso.2014.07.031] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2014] [Revised: 07/07/2014] [Accepted: 07/08/2014] [Indexed: 01/15/2023] Open
|
40
|
Liu K, Ji B, Zhang W, Liu S, Wang Y, Liu Y. Comparison of iodine-125 seed implantation and pancreaticoduodenectomy in the treatment of pancreatic cancer. Int J Med Sci 2014; 11:893-6. [PMID: 25013369 PMCID: PMC4081311 DOI: 10.7150/ijms.8948] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2014] [Accepted: 05/29/2014] [Indexed: 12/20/2022] Open
Abstract
OBJECTIVE This retrospective study compared the advantages and disadvantages of iodine-125 (125I) seed implantation and pancreaticoduodenectomy (PD) in the treatment of pancreatic cancer. METHODS Patients with diagnosed pancreatic cancer who were treated with 125125I seed implantation (30 patients) or PD (30 patients) in our hospital were evaluated for operative time, bleeding, liver function, time to first bowel movement and normal diet, survival, and medical costs. RESULTS Compared with patients who underwent PD, those given 125I seed implantation had significantly shorter operative time, less bleeding, higher albumin, shorter periods to bowel movement and normal diet, lower risk of complications, and lower medical costs (P < 0.001, each). The difference of bilirubin level, time to feeding, and median survival were not significant statistically between two treatment grouops. CONCLUSION For pancreatic cancer patients for whom PD is not appropriate or who refuse PD, 125I seed implantation is a good option.
Collapse
Affiliation(s)
| | | | | | | | | | - Yahui Liu
- Department of Hepatobiliary and Pancreatic Surgery, the First Bethune Hospital, Jilin University, Jilin 130021, China
| |
Collapse
|