Combined modality treatment for patients with locally advanced pancreatic adenocarcinoma

Endoscopic Ultrasound-Guided Ablation of Premalignant Pancreatic Cysts and Pancreatic Cancer

Pancreatic cancer is on the rise and expected to become the second leading cause of cancer-related death by 2030. Up to a one-fifth of pancreatic cancers may arise from mucinous pancreatic cysts, which are frequently present in the general population. Currently, surgical resection is the only curative approach for pancreatic cancer and its cystic precursors. However, only a dismal proportion of patients are eligible for surgery. Therefore, novel treatment approaches to treat pancreatic cancer and precancerous pancreatic cysts are needed. Endoscopic ultrasound (EUS)-guided ablation is an emerging minimally invasive method to treat pancreatic cancer and premalignant pancreatic cysts. Different ablative modalities have been used including alcohol, chemotherapy agents, and radiofrequency ablation. Cumulative data over the past two decades have shown that endoscopic ablation of mucinous pancreatic cysts can lead to cyst resolution in a significant proportion of the treated cysts. Furthermore, novel data are emerging about the ability to endoscopically ablate early and locally advanced pancreatic cancer. In this review, we aim to summarize the available data on the efficacy and safety of the different EUS-ablation modalities for the management of premalignant pancreatic cysts and pancreatic cancer.

A Review on Endoscopic Ultrasound-Guided Radiofrequency Ablation (EUS-RFA) of Pancreatic Lesions

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.

Endobiliary and Pancreatic Radiofrequency Ablations

Radio frequency ablation (RFA) involves use of thermal energy to perform ablation of tissues. It has a wide range of application in gastrointestinal tract. Over the last few years, several studies have reported successful and safe application in the biliary and pancreatic tissues. It is particularly beneficial in patients with biliary malignancies in whom it has shown to improve survival. Additionally, it can be applied in occluded metal stents secondary to tumor ingrowth to prolong the patency of stents. In pancreas, RFA can successfully ablate cystic lesions and neuroendocrine tumors. It has also been applied in unresectable pancreatic cancers. This review discusses the application of endobiliary and pancreatic RFAs.

Interventional gastroenterology in oncology

Cancer is one of the foremost health problems worldwide and is among the leading causes of death in the United States. Gastrointestinal tract cancers account for almost one third of the cancer-related mortality globally, making it one of the deadliest groups of cancers. Early diagnosis and prompt management are key to preventing cancer-related morbidity and mortality. With advancements in technology and endoscopic techniques, endoscopy has become the core in diagnosis and management of gastrointestinal tract cancers. In this extensive review, the authors discuss the role endoscopy plays in early detection, diagnosis, and management of esophageal, gastric, colorectal, pancreatic, ampullary, biliary tract, and small intestinal cancers.

EUS-guided ablation with the HybridTherm Probe as second-line treatment in patients with locally advanced pancreatic ductal adenocarcinoma: A case-control study

Background and Objectives

Data on the clinical efficacy of EUS-guided ablation using the HybridTherm-Probe (EUS-HTP) in locally advanced pancreatic ductal adenocarcinoma (LA-PDAC) are lacking. The aim of the study was to assess the impact of EUS-HTP added to chemotherapy (CT) on overall survival (OS) and progression-free survival (PFS) of LA-PDAC patients with local disease progression (DP) after first-line therapy, compared to CT alone in controls.

Methods

LA-PDAC cases, prospectively treated by EUS-HTP, were retrospectively compared to matched controls (1:2) receiving standard treatment. Study endpoints were the OS and PFS from local DP after first-line therapy, compared through log-rank test calculating hazard ratios and differences in restricted mean OS/PFS time (RMOST/RMPFST) within prespecified time points (4, 6, and 12 months).

Results

Thirteen cases and 26 controls were included. Clinical, tumor, and therapy features before and after first-line therapy were case-control balanced. The median OS and PFS were not significantly improved in cases over controls (months: 7 vs. 5 and 5 vs. 3, respectively). At 4 and 6 months, the RMPFST difference was in favor of cases (P = 0.0001 and P = 0.003, respectively). In cases and controls not candidate to further CT (N = 5 and N = 9), the median OS and PFS were not significantly improved in cases over controls (months: 6 vs. 3 and 4 vs. 2, respectively), but the RMPFST difference was in favor of cases at 4 months (P = 0.002).

Conclusions

In locally progressive PDAC patients experiencing failure of first-line therapy, EUS-HTP achieves a significantly better RMPFST up to 6 months compared to standard treatment, although without a significant impact on OS.

US-Guided Percutaneous Radiofrequency Ablation of Locally Advanced Pancreatic Adenocarcinoma: A 5-Year High-Volume Center Experience

PURPOSE

 The aim of this study was to investigate the safety and effectiveness of percutaneous radiofrequency ablation (RFA) in locally advanced pancreatic cancer (LAPC) of the pancreatic body by assessing the overall survival of patients and evaluating the effects of the procedure in the clinical and radiological follow-up.

MATERIALS AND METHODS

 Patients with unresectable LAPC after failed chemoradiotherapy for at least six months were retrospectively included. Percutaneous RFA was performed after a preliminary ultrasound (US) feasibility evaluation. Contrast-enhanced computed tomography (CT) and CA 19.9 sampling were performed before and 24 hours and 30 days after the procedure to evaluate the effects of the ablation. Patients were followed-up after discharge considering the two main endpoints: procedure-related complications and death.

RESULTS

 35 patients were included, 5 were excluded. All patients underwent RFA with no procedure-related complications reported. The mean size of tumors was 49 mm before treatment. The mean dimension of the ablated necrotic zone was 32 mm, with a mean extension of 65 % compared to the whole tumor size. Tumor density was statistically reduced one day after the procedure (p < 0.001). The mean CA 19.9 levels before and 24 hours and 30 days after the procedure were 285.8 U/mL, 635.2 U/mL, and 336.0 U/mL, respectively, with a decrease or stability at the 30-day evaluation in 80 % of cases. The mean survival was 310 (65-718) days.

CONCLUSION

 Percutaneous RFA of LAPC is a feasible technique in patients who cannot undergo surgery, with great debulking effects and a very low complication rate.

The underlying molecular mechanism of intratumoral radiofrequency hyperthermia-enhanced chemotherapy of pancreatic cancer

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.

EUS-RFA of the pancreas: where are we and future directions

Surgical resection remains the gold standard for pancreatic cancer, high-risk pancreatic neuroendocrine tumors (PNETs) and pancreatic cystic neoplasms (PCNs). However, a majority of pancreatic cancers are unresectable at the time of diagnosis. In addition, surgical resection of pancreatic lesions can be associated with morbidity and mortality. A less-invasive alternative therapeutic intervention to avoid short term and long-term adverse events is desirable, as is a minimally-invasive palliative therapy for unresectable or recurrent pancreatic cancers. Endoscopic ultrasound guided radiofrequency ablation (EUS-RFA) allows for selective tissue ablation with minimal injury to the surrounding tissue. EUS-RFA of pancreatic tumors has shown high clinical and technical success with acceptable side effects in pancreatic lesions, lymph nodes, and the celiac plexus. This paper will review the pathophysiology, available technology, safety and efficacy, and future directions of EUS-RFA.

Role of endoscopic ultrasound in anticancer therapy: Current evidence and future perspectives

The digestive system is one of the most common sites of malignancies in humans. Since gastrointestinal tumors represent a massive global health burden both in terms of morbidity and health care expenditures, scientists continuously develop novel diagnostic and therapeutic methods to ameliorate the detrimental effects of this group of diseases. Apart from the well-established role of the endoscopic ultrasound (EUS) in the diagnostic course of gastrointestinal and hepatobiliary malignancies, we have recently become acquainted with a vast array of its therapeutic possibilities. A multitude of previously established, evidence-based methods that might now be guided by the EUS emerged: Radiofrequency ablation, brachytherapy, fine needle injection, celiac plexus neurolysis, and endoscopic submucosal dissection. In this review we endeavored to provide a comprehensive overview of the role of these methods in different malignancies of the digestive system, primarily in the treatment and symptom control in pancreatic cancer, and additionally in the management of hepatic, gastrointestinal tumors, and pancreatic cysts.

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

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.

Radiofrequency ablation and chemotherapy versus chemotherapy alone for locally advanced pancreatic cancer (PELICAN): study protocol for a randomized controlled trial

Background

Approximately 80% of patients with locally advanced pancreatic cancer (LAPC) are treated with chemotherapy, of whom approximately 10% undergo a resection. Cohort studies investigating local tumor ablation with radiofrequency ablation (RFA) have reported a promising overall survival of 26–34 months when given in a multimodal setting. However, randomized controlled trials (RCTs) investigating the effect of RFA in combination with chemotherapy in patients with LAPC are lacking.

Methods

The “Pancreatic Locally Advanced Unresectable Cancer Ablation” (PELICAN) trial is an international multicenter superiority RCT, initiated by the Dutch Pancreatic Cancer Group (DPCG). All patients with LAPC according to DPCG criteria, who start with FOLFIRINOX or (nab-paclitaxel/)gemcitabine, are screened for eligibility. Restaging is performed after completion of four cycles of FOLFIRINOX or two cycles of (nab-paclitaxel/)gemcitabine (i.e., 2 months of treatment), and the results are assessed within a nationwide online expert panel. Eligible patients with RECIST stable disease or objective response, in whom resection is not feasible, are randomized to RFA followed by chemotherapy or chemotherapy alone. In total, 228 patients will be included in 16 centers in The Netherlands and four other European centers. The primary endpoint is overall survival. Secondary endpoints include progression-free survival, RECIST response, CA 19.9 and CEA response, toxicity, quality of life, pain, costs, and immunomodulatory effects of RFA.

Discussion

The PELICAN RCT aims to assess whether the combination of chemotherapy and RFA improves the overall survival when compared to chemotherapy alone, in patients with LAPC with no progression of disease following 2 months of systemic treatment.

Trial registration

Dutch Trial RegistryNL4997. Registered on December 29, 2015. ClinicalTrials.govNCT03690323. Retrospectively registered on October 1, 2018

Locally Advanced Pancreatic Cancer: Percutaneous Management Using Ablation, Brachytherapy, Intra-arterial Chemotherapy, and Intra-tumoral Immunotherapy

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.

The Landmark Series: Locally Advanced Pancreatic Cancer and Ablative Therapy Options

Locally advanced pancreatic cancer (LAPC) is a challenging disease to treat. There is consensus that systemic chemotherapy should be the first line of therapy for most patients. However, there is no consensus on how to manage those patients who do not have sufficient response to become candidates for resection but also do not have distant progression after weeks or months of systemic therapy. Radiation therapy is the most commonly used and best-studied local ablative therapy. One recent randomized controlled trial (LAP-07) failed to demonstrate an overall survival benefit for conventional chemoradiation therapy after induction chemotherapy versus chemotherapy alone. This study had several limitations, and ongoing studies are re-evaluating the role of chemoradiation after more effective chemotherapy regimens as well as more advanced radiation techniques. In parallel, there has been increasing interest in other thermal and non-thermal methods of ablation. In particular, irreversible electroporation has gained traction for treatment of LAPC, with at least one ongoing randomized controlled trial designed to address its role compared with systemic chemotherapy alone. Multiple preclinical and clinical studies are investigating combinations of local ablation and immunotherapy with the goal of generating immune responses that will meaningfully improve outcomes.

Role of Radiofrequency Ablation in the Management of Unresectable Pancreatic Cancer

Pancreatic cancer is one of the most aggressive malignancies of the digestive tract and carries a poor prognosis. The majority of patients have advanced disease at the time of diagnosis. Surgical resection offers the only curative treatment, but only a small proportion of patients can undergo surgical resection. Radiofrequency ablation (RFA) is a well-known modality in the management of solid organ tumors, however, its utility in the management of pancreatic cancer is under investigation. Since the past decade, there is increasing use of RFA as it provides a feasible palliation treatment in the management of unresectable pancreatic cancer. RFA causes tumor cytoreduction through multiple mechanisms such as coagulative necrosis, protein denaturation, and activation of anticancer immunity. The safety profile of RFA is controversial because of the high risk for complications, however, small prospective and retrospective studies have shown promising results in its applicability for palliative management of unresectable pancreatic malignancies. In this review, we discuss different approaches of RFA, their indications, technical accessibility, safety, and major complications in the management of unresectable pancreatic cancer.

Imaging response evaluation after local ablative treatments in locally advanced pancreatic cancer: an expedited systematic review

BACKGROUND

Several local ablative modalities have been introduced for the treatment of locally advanced pancreatic cancer (LAPC). However, there is no consensus on how to evaluate the imaging response after treatment. A systematic review was performed regarding the use of imaging for response assessment in LAPC.

METHODS

A systematic literature search was conducted in PubMed. Studies reporting imaging outcomes were included in the review. Studies were excluded if the imaging outcomes could not be differentiated between different disease stages, tumor histology or surgical approaches.

RESULTS

Thirty-four studies were included in the analysis. Fourteen studies used standardized response criteria, while six studies did not report the response evaluation method. The rest used self-determined criteria, absolute size comparisons or similar methods. One study found a correlation between early systemic progression (<6 months) and overall survival.

CONCLUSION

There was notable variation in the use of imaging for response assessment in LAPC. This significantly hinders cross-comparison of results among studies. There is currently only sparse evidence of an association between imaging responses and overall survival. The field calls for standardized recommendations regarding the choice of response assessment method, timing of scans, target definition and reporting of outcomes.

Endosonography-guided Radiofrequency Ablation in Pancreatic Diseases: Time to Fill the Gap Between Evidence and Enthusiasm

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.

Effects of high-intensity focused ultrasound treatment on peripancreatic arterial and venous blood vessels in pancreatic cancer

The present study aimed to evaluate the safety of high-intensity focused ultrasound (HIFU) treatment on peripancreatic arterial and venous blood vessels in patients with pancreatic cancer. This trial included 15 patients with pancreatic cancer (9 females and 6 males; age, 39-81 years; median age, 62 years). All patients underwent preoperative computed tomography (CT) or magnetic resonance imaging (MRI) and color Doppler flow imaging (CDFI) to assess the vascular hemodynamics of peripancreatic arterial and venous blood vessels pre-treatment. These patients were re-examined within 1 week post-HIFU treatment. Then, vascular adverse events were observed and followed up clinically. Prior to HIFU treatment, vessel involvement was recorded in 13 patients, including tumor lesions invading 19 veins and 14 arteries, which refers to the growth of pancreatic tumor lesions surrounding blood vessels, or tumor growth into blood vessels. In addition, 9 veins and 13 arteries were <1 cm from the lesions. The hemodynamic parameters of peripancreatic vessels were measured using CDFI, including mean blood flow velocity, peak systolic blood flow velocity, vascular resistance index, vascular pulsatility index, vascular diameter, vascular blood flow and other indicators, to assess vascular perfusion in CT/MRI. There were no significant differences in preoperative and postoperative hemodynamic data (P>0.05). Overall, HIFU demonstrated no negative effects on peripancreatic arterial and venous blood vessels in patients with pancreatic cancer, even with tumor lesions wrapped in blood vessels. In addition, no complications of vascular stenosis and vascular adverse events were observed in the present study.

Endoscopic Ultrasound-Guided Treatment of Pancreatic Cancer

PURPOSE OF REVIEW

The aim of this review is to evaluate the emerging role of endoscopic ultrasound (EUS) in the guidance of tumor-targeted therapies for patients with pancreatic cancer (PC).

RECENT FINDINGS

EUS-guided ablation, brachytherapy, fiducial marker placement, and antitumor agent injection have been described to date. EUS-guided fiducial placement for SBRT in pancreatic cancer has entered the clinical practice and is performed at many centers clinically without a research protocol. EUS-guided brachytherapy and RFA have been shown to be feasible and safe procedures, and potentially offer local disease control. Other potential techniques of EUS-guided treatment of pancreatic cancer are still considered experimental, with many of them appearing to be safe and reasonably well tolerated. However, their effectiveness and exact role in oncological treatment have yet to be established. Clinical trials with many of the techniques/agents described are underway and multicentric randomized trials with prospective design are eagerly awaited.

[Ablative treatment options for locally advanced unresectable and borderline resectable pancreatic carcinoma]

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.

Efficacy and feasibility of stereotactic radiotherapy after folfirinox in patients with locally advanced pancreatic cancer (LAPC-1 trial)

BACKGROUND

We conducted a multicentre phase II trial to investigate feasibility and antitumor activity of sequential FOLFIRINOX and Stereotactic Body Radiotherapy (SBRT) in patients with locally advanced pancreatic cancer (LAPC), (LAPC-1 trial).

METHODS

Patients with biopsy-proven LAPC treated in four hospitals in the Netherlands between December 2014 and June 2017. Patients received 8 cycles of FOLFIRINOX followed by SBRT (5 fractions/8 Gy) if no tumour progression after the FOLFIRINOX treatment was observed. Primary outcome was 1-year overall survival (OS). Secondary outcomes were median OS, 1-year progression-free survival (PFS), treatment-related toxicity, and resection rate. The study is registered with ClinicalTrials.gov, NCT02292745, and is completed.

FINDINGS

Fifty patients were included. Nineteen (38%) patients did not receive all 8 cycles of FOLFIRINOX, due to toxicity (n = 12), disease progression (n = 6), or patients' preference (n = 1). Thirty-nine (78%) patients received the SBRT treatment. The 1-year OS and PFS were 64% (95% CI: 50%-76%) and 34% (95% CI: 22%-48%), respectively. Thirty grade 3 or 4 adverse events were observed during FOLFIRINOX. Two (5%) grade 3 or 4 adverse events after SBRT were observed. Two (5%) patients died due to a gastro-intestinal bleeding within three months after SBRT were observed. Six (12%) patients underwent a resection, all resulting in a complete (R0) resection. Two patients had a complete pathological response.

INTERPRETATION

FOLFIRINOX followed by SBRT in patients with LAPC is feasible and shows relevant antitumor activity. In 6 (12%) patients a potentially curative resection could be pursued following this combined treatment, with a complete histological response being observed in two patients.

Safety of radiofrequency ablation in patients with locally advanced, unresectable pancreatic cancer: A phase II study

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.

Palliative therapy in pancreatic cancer-interventional treatment with radiofrequency ablation/irreversible electroporation

Pancreatic cancer (PC) is a solid tumor with still a dismal prognosis. Diagnosis is usually late, when the disease is metastatic or locally advanced (LAPC). Only 20% of PC are amenable to surgery at the time of diagnosis and the vast majority of them, despite radically resected will unavoidably recur. The treatment of LAPC is a challenge. Current guidelines suggest to adopt systemic therapies upfront, based on multi-drugs chemotherapy regimens. However, the vast majority of patients will never experience conversion to surgical exploration and radical resection. Thus, there a large subgroup of LAPC patients where the only therapeutic chance is to offer palliative treatments, such as interventional ablative treatments, in order to obtain a cytoreduction of the tumor, trying to delay its growth and spread. Radiofrequency ablation (RFA) and irreversible electroporation (IRE) demonstrated to be safe and effective in obtaining a local control of the disease with some promising oncological results in terms of overall survival (OS). However, they should be adopted as a treatment strategy to adopt in parallel with other systemic therapies, within multidisciplinary choices. They are not free from complications, even serious, thus they should applied only in specialized centers of pancreatology. This review depicts the state of the art of the two techniques.

Feasibility of EUS-guided Nd:YAG laser ablation of unresectable pancreatic adenocarcinoma

BACKGROUND AND AIMS

EUS has become an interventional technique in which a needle may be used as a vehicle to deliver therapeutic agents. Laser ablation (LA) has been used to treat many primary and secondary neoplasms. This study aimed to assess the feasibility of EUS-guided LA for unresectable (UR) pancreatic cancer.

METHODS

Patients with stage IIb-III pancreatic cancer underwent EUS-guided LA. All patients were unresponsive to previous chemoradiotherapy. LA was performed by using a 300-μm flexible fiber preloaded onto a 22-gauge fine needle. A 1064-nm wavelength neodymium-yttrium aluminum garnet (Nd:YAG) laser light with different power settings of 2 W for 800 J, 1000 J, and 1200 J; 3 W for 800 J, 1000 J, and 1200 J; and 4 W for 800 J, 1000 J, and 1200 J was used. Each patient was treated with a single application of 1 of these settings. The application time of the power settings ranged from 200 to 600 seconds.

RESULTS

Nine patients (median age, 74.7; range 55-85) underwent Nd:Yag LA. The mean size of the focal lesion was 35.4 mm (range, 21-45). The ablation area, demonstrated by 24-hour CT, ranged from .4 cm³ (for the lower power setting of 2 W/800 J) to a maximum of 6.4 cm³ (for 4 W/1000 J). The procedure was completed in all 9 patients without adverse events.

CONCLUSION

In our human experience, EUS-guided LA was feasible and well tolerated in patients with UR pancreatic cancer.

Locally Advanced Pancreatic Cancer: A Review of Local Ablative Therapies. Cancers (Basel). 2018;10. [PMID: 29320420 PMCID: PMC5789366 DOI: 10.3390/cancers10010016]

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

Ablative Therapies for Locally Advanced Pancreatic Cancer

The vast majority of patients who present with pancreatic adenocarcinoma have locally advanced or metastatic disease at the time of presentation without possibility of cure. Although in recent years there have been some new promising chemotherapy regimens that improve overall survival by a few months, the prognosis remains dismal. There is, however, a subset of patients who experience durable stable disease or partial responses after initial courses of chemotherapy with locally advanced disease. In these select patients, there remains interest in local ablative therapy with or without resection as a means for local control, palliation of symptoms, and possible improved survival. This review describes the techniques, complications, and expected benefits of several ablative techniques as a treatment modality for locally advanced pancreatic cancer.

The role of irreversible electroporation (IRE) for locally advanced pancreatic cancer: a systematic review of safety and efficacy

OBJECTIVES

Irreversible electroporation (IRE) is a new modality for tumor ablation. Electrodes are placed around the tumor, and a pulsed, direct current with a field strength of 2000 V/cm is delivered. The direct current drives cells into apoptosis and cell death without causing significant heating of the tissues, which spares the extracellular matrix and proteins. The purpose of this review was to evaluate current experience of IRE for the ablation of pancreatic cancer.

MATERIAL AND METHODS

We searched PubMed for all studies of IRE in human pancreatic cancer in English reporting at least 10 patients.

RESULTS

The search yielded 10 studies, comprising a total of 446 patients. Percutaneous IRE was done in 142 patients, while 304 patients were treated during laparotomy. Tumor sizes ranged from median 2.8 to 4.5 cm. Post-procedural complications occurred in 35% of patients, most of them were less severe. Nine patients (2.0%) died after the procedure. The technical success rate was 85-100%. The median recurrence-free survival was 2.7-12.4 months after IRE treatment. The median overall survival was 7-23 months postoperatively. The longest overall survival was noted when IRE was used in conjunction with pancreatic resection.

CONCLUSIONS

IRE seems feasible and safe with a low post-procedural mortality. Further efforts are needed to address patient selection and efficacy of IRE, as well as the use of IRE for 'margin accentuation' during surgical resection.

Radiofrequency ablation for locally advanced pancreatic cancer: SMAD4 analysis segregates a responsive subgroup of patients

PURPOSE

SMAD4 mutational status correlates with pancreatic ductal adenocarcinoma (PDAC) failure pattern. We investigated in a subset of locally advanced patients submitted to radiofrequency ablation (RFA) whether the assessment of SMAD4 status is a useful way to select the patients.

METHODS

Clinical, radiological, and follow-up details of patients submitted to RFA for locally advanced pancreatic cancer (LAPC), in whom cytohistological material was available at our institution, were retrospectively retrieved. SMAD4 expression was evaluated by immunohistochemistry (IHC) and considered "negative" or "positive." The survival analysis was conducted using Kaplan-Meier and Cox proportional hazards models.

RESULTS

The study population consisted of 30 patients. Thirteen patients (43.3%) received RFA upfront, whereas 17 (56.7%) after induction treatments. SMAD4 was mutant in 18 out of 30 patients (60%). The overall estimated post-RFA disease-specific survival (DSS) was 15 months (95% CI 11.64-18.35). The estimated post-RFA DSS of patients with wild-type and mutant SMAD4 was 22 and 12 months, respectively (log-rank p < 0.05). At the multivariate analysis, SMAD4 was the only independent predictor of survival (p = 0.05). The pattern of failure was not associated with SMAD4 status (p = 0.4).

CONCLUSIONS

Within patients undergoing RFA for LAPC, SMAD4 analysis could segregate a subgroup of subjects with improved survival, who likely benefited from tumor ablation.

Endoscopic ultrasound-guided radiofrequency ablation in gastroenterology: New horizons in search

Radiofrequency ablation (RFA) has been widely used for the treatment of various solid organ malignancies. Over the last decade, endosonographers have gradually shifted the application of RFA from porcine models to humans to treat a spectrum of diseases. RFA is performed in patients with pancreatic carcinoma who are not candidates for surgery. In this paper, we will discuss various indications for RFA, its procedural details and complications. At present, endoscopic ultrasound-guided RFA is gradually incorporated into the management of various diseases and opens a new avenue for disease treatment.

Theoretical investigation of transgastric and intraductal approaches for ultrasound-based thermal therapy of the pancreas

Background

The goal of this study was to theoretically investigate the feasibility of intraductal and transgastric approaches to ultrasound-based thermal therapy of pancreatic tumors, and to evaluate possible treatment strategies.

Methods

This study considered ultrasound applicators with 1.2 mm outer diameter tubular transducers, which are inserted into the tissue to be treated by an endoscopic approach, either via insertion through the gastric wall (transgastric) or within the pancreatic duct lumen (intraductal). 8 patient-specific, 3D, transient, biothermal and acoustic finite element models were generated to model hyperthermia (n = 2) and ablation (n = 6), using sectored (210°–270°, n = 4) and 360° (n = 4) transducers for treatment of 3.3–17.0 cm³ tumors in the head (n = 5), body (n = 2), and tail (n = 1) of the pancreas. A parametric study was performed to determine appropriate treatment parameters as a function of tissue attenuation, blood perfusion rates, and distance to sensitive anatomy.

Results

Parametric studies indicated that pancreatic tumors up to 2.5 or 2.7 cm diameter can be ablated within 10 min with the transgastric and intraductal approaches, respectively. Patient-specific simulations demonstrated that 67.1–83.3% of the volumes of four sample 3.3–11.4 cm³ tumors could be ablated within 3–10 min using transgastric or intraductal approaches. 55.3–60.0% of the volume of a large 17.0 cm³ tumor could be ablated using multiple applicator positions within 20–30 min with either transgastric or intraductal approaches. 89.9–94.7% of the volume of two 4.4–11.4 cm³ tumors could be treated with intraductal hyperthermia. Sectored applicators are effective in directing acoustic output away from and preserving sensitive structures. When acoustic energy is directed towards sensitive structures, applicators should be placed at least 13.9–14.8 mm from major vessels like the aorta, 9.4–12.0 mm from other vessels, depending on the vessel size and flow rate, and 14 mm from the duodenum.

Conclusions

This study demonstrated the feasibility of generating shaped or conformal ablative or hyperthermic temperature distributions within pancreatic tumors using transgastric or intraductal ultrasound.

Multi-modality imaging-monitored creation of rat orthotopic pancreatic head cancer with obstructive jaundice

Purpose

To investigate the feasibility of using multi-modality imaging to monitor the creation of rat models with orthotopic pancreatic head cancer with obstructive jaundice.

Results

27 of 52 rats (51.92%) developed pancreatic head cancer. The tumor formation rate was significantly higher in the animal group receiving bioluminescent tumor, compared to the group receiving non-bioluminescent donor tumors [78.1% (25/32 rats) vs 10.0% (2/20 rats), P = 0.0001]. Both ultrasound imaging and MRI clearly characterized the orthotopic tumors. Laboratory biochemistry test for those rats with obstructive jaundice showed elevated levels of bilirubin, aspartate transaminase (AST), alkaline phosphatase (ALT) and gamma-glutamyl transpeptidase (λ-GGT), compared with those rats without jaundice (P < 0.05). Correlative pathology confirmed that all tumors were ductal adenocarcinomas, and located in pancreatic head regions.

Materials and Methods

Rat pancreatic adenocarcinoma cells (DSL-6A/C1) were first transfected with lentivirus/mCherry-luciferase genes, and then subcutaneously implanted into flanks of donor immunocompetent Lewis rats, to create pancreatic tumor tissues. The tumor tissues from donor rats with either bioluminescence signal or without the signal were then transplanted into the pancreatic heads of 52 recipient Lewis rats. Bioluminescence optical and ultrasound imaging, as well as magnetic resonance imaging (MRI), were performed to follow up the tumor formation and growth in these tumor-transplanted rats. Physical examination and biochemistry test were used to discern the rats with obstructive jaundice. The rats were euthanized for subsequent histologic correlation and confirmation.

Conclusions

We successfully created a new rat model with orthotopic pancreatic head cancer, which can be accurately monitored and visualized by different imaging modalities.

Endoscopic Radiofrequency Ablation of the Pancreas

Radiofrequency ablation (RFA) is a well-established technique to ablate dysplastic and neoplastic tissue via local thermal coagulative necrosis. Despite the widespread use in management of several cancers, the application of RFA in pancreas has been limited due to the increased risks of complications from the increased sensitivity of pancreatic tissue to thermal injury and proximity to vascular and biliary structures. RFA has been successfully used during laparotomy for locally advanced pancreatic carcinoma but requires an invasive approach. Endoscopic ultrasound-guided RFA offers the best combination of excellent visualization, real-time imaging guidance, and precise localization with minimal invasiveness. Several animal and human studies have demonstrated the technical feasibility and safety of endoscopic RFA in the pancreas. This article provides a comprehensive review of endoscopic RFA in the management of pancreatic lesions.

Irreversible electroporation as treatment of locally advanced and as margin accentuation in borderline resectable pancreatic adenocarcinoma. Med Biol Eng Comput. 2017;55:1123-1127. [PMID: 28078482 DOI: 10.1007/s11517-016-1603-9]

In recent years, many local ablation technologies based on thermal damage have been used in the treatment of locally advanced pancreatic carcinoma (LAPC) and borderline resectable pancreatic carcinoma (BLRPC). However, they are associated with major complications because of possible vascular and ductal damage. Irreversible electroporation (IRE) is a nonthermal ablation technology that seems safe near vital vascular and ductal structures. IRE could be used as exclusive treatment of LAPC (en situ to IRE) after induction chemotherapy In BLRPC, surgery is not really radical in 6% of patients (microscopic residual) and local recurrences occur in 11-42% of apparent radical resections. IRE could be used as margin accentuation to increase posterior margin during radical surgery in BLRPC. Our outcomes are safety, time to progression. Secondary outcomes are overall survival, pain control and quality of life. We are performing a prospective evaluation of patients undergoing IRE for LAPC or BLRPC since July 2014. We have included patients with non-metastatic LAPC with maximum size ≤4 cm (en situ to IRE) and patients with BLRPC (complementary IRE). We have performed induction chemotherapy in both groups. After treatment, patients were evaluated on days 1, 2, 4, 7, 14, 21, 30, 60 and 90 with amylase and lipase serum and abdominal drainage test. Based on Ethics Committee's request, follow-up imaging was performed at the 10th day for safety evaluation, at 30, 60 and 90 days for response evaluation and then every 3 months. Seven patients (two women and five men) underwent IRE. Two patients had LAPC and received en situ to IRE. In five patients affected by BLRPC we performed IRE and pancreatic head resection. In all patients, intraoperative imaging confirmed that the treatment of the whole tumor volume was complete. All seven patients demonstrated nonclinically relevant elevation of their amylase and lipase, which returned normal at 5 days postprocedure. No patient showed evidence of clinical pancreatitis or fistula. No major complications were recorded. Patients with LAPC died of distant metastases 6 month after treatment. At 3- and 6-month follow-up, all patients with BLPRC were alive and disease free. Only one patient has already reached 9-month follow-up and is alive and disease free. Our results are only preliminary. However, IRE ablation of LAPC and BLRPC seems a safe and feasible treatment.

Irreversible Electroporation of the Pancreas Using Parallel Plate Electrodes in a Porcine Model: A Feasibility Study

BACKGROUND

Irreversible electroporation (IRE) with needle electrodes is being explored as treatment option in locally advanced pancreatic cancer. Several studies have shown promising results with IRE needles, positioned around the tumor to achieve tumor ablation. Disadvantages are the technical difficulties for needle placement, the time needed to achieve tumor ablation, the risk of needle track seeding and most important the possible occurrence of postoperative pancreatic fistula via the needle tracks. The aim of this experimental study was to evaluate the feasibility of a new IRE-technique using two parallel plate electrodes, in a porcine model.

METHODS

Twelve healthy pigs underwent laparotomy. The pancreas was mobilized to enable positioning of the paddles. A standard monophasic external cardiac defibrillator was used to perform an ablation in 3 separate parts of the pancreas; either a single application of 50 or 100J or a serial application of 4x50J. After 6 hours, pancreatectomy was performed for histology and pigs were terminated.

RESULTS

Histology showed necrosis of pancreatic parenchyma with neutrophil influx in 5/12, 11/12 and 12/12 of the ablated areas at 50, 100, and 4x50J respectively. The electric current density threshold to achieve necrosis was 4.3, 5.1 and 3.4 A/cm2 respectively. The ablation threshold was significantly lower for the serial compared to the single applications (p = 0.003). The content of the ablated areas differed between the applications: areas treated with a single application of 50 J often contained vital areas without obvious necrosis, whereas half of the sections treated with 100 J showed small islands of normal looking cells surrounded by necrosis, while all sections receiving 4x 50 J showed a homogeneous necrotic lesion.

CONCLUSION

Pancreatic tissue can be successfully ablated using two parallel paddles around the tissue. A serial application of 4x50J was most effective in creating a homogeneous necrotic lesion.

Variation of tumoral marker after radiofrequency ablation of pancreatic adenocarcinoma

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.

Electrochemotherapy in pancreatic adenocarcinoma treatment: pre-clinical and clinical studies

Background

Pancreatic adenocarcinoma is currently one of the deadliest cancers with high mortality rate. This disease leads to an aggressive local invasion and early metastases, and is poorly responsive to treatment with chemotherapy or chemo-radiotherapy. Radical resection is still the only curative treatment for pancreatic cancer, but it is generally accepted that a multimodality strategy is necessary for its management. Therefore, new alternative therapies have been considered for local treatment.

Conclusions

Chemotherapeutic resistance in pancreatic cancer is associated to a low penetration of drugs into tumour cells due to the presence of fibrotic stroma surrounding cells. In order to increase the uptake of chemotherapeutic drugs into tumour cells, electrochemotherapy can be used for treatment of pancreatic adenocarcinoma leading to an increased tumour response rate. This review will summarize the published papers reported in literature on the efficacy and safety of electrochemotherapy in pre-clinical and clinical studies on pancreatic cancer.

Local Ablative Strategies for Ductal Pancreatic Cancer (Radiofrequency Ablation, Irreversible Electroporation): A Review. Gastroenterol Res Pract. 2016;2016:4508376. [PMID: 26981115 PMCID: PMC4770121 DOI: 10.1155/2016/4508376]

Pancreatic ductal adenocarcinoma (PDAC) has still a dismal prognosis. Locally advanced pancreatic cancer (LAPC) accounts for the 40% of the new diagnoses. Current treatment options are based on chemo- and radiotherapy regimens. Local ablative techniques seem to be the future therapeutic option for stage-III patients with PDAC. Radiofrequency Ablation (RFA) and Irreversible Electroporation (IRE) are actually the most emerging local ablative techniques used on LAPC. Initial clinical studies on the use of these techniques have already demonstrated encouraging results in terms of safety and feasibility. Unfortunately, few studies on their efficacy are currently available. Even though some reports on the overall survival are encouraging, randomized studies are still required to corroborate these findings. This study provides an up-to-date overview and a thematic summary of the current available evidence on the application of RFA and IRE on PDAC, together with a comparison of the two procedures.

Initial experience of EUS-guided radiofrequency ablation of unresectable pancreatic cancer

BACKGROUND AND AIMS

Radiofrequency ablation (RFA) has been used as a valuable treatment modality for various unresectable malignancies. EUS-guided radiofrequency ablation (EUS-RFA) of the porcine pancreas was reported to be feasible and safe in our previous study, suggesting that EUS-RFA may be applicable as an adjunct and effective alternative treatment method for unresectable pancreatic cancer. This study aimed to assess the technical feasibility and safety of EUS-RFA for unresectable pancreatic cancer.

METHODS

An 18-gauge endoscopic RFA electrode and a radiofrequency generator were used for the procedure. The length of the exposed tip of the RFA electrode was 10 mm. After insertion of the RFA electrode into the mass, the radiofrequency generator was activated to deliver 20 to 50 W ablation power for 10 seconds. Depending on tumor size, the procedure was repeated to sufficiently cover the tumor.

RESULTS

EUS-RFA was performed successfully in all 6 patients (median age 62 years, range 43-73 years). Pancreatic cancer was located in the head (n = 4) or body (n = 2) of the pancreas. The median diameter of masses was 3.8 cm (range 3cm-9cm). Four patients had stage 3 disease, and 2 patients had stage 4 disease. After the procedure, 2 patients experienced mild abdominal pain, but there were no other adverse events such as pancreatitis or bleeding.

CONCLUSIONS

EUS-RFA could be a technically feasible and safe option for patients with unresectable pancreatic cancer.

International Association of Pancreatology (IAP)/European Pancreatic Club (EPC) consensus review of guidelines for the treatment of pancreatic cancer

BACKGROUND

Pancreatic cancer is one of the most devastating diseases with an extremely high mortality. Medical organizations and scientific societies have published a number of guidelines to address active treatment of pancreatic cancer. The aim of this consensus review was to identify where there is agreement or disagreement among the existing guidelines and to help define the gaps for future studies.

METHODS

A panel of expert pancreatologists gathered at the 46th European Pancreatic Club Meeting combined with the 18th International Association of Pancreatology Meeting and collaborated on critical reviews of eight English language guidelines for the clinical management of pancreatic cancer. Clinical questions (CQs) of interest were proposed by specialists in each of nine areas. The recommendations for the CQs in existing guidelines, as well as the evidence on which these were based, were reviewed and compared. The evidence was graded as sufficient, mediocre or poor/absent.

RESULTS

Only 4 of the 36 CQs, had sufficient evidence for agreement. There was also agreement in five additional CQs despite the lack of sufficient evidence. In 22 CQs, there was disagreement regardless of the presence or absence of evidence. There were five CQs that were not addressed adequately by existing guidelines.

CONCLUSION

The existing guidelines provide both evidence- and consensus-based recommendations. There is also considerable disagreement about the recommendations in part due to the lack of high level evidence. Improving the clinical management of patients with pancreatic cancer, will require continuing efforts to undertake research that will provide sufficient evidence to allow agreement.

Multimodality treatment of recurrent pancreatic cancer: Mith or reality?

Pancreatic adenocarcinoma is the fourth cause of cancer-related death in the United States. Surgery is the only potentially curative treatment, but most patients present at diagnosis with unresectable or metastatic disease. Moreover, even with an R0 resection, the majority of patients will die of disease recurrence. Most recurrences occur in the first 2-year after pancreatic resection, and are commonly located in the abdomen, even if distant metastases can occur. Recurrent pancreatic adenocarcinoma remains a significant therapeutic challenge, due to the limited role of surgery and radio-chemotherapy. Surgical management of recurrence is usually unreliable because tumor relapse typically presents as a technically unresectable, or as multifocal disease with an aggressive growth. Therefore, treatment of patients with recurrent pancreatic adenocarcinoma has historically been limited to palliative chemotherapy or supportive care. Only few data are available in the Literature about this issue, even if in recent years more studies have been published to determine whether treatment after recurrence have any effect on patients outcome. Recent therapeutic advances have demonstrated the potential to improve survival in selected patients who had undergone resection for pancreatic cancer. Multimodality management of recurrent pancreatic carcinoma may lead to better survival and quality of life in a small but significant percentage of patients; however, more and larger studies are needed to clarify the role of the different therapeutic options and the optimal way to combine them.

Endoscopic ultrasound guided radiofrequency ablation, for pancreatic cystic neoplasms and neuroendocrine tumors

AIM

To outline the feasibility, safety, adverse events and early results of endoscopic ultrasound (EUS)-radiofrequency ablation (RFA) in pancreatic neoplasms using a novel probe.

METHODS

This is a multi-center, pilot safety feasibility study. The intervention described was radiofrequency ablation (RF) which was applied with an innovative monopolar RF probe (1.2 mm Habib EUS-RFA catheter) placed through a 19 or 22 gauge fine needle aspiration (FNA) needle once FNA was performed in patients with a tumor in the head of the pancreas. The Habib™ EUS-RFA is a 1 Fr wire (0.33 mm, 0.013") with a working length of 190 cm, which can be inserted through the biopsy channel of an echoendoscope. RF power is applied to the electrode at the end of the wire to coagulate tissue in the liver and pancreas.

RESULTS

Eight patients [median age of 65 (range 27-82) years; 7 female and 1 male] were recruited in a prospective multicenter trial. Six had a pancreatic cystic neoplasm (four a mucinous cyst, one had intraductal papillary mucinous neoplasm and one a microcystic adenoma) and two had a neuroendocrine tumors (NET) in the head of pancreas. The mean size of the cystic neoplasm and NET were 36.5 mm (SD ± 17.9 mm) and 27.5 mm (SD ± 17.7 mm) respectively. The EUS-RFA was successfully completed in all cases. Among the 6 patients with a cystic neoplasm, post procedure imaging in 3-6 mo showed complete resolution of the cysts in 2 cases, whilst in three more there was a 48.4% reduction [mean pre RF 38.8 mm (SD ± 21.7 mm) vs mean post RF 20 mm (SD ± 17.1 mm)] in size. In regards to the NET patients, there was a change in vascularity and central necrosis after EUS-RFA. No major complications were observed within 48 h of the procedure. Two patients had mild abdominal pain that resolved within 3 d.

CONCLUSION

EUS-RFA of pancreatic neoplasms with a novel monopolar RF probe was well tolerated in all cases. Our preliminary data suggest that the procedure is straightforward and safe. The response ranged from complete resolution to a 50% reduction in size.

Feasibility and safety of electrochemotherapy (ECT) in the pancreas: a pre-clinical investigation

Background.

Pancreatic ductal adenocarcinoma (PDAC) is a lethal disease generally refractory to standard chemotherapeutic agents; therefore improvements in anticancer therapies are mandatory. A major determinant of therapeutic resistance in PDAC is the poor drug delivery to neoplastic cells, mainly due to an extensive fibrotic reaction. Electroporation can be used in vivo to increase cancer cells’ local uptake of chemotherapeutics (electrochemotherapy, ECT), thus leading to an enhanced tumour response rate. In the present study, we evaluated the in vivo effects of reversible electroporation in normal pancreas in a rabbit experimental model. We also tested the effect of electroporation on pancreatic cancer cell lines in order to evaluate their increased sensitivity to chemotherapeutic agents.

Materials and methods.

The application in vivo of the European Standard Operating Procedure of Electrochemotherapy (ESOPE) pulse protocol (1000 V/cm, 8 pulses, 100 μs, 5 KHz) was tested on the pancreas of normal New Zealand White Rabbits and short and long-term toxicity were assessed. PANC1 and MiaPaCa2 cell lines were tested for in vitro electrochemotherapy experiments with and without electroporation. Levels of cell permeabilization were determined by flow cytometry, whereas cell viability and drug (cisplatin and bleomycin) sensitivity of pulsed cells were measured by 3-(4,5-dimethylthiazol-2-yl)-5-(3-carboxymethoxyphenyl)-2-(4-sulfophenyl)-2H-tetrazolium (MTS) assay.

Results.

In healthy rabbits, neither systemic nor local toxic effects due to the electroporation procedure were observed, demonstrating the safety of the optimized electric parameters in the treatment of the pancreas in vivo. In parallel, we established an optimized protocol for ECT in vitro that determined an enhanced anti-cancer effect of bleomycin and cisplatin with respect to treatment without electroporation.

Conclusions.

Our data suggest that electroporation is a safe procedure in the treatment of PDAC because it does not affect normal pancreatic parenchyma, but has a potentiating effect on cytotoxicity of bleomycin in pancreatic tumour cell lines. Therefore, ECT could be considered as a valid alternative for the local control of non-resectable pancreatic cancer.

Radiofrequency ablation of pancreatic ductal adenocarcinoma: The past, the present and the future

Pancreatic ductal adenocarcinoma (PDAC) is one of the most aggressive cancers with a grim overall 5-year survival rate of 5%. Advances in surgical techniques, critical care, molecular diagnosis, diagnostic imaging, endosonology and adjuvant therapy have improved outcomes; but still more needs to be achieved. There is an urgent need to discover new avenues that may impact survival. Radiofrequency ablation (RFA) has attracted attention as an adjunctive treatment in PDAC. A review of English literature in PubMed was done using the MESH terms for PDAC and RFA. All the articles were reviewed and core information was tabulated for reference. After a comprehensive review of all articles the data was evaluated to discover the role of RFA in PDAC management. Indications, contraindications, feasibility, success rate, safety, complications and impact on survival were reviewed and are discussed further. RFA appears to be an attractive option for non-metastatic locally advanced PDAC. RFA is feasible but has a significant morbidity. At the present time the integration of RFA into the management of pancreatic ductal adenocarcinoma is evolving. It should be considered as having a complimentary role to current standard therapy in the multimodal management care model. It is likely that indications and patient selection for pancreatic RFA will expand.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Radiofrequency ablation for unresectable locally advanced pancreatic cancer: a systematic review

BACKGROUND

Median survival in patients with unresectable locally advanced pancreatic cancer lies in the range of 9-15 months. Radiofrequency ablation (RFA) may prolong survival, but data on its safety and efficacy are scarce.

METHODS

A systematic literature search was performed in PubMed, EMBASE and the Cochrane Library with the syntax '(radiofrequency OR RFA) AND (pancreas OR pancreatic)' for studies published until 1 January 2012. In addition, a search of the proceedings of conferences on pancreatic disease that took place during 2009-2011 was performed. Studies with fewer than five patients were excluded as they were considered to be case reports. The primary endpoint was survival. Secondary endpoints included morbidity and mortality.

RESULTS

Five studies involving a total of 158 patients with pancreatic cancer treated with RFA fulfilled the eligibility criteria. These studies reported median survival after RFA of 3-33 months, morbidity related to RFA of 4-37%, mortality of 0-19% and overall morbidity of 10-43%. Pooling of data was not appropriate as the study populations and reported outcomes were heterogeneous. Crucial safety aspects included ensuring a maximum RFA tip temperature of < 90 °C and ensuring minimum distances between the RFA probe and surrounding structures.

CONCLUSIONS

Radiofrequency ablation seems to be feasible and safe when it is used with the correct temperature and at an appropriate distance from vital structures. It appears to have a positive impact on survival. Multicentre randomized trials are necessary to determine the true effect size of RFA and to minimize the impacts of selection and publication biases.

Short term chemotherapy followed by radiofrequency ablation in stage III pancreatic cancer: results from a single center

BACKGROUND

Neo-adjuvant chemotherapy (CHT) has gained increasing importance in resectable and borderline resectable pancreatic cancer leading to a better performing surgery when we look at negative resection margins and selection of patients with less aggressive disease. We apply this principle to patients with Stage III (LAC) pancreatic cancer undergoing RFA and try to select patients who may benefit from a local treatment.

METHODS

All patients affected by LAC were treated with RFA for a stable disease after a short CHT. Postoperative morbidity and mortality were evaluated together with overall survival (OS) and disease specific survival (DSS).

RESULTS

We consecutively treated 57 patients affected by LAC. Median duration of CHT before RFA was 5 months. The postoperative mortality rate was zero. Overall morbidity was 14 % with RFA-related morbidity of 3.5 %. The OS and DSS were 19 months and when compared to a similar population who received RFA as up front treatment, there was no difference.

CONCLUSIONS

Our results do not support the adoption of a short CHT as a way to identify patients to treat with RFA with the most benefit. Based on this and by knowing the role of immune modulation after RFA and its specific involvement in pancreatic carcinoma, we can propose RFA as upfront treatment.