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Abdominal Radiology

, Volume 43, Issue 2, pp 457–466 | Cite as

Irreversible electroporation of pancreatic adenocarcinoma: a primer for the radiologist

  • M. Farzan Rashid
  • Elizabeth M. Hecht
  • Jonathan A. Steinman
  • Michael D. KlugerEmail author
Article

Abstract

Irreversible electroporation (IRE) is increasingly used for the ablation of unresectable locally advanced pancreatic adenocarcinoma. Unlike other ablation technologies that cannot be safely used around critical vasculature or ducts for risk of thermal damage, IRE uses high-voltage pulses to disrupt cellular membranes. This causes cell death by apoptosis and inflammation. IRE has been deployed by both open and percutaneous approaches. Generator parameters are the same for both approaches, and settings are pancreas specific. Variations in settings, probe placement, and probe exposure can result in thermal damage or reversible electroporation and resultant treatment failure, morbidity, or mortality. When used properly, IRE appears to improve overall survival and local recurrence, but does not influence the rate of distant recurrence. However, studies of both open and percutaneous approaches have been relatively small, non-controlled, and without appropriate comparisons. It is challenging for the radiologist to interpret treatment effects after IRE because of a dearth of guiding literature and pathologic correlates. This primer describes technical aspects, pathology correlates, post-IRE imaging, and outcomes for percutaneous and open approaches.

Keywords

Pancreatic adenocarcinoma Irreversible electroporation Interventional radiology Computed tomography Percutaneous Ablation techniques 

Abbreviations

IRE

Irreversible electroporation

LAPC

Locally advanced pancreatic cancer

Notes

Author Contribution

All authors contributed to the conception or design of the project, assisted with acquisition, analysis, or interpretation of data, drafted and/or revised the manuscript and had final approval of the version to be published. All authors agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity may be resolved.

Compliance with ethical standards

Funding

No funding was received for this study.

Conflicts of interest

None.

References

  1. 1.
    Hammel P, Huguet F, van Laethem JL, et al. (2016) Effect of chemoradiotherapy vs. chemotherapy on survival in patients with locally advanced pancreatic cancer controlled after 4 months of gemcitabine with or without erlotinib: the LAP07 randomized clinical trial. JAMA 315:1844–1853CrossRefPubMedGoogle Scholar
  2. 2.
    Strobel O, Berens V, Hinz U, et al. (2012) Resection after neoadjuvant therapy for locally advanced, “unresectable” pancreatic cancer. Surgery. 152(3 Suppl 1):S33–42CrossRefPubMedGoogle Scholar
  3. 3.
    Kluger MD, Rashid MF, Rosario VL, Schrope BA, Steinman J, Hecht EM, Chabot JA. (2017) Resection of locally advanced pancreatic cancer without regression of arterial encasement after modern-era neoadjuvant therapy. J Gastrointest Surg. doi: 10.1007/s11605-017-3556-1 PubMedGoogle Scholar
  4. 4.
    Ferrone CR, Marchegiani G, Hong TS, et al. (2015) Radiological and surgical implications of neoadjuvant treatment with FOLFIRINOX for locally advanced and borderline resectable pancreatic cancer. Ann Surg 261(1):12–17CrossRefPubMedPubMedCentralGoogle Scholar
  5. 5.
    Pezzilli R, Serra C, Ricci C, et al. (2011) Radiofrequency ablation for advanced ductal pancreatic carcinoma: is this approach beneficial for our patients? A systematic review. Pancreas 40:163–165CrossRefPubMedGoogle Scholar
  6. 6.
    Varshney S, Sewkani A, Sharma S, et al. (2006) Radiofrequency ablation of unresectable pancreatic carcinoma: feasibility, efficacy and safety. JOP 7:74–78PubMedGoogle Scholar
  7. 7.
    Rubinsky B (2007) Irreversible electroporation in medicine. Technol Cancer Res Treat 6(4):255–259CrossRefPubMedGoogle Scholar
  8. 8.
    Martin RC 2nd, McFarland K, Ellis S, Velanovich V (2013) Irreversible electroporation in locally advanced pancreatic cancer: potential improved overall survival. Ann Surg Oncol 20(Suppl 3):S443–449CrossRefPubMedGoogle Scholar
  9. 9.
    Martin RC 2nd, Durham AN, Besselink MG, et al. (2016) Irreversible electroporation in locally advanced pancreatic cancer: a call for standardization of energy delivery. J Surg Oncol 114:865–871CrossRefPubMedGoogle Scholar
  10. 10.
    Philips P, Hays D, Martin RC (2013) Irreversible electroporation ablation (IRE) of unresectable soft tissue tumors: learning curve evaluation in the first 150 patients treated. PLoS ONE 8(11):e76260CrossRefPubMedPubMedCentralGoogle Scholar
  11. 11.
    Ricke J, Jürgens JH, Deschamps F, et al. (2015) Irreversible electroporation (IRE) fails to demonstrate efficacy in a prospective multicenter phase II trial on lung malignancies: the ALICE trial. Cardiovasc Intervent Radiol 38:401–408CrossRefPubMedGoogle Scholar
  12. 12.
    Bower M, Sherwood L, Li Y, Martin R (2011) Irreversible electroporation of the pancreas: definitive local therapy without systemic effects. J Surg Oncol 104(1):22–28CrossRefPubMedGoogle Scholar
  13. 13.
    Martin RCG, Kwon D, Chalikonda S, et al. (2015) Treatment of 200 locally advanced (Stage III) pancreatic adenocarcinoma patients with irreversible electroporation. Ann Surg 262(3):486–494CrossRefPubMedGoogle Scholar
  14. 14.
    Dunki-Jacobs EM, Philips P, Martin RC (2014) Evaluation of resistance as a measure of successful tumor ablation during irreversible electroporation of the pancreas. J Am Coll Surg 218(2):179–187CrossRefPubMedGoogle Scholar
  15. 15.
    Olweny EO, Kapur P, Tan YK, et al. (2013) Irreversible electroporation: evaluation of nonthermal and thermal ablative capabilities in the porcine kidney. Urology 81(3):679–684CrossRefPubMedGoogle Scholar
  16. 16.
    Faroja M, Ahmed M, Appelbaum L, et al. (2013) Irreversible electroporation ablation: is all the damage nonthermal? Radiology 266(2):462–470CrossRefPubMedGoogle Scholar
  17. 17.
    Dunki-Jacobs EM, Philips P, Ii RCGM (2014) Evaluation of thermal injury to liver, pancreas and kidney during irreversible electroporation in an in vivo experimental model. Br J Surg 101(9):1113–1121CrossRefPubMedGoogle Scholar
  18. 18.
    Charpentier KP, Wolf F, Noble L, et al. (2010) Irreversible electroporation of the pancreas in swine: a pilot study. HPB (Oxford). 12(5):348–351CrossRefPubMedPubMedCentralGoogle Scholar
  19. 19.
    Fritz S, Sommer CM, Vollherbst D, et al. (2015) Irreversible electroporation of the pancreas is feasible and safe in a porcine survival model. Pancreas 44(5):791–798CrossRefPubMedGoogle Scholar
  20. 20.
    Wimmer T, Srimathveeravalli G, Gutta N, et al. (2013) Comparison of simulation-based treatment planning with imaging and pathology outcomes for percutaneous CT-guided irreversible electroporation of the porcine pancreas: a pilot study. J Vasc Interv Radiol 24(11):1709–1718CrossRefPubMedGoogle Scholar
  21. 21.
    Zhang Z, Li W, Procissi D, et al. (2014) Rapid dramatic alterations to the tumor microstructure in pancreatic cancer following irreversible electroporation ablation. Nanomedicine. 9(8):1181–1192CrossRefPubMedGoogle Scholar
  22. 22.
    José A, Sobrevals L, Ivorra A, Fillat C (2012) Irreversible electroporation shows efficacy against pancreatic carcinoma without systemic toxicity in mouse models. Cancer Lett 317(1):16–23CrossRefPubMedGoogle Scholar
  23. 23.
    Al-Hawary MM, Francis IR, Chari ST, et al. (2014) Pancreatic ductal adenocarcinoma radiology reporting template: consensus statement of the Society of Abdominal Radiology and the American Pancreatic Association. Radiology 270(1):248–260CrossRefPubMedGoogle Scholar
  24. 24.
    Schulz B, Ou J, Meter TV, Martin RCG (2016) Early nontumorous CT findings after irreversible electroporation of locally advanced pancreatic cancer. Abdom Radiol. 41(11):2142–2149CrossRefGoogle Scholar
  25. 25.
    Gonzalez-Beicos A, Venkat S, Songrug T, et al. (2015) Irreversible electroporation of hepatic and pancreatic malignancies: radiologic-pathologic correlation. Tech Vasc Interv Radiol. 18(3):176–182CrossRefPubMedGoogle Scholar
  26. 26.
    Akinwande O, Ahmad SS, Van Meter T, Schulz B, Martin RC (2015) CT findings of patients treated with irreversible electroporation for locally advanced pancreatic cancer. J Oncol. 2015:680319CrossRefPubMedPubMedCentralGoogle Scholar
  27. 27.
    Vroomen LGPH, Scheffer HJ, Melenhorst MCAM, et al. (2017) MR and CT imaging characteristics and ablation zone volumetry of locally advanced pancreatic cancer treated with irreversible electroporation. Eur Radiol 27(6):2521–2531CrossRefPubMedGoogle Scholar
  28. 28.
    Yeh R, Steinman J, Luk L, Kluger MD, Hecht EM (2017) Imaging of pancreatic cancer: what the surgeon wants to know. Clin Imaging 42:203–217Google Scholar
  29. 29.
    Kwon D, Mcfarland K, Velanovich V, Martin RC (2014) Borderline and locally advanced pancreatic adenocarcinoma margin accentuation with intraoperative irreversible electroporation. Surgery. 156(4):910–922CrossRefPubMedGoogle Scholar
  30. 30.
    Kluger MD, Epelboym I, Schrope BA, et al. (2015) Single-institution experience with irreversible electroporation for T4 pancreatic cancer: first 50 patients. Ann Surg Oncol 23(5):1736–1743CrossRefPubMedGoogle Scholar
  31. 31.
    Lambert L, Horejs J, Krska Z, et al. (2016) Treatment of locally advanced pancreatic cancer by percutaneous and intraoperative irreversible electroporation: general hospital cancer center experience. NeoplasmaGoogle Scholar
  32. 32.
    Narayanan G, Hosein PJ, Beulaygue IC, et al. (2017) Percutaneous image-guided irreversible electroporation for the treatment of unresectable, locally advanced pancreatic adenocarcinoma. J Vasc Interv Radiol 28(3):342–348CrossRefPubMedGoogle Scholar
  33. 33.
    Månsson C, Brahmstaedt R, Nilsson A, Nygren P, Karlson B-M (2016) Percutaneous irreversible electroporation for treatment of locally advanced pancreatic cancer following chemotherapy or radiochemotherapy. Eur J Surg Oncol (EJSO). 42(9):1401–1406CrossRefPubMedGoogle Scholar
  34. 34.
    Belfiore MP, Ronza FM, Romano F, et al. (2015) Percutaneous CT-guided irreversible electroporation followed by chemotherapy as a novel neoadjuvant protocol in locally advanced pancreatic cancer: our preliminary experience. Int J Surg. 21:34–39CrossRefGoogle Scholar
  35. 35.
    Scheffer HJ, Vroomen LGPH, Jong MCD, et al. (2017) Ablation of locally advanced pancreatic cancer with percutaneous irreversible electroporation: results of the phase I/II PANFIRE study. Radiology 282(2):585–597CrossRefPubMedGoogle Scholar
  36. 36.
    Cannon R, Ellis S, Hayes D, Narayanan G, Martin RC (2012) Safety and early efficacy of irreversible electroporation for hepatic tumors in proximity to vital structures. J Surg Oncol 107(5):544–549CrossRefPubMedGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC 2017

Authors and Affiliations

  • M. Farzan Rashid
    • 1
  • Elizabeth M. Hecht
    • 2
  • Jonathan A. Steinman
    • 2
  • Michael D. Kluger
    • 1
    Email author
  1. 1.Division of Gastrointestinal and Endocrine Surgery, Department of SurgeryColumbia University College of Physicians and SurgeonsNew YorkUSA
  2. 2.Division of Abdominal Imaging, Department of RadiologyColumbia University College of Physicians and SurgeonsNew YorkUSA

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