Local ablation of pancreatic tumors: State of the art and future perspectives

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.

A Multicenter Randomized Controlled Prospective Study to Assess Efficacy of Laparoscopic Electrochemotherapy in the Treatment of Locally Advanced Pancreatic Cancer

“…The effectiveness of ECT with bleomycin has been in several cutaneous and subcutaneous tumors such as melanoma and chest wall breast cancer recurrence or for the treatment of squamous cell carcinoma of the head and neck [1][2][3][4][5][6][7][8][9][10][11][12][13]. Recently, the benefits of the ECT were also highlighted on deep solid tumors such as the liver and pancreas both in preclinical and clinical studies [14][15][16][17][18][19][20][21][22][23][24].…”

“…The only curative treatment is surgery; however, many patients have locally advanced or metastatic disease at diagnosis, and systemic chemotherapy is usually the main treatment [14]. The median survival of patients with metastatic disease treated with FOLFIRINOX therapy is only 3 mo [14].…”

“…The only curative treatment is surgery; however, many patients have locally advanced or metastatic disease at diagnosis, and systemic chemotherapy is usually the main treatment [14]. The median survival of patients with metastatic disease treated with FOLFIRINOX therapy is only 3 mo [14]. FOLFIRINOX or modified FOLFIRINOX and gemcitabine/albumin-bound nab-paclitaxel remain the first-line treatment regimens, and for patients with BRCA1/2 and PALB2 mutations, FOLFIRINOX or modified FOLFIRINOX and gemcitabine/cisplatin are a second option [14].…”

“…The median survival of patients with metastatic disease treated with FOLFIRINOX therapy is only 3 mo [14]. FOLFIRINOX or modified FOLFIRINOX and gemcitabine/albumin-bound nab-paclitaxel remain the first-line treatment regimens, and for patients with BRCA1/2 and PALB2 mutations, FOLFIRINOX or modified FOLFIRINOX and gemcitabine/cisplatin are a second option [14]. Despite the recent introduction of novel chemotherapeutic schemes, these treatments still correlate with inadequate survival and significant systemic complications [14].…”

“…FOLFIRINOX or modified FOLFIRINOX and gemcitabine/albumin-bound nab-paclitaxel remain the first-line treatment regimens, and for patients with BRCA1/2 and PALB2 mutations, FOLFIRINOX or modified FOLFIRINOX and gemcitabine/cisplatin are a second option [14]. Despite the recent introduction of novel chemotherapeutic schemes, these treatments still correlate with inadequate survival and significant systemic complications [14]. In our experience, by inserting a cytoreductive treatment in the multimodality approach of locally advanced disease, it is possible to obtain encouraging results both in terms of feasibility, safety, efficacy, and overall survival [14,15,22,23].…”