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1
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Wang Z, Liang M, Sun J, Zhang J, Li Y, Xu L, Han Y. Epicardial pulsed-field ablation-impact of electric field and heat distribution induced by coronary metallic stents. Front Cardiovasc Med 2024; 11:1445424. [PMID: 39267803 PMCID: PMC11391106 DOI: 10.3389/fcvm.2024.1445424] [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: 06/07/2024] [Accepted: 08/13/2024] [Indexed: 09/15/2024] Open
Abstract
Background Pulsed-field ablation (PFA) technique is a nonthermal ablation technique. No study has yet evaluated the effect of the positional relationship between the ablation electrode (AE) and the coronary metal stent (CMS) on the electric field distribution and temperature distribution in epicardial ablation. Our study aimed to evaluate the effect of the CMS on the electric field as well as the temperature distribution in different models. Methods Multi-angle modeling of the CMS and AE was performed. The PFA ablation region was evaluated with a field strength contour of 1,000 V/cm, which was used to assess the validity of the two-dimensional (2D) model simulation data as well as the distribution of the multi-angle electric field and temperature in the three-dimensional (3D) model. Results The presence of the CMS had little effect on the width of the ablation area (0.2 mm). In the 3D model, the temperature of the ablation area was highest when the angle between the AE and the CMS was in the 90° position (43.4°C, 41.3°C); a change in the distance between the AE and the CMS affected the temperature of the ablation area (maximum 2.1°C) and the width of the ablation (maximum 0.32 mm). Conclusion The presence of the CMS distorts the distribution of the electric field, but does not produce a change in the extent of the ablation damage, nor does it bring thermal damage to the ablation region. Different simulation models give similar results in PFA calculations, and this study effectively reduces the complexity of modeling simulation.
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Affiliation(s)
- Zhen Wang
- College of Medicine and Biological Information Engineering, Northeastern University, Shenyang, China
- Department of Cardiology, General Hospital of Northern Theater Command, Shenyang, China
| | - Ming Liang
- Department of Cardiology, General Hospital of Northern Theater Command, Shenyang, China
- National Key Laboratory of Frigid Zone Cardiovascular Diseases, General Hospital of Northern Theater Command, Shenyang, China
| | - Jingyang Sun
- Department of Cardiology, General Hospital of Northern Theater Command, Shenyang, China
| | - Jie Zhang
- Department of Cardiology, General Hospital of Northern Theater Command, Shenyang, China
| | - Yunhao Li
- Department of Cardiology, General Hospital of Northern Theater Command, Shenyang, China
- Graduate School of China Medical University, China Medical University, Shenyang, China
| | - Lisheng Xu
- College of Medicine and Biological Information Engineering, Northeastern University, Shenyang, China
| | - Yaling Han
- Department of Cardiology, General Hospital of Northern Theater Command, Shenyang, China
- National Key Laboratory of Frigid Zone Cardiovascular Diseases, General Hospital of Northern Theater Command, Shenyang, China
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2
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Chae MS, Lee N, Koh HJ. Sudden Occurrence of Pacemaker Capture Failure during Irreversible Electroporation Ablation for Prostate Cancer in Post-COVID-19 Patient: A Case Report. Medicina (B Aires) 2022; 58:medicina58101407. [PMID: 36295568 PMCID: PMC9607448 DOI: 10.3390/medicina58101407] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2022] [Revised: 09/30/2022] [Accepted: 10/06/2022] [Indexed: 11/16/2022] Open
Abstract
Irreversible electroporation (IRE) ablation is a novel treatment option for localized prostate cancer. Here, we present a case of an abrupt and fatal arrhythmia during the IRE procedure in a prostate cancer patient with an implanted permanent pacemaker. A 78-year-old male patient with a pacemaker due to sick sinus syndrome and syncope was scheduled for IRE prostate ablation surgery under general anesthesia. He had a history of recovering from coronavirus disease 2019 (COVID-19) after having been vaccinated against it and recovered without sequalae. Pacemaker interrogation and reprogramming to asynchronous AOO mode was carried out before surgery, however, sinus pause occurred repeatedly during ablation pulse delivery. After the first sinus pause of 2.25 s there was a decrease in continuous arterial blood pressure (ABP). During the delivery of the second and third pulses, identical sinus pauses were observed due to failure to capture. However, the atrial-paced rhythm recovered instantly, and vital signs became acceptable. Although sinus pause recovered gradually, the duration thereof was increased by the delivery of more IRE pulses, with a subsequent abrupt decrease seen in blood pressure. The pacemaker was urgently reprogrammed to DOO mode, after which there were no further pacing failures and no hemodynamic adverse events. For patients with pacemakers, close cardiac monitoring in addition to the interrogation of the pacemaker during the electromagnetic interference (EMI) procedure is recommended, especially in the case of having a disease that may aggravate cardiac vulnerability, such as COVID-19.
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Affiliation(s)
| | | | - Hyun Jung Koh
- Correspondence: ; Tel.: +82-2-2258-6156; Fax: +82-2-537-1951
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3
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Yan L, Liang B, Feng J, Zhang HY, Chang HS, Liu B, Chen YL. Safety and feasibility of irreversible electroporation for the pancreatic head in a porcine model. World J Gastrointest Oncol 2022; 14:1499-1509. [PMID: 36160734 PMCID: PMC9412922 DOI: 10.4251/wjgo.v14.i8.1499] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2022] [Revised: 05/12/2022] [Accepted: 07/11/2022] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Irreversible electroporation (IRE) is a local non-thermal ablative technique which has been suggested as a potential cancer therapy. However, the specific anatomic characteristics of the pancreatic head make it challenging to perform any local ablation in this region. Therefore, the safety and feasibility of IRE in the pancreatic head region should be further explored.
AIM To evaluate the safety of IRE in pancreatic head region including its effects on pancreatic ducts, vessels, and adjacent gastrointestinal organs.
METHODS Eight landrace miniature pigs underwent IRE of pancreatic head tissue successfully, with a total of 16 lesions created. Laboratory testing including white blood cell (WBC) count and serum amylase before IRE with follow-up laboratory analysis and pathological examination at 1, 7, 14, and 28 d postablation were performed.
RESULTS All pigs tolerated the ablation procedure without serious perioperative complications. Transiently elevated WBC count and amylase were observed at 24 h post-IRE, suggesting an acute pancreatic tissue damage which was confirmed by pathological observations. Vascular endothelial cells and pancreatic duct epithelial cells in ablation zone were also positive in terminal deoxynucleotidyl transferase dUTP nick end labeling staining. There was extensive duodenum mucosa damage with local hemorrhage 24 h after ablation, while regeneration of new villous structures were observed at 7 and 28 d post-IRE. Masson’s trichromatic staining showed that the extracellular matrix was still intact in vessels and pancreatic ducts, and even in the duodenum.
CONCLUSION IRE ablation to the pancreatic head may be safe and feasible without long-term damage to the surrounding vital structures. However, risks of stress injuries in acute phase should be taken into consideration to prevent severe perioperative complications.
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Affiliation(s)
- Li Yan
- Faculty of Hepato-Pancreato-Biliary Surgery, Institute of Hepatobiliary Surgery of Chinese PLA, Key Laboratory of Digital Hepetobiliary Surgery, The First Medical Centre, Chinese PLA General Hospital, Beijing 100853, China
| | - Bin Liang
- Faculty of Hepato-Pancreato-Biliary Surgery, Institute of Hepatobiliary Surgery of Chinese PLA, Key Laboratory of Digital Hepetobiliary Surgery, The First Medical Centre, Chinese PLA General Hospital, Beijing 100853, China
| | - Jian Feng
- Department of Hepatopancreatobiliary Surgery, Peking University Shougang Hospital, Beijing 100144, China
| | - Hang-Yu Zhang
- Faculty of Hepato-Pancreato-Biliary Surgery, Institute of Hepatobiliary Surgery of Chinese PLA, Key Laboratory of Digital Hepetobiliary Surgery, The First Medical Centre, Chinese PLA General Hospital, Beijing 100853, China
| | - Hao-Sheng Chang
- Faculty of Hepato-Pancreato-Biliary Surgery, Institute of Hepatobiliary Surgery of Chinese PLA, Key Laboratory of Digital Hepetobiliary Surgery, The First Medical Centre, Chinese PLA General Hospital, Beijing 100853, China
| | - Bing Liu
- Faculty of Hepato-Pancreato-Biliary Surgery, Institute of Hepatobiliary Surgery of Chinese PLA, Key Laboratory of Digital Hepetobiliary Surgery, The First Medical Centre, Chinese PLA General Hospital, Beijing 100853, China
| | - Yong-Liang Chen
- Faculty of Hepato-Pancreato-Biliary Surgery, Institute of Hepatobiliary Surgery of Chinese PLA, Key Laboratory of Digital Hepetobiliary Surgery, The First Medical Centre, Chinese PLA General Hospital, Beijing 100853, China
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4
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Bibok A, Kim DW, Malafa M, Kis B. Minimally invasive image-guided therapy of primary and metastatic pancreatic cancer. World J Gastroenterol 2021; 27:4322-4341. [PMID: 34366607 PMCID: PMC8316906 DOI: 10.3748/wjg.v27.i27.4322] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Revised: 05/21/2021] [Accepted: 06/23/2021] [Indexed: 02/06/2023] Open
Abstract
Pancreatic cancer is a challenging malignancy with limited treatment options and poor life expectancy. The only curative option is surgical resection, but only 15%-20% of patients are resectable at presentation because more than 50% of patients has distant metastasis at diagnosis and the rest of them has locally advanced pancreatic cancer (LAPC). The standard of care first line treatment for LAPC patients is chemotherapy with or without radiation therapy. Recent developments in minimally invasive ablative techniques may add to the treatment armamentarium of LAPC. There are increasing number of studies evaluating these novel ablative techniques, including radiofrequency ablation, microwave ablation, cryoablation and irreversible electroporation. Most studies which included pancreatic tumor ablation, demonstrated improved overall survival in LAPC patients. However, the exact protocols are yet to set up to which stage of the treatment algorithm ablative techniques can be added and in what kind of treatment combinations. Patients with metastatic pancreatic cancer has dismal prognosis with 5-year survival is only 3%. The most common metastatic site is the liver as 90% of pancreatic cancer patients develop liver metastasis. Chemotherapy is the primary treatment option for patients with metastatic pancreatic cancer. However, when the tumor is not responding to chemotherapy or severe drug toxicity develops, locoregional liver-directed therapies can provide an opportunity to control intrahepatic disease progression and improve survival in selected patients. During the last decade new therapeutic options arose with the advancement of minimally invasive technologies to treat pancreatic cancer patients. These new therapies have been a topic of increasing interest due to the severe prognostic implications of locally advanced and metastatic pancreatic cancer and the low comorbid risk of these procedures. This review summarizes new ablative options for patients with LAPC and percutaneous liver-directed therapies for patients with liver-dominant metastatic disease.
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Affiliation(s)
- Andras Bibok
- Department of Diagnostic Imaging and Interventional Radiology, H. Lee Moffitt Cancer Center, Tampa, FL 33612, United States
- Department of Transplantation & Surgery, Radiology Unit, Semmelweis University, Budapest 1085, Hungary
| | - Dae Won Kim
- Department of Gastrointestinal Oncology, H. Lee Moffitt Cancer Center, Tampa, FL 33612, United States
| | - Mokenge Malafa
- Department of Gastrointestinal Oncology, H. Lee Moffitt Cancer Center, Tampa, FL 33612, United States
| | - Bela Kis
- Department of Diagnostic Imaging and Interventional Radiology, H. Lee Moffitt Cancer Center, Tampa, FL 33612, United States
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Hogenes AM, Slump CH, Te Riet O G Scholten GA, Meijerink MR, Fütterer JJ, van Laarhoven CJHM, Overduin CG, Stommel MWJ. Effect of irreversible electroporation parameters and the presence of a metal stent on the electric field line pattern. Sci Rep 2020; 10:13517. [PMID: 32782339 PMCID: PMC7421881 DOI: 10.1038/s41598-020-70308-3] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2020] [Accepted: 07/24/2020] [Indexed: 12/25/2022] Open
Abstract
The final ablation zone created with irreversible electroporation (IRE) depends on the size, shape and strength of the electric field that is influenced by several parameters. A profound understanding of the effect of IRE parameter alterations on the electric field are a prerequisite for a safe and effective treatment. Here, we demonstrate a semolina in castor oil model that enables visualization of the static electric field developed by a high-voltage generator between two needle-electrodes. We intuitively visualize the variation in electric field line pattern for selected IRE parameters; active needle length, inter-needle distance, applied voltage and presence of a nearby metal stent, by cameras in three dimensions. The observations were compared to and supported by two-dimensional numerical simulations of the electric field. Our semolina model visualizes the disturbance of the electric field by a metal stent, potentially leading to an incomplete tumour ablation between the needles. The reduction in electric field strength and the area at risk for incomplete tumour ablation are confirmed by the numerical simulations. The semolina model provides insight in the fundamental physics of the electric field, the effect of alterations in IRE parameter combinations and presence of a metal stent within the ablation zone.
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Affiliation(s)
- Annemiek M Hogenes
- Department of Radiology, Nuclear Medicine and Anatomy, Radboud University Medical Centre, P.O. box 9101 (766), 6500 HB, Nijmegen, The Netherlands.
| | - Cornelis H Slump
- Department of Robotics and Mechatronics, University of Twente, Enschede, The Netherlands
| | | | - Martijn R Meijerink
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centre, Vrije Universiteit-Cancer Centre Amsterdam, Amsterdam, The Netherlands
| | - Jurgen J Fütterer
- Department of Radiology, Nuclear Medicine and Anatomy, Radboud University Medical Centre, P.O. box 9101 (766), 6500 HB, Nijmegen, The Netherlands.,Department of Robotics and Mechatronics, University of Twente, Enschede, The Netherlands
| | | | - Christiaan G Overduin
- Department of Radiology, Nuclear Medicine and Anatomy, Radboud University Medical Centre, P.O. box 9101 (766), 6500 HB, Nijmegen, The Netherlands
| | - Martijn W J Stommel
- Department of Surgery, Radboud University Medical Centre, Nijmegen, The Netherlands
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6
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Thermodynamic profiling during irreversible electroporation in porcine liver and pancreas: a case study series. J Clin Transl Res 2020; 5:109-132. [PMID: 32617426 PMCID: PMC7326268] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2020] [Revised: 03/05/2020] [Accepted: 03/07/2020] [Indexed: 11/24/2022] Open
Abstract
AIMS First, the aim of the study was to determine whether irreversible electroporation (IRE) is associated with heat generation in the liver and pancreas at clinical (≤1,500 V/cm) and supraclinical (>1,500 V/cm) electroporation settings; second, to assess the risk of thermal tissue damage in and adjacent to the treated volume in highly perfused versus moderately perfused parts of both organs; third, to investigate the influence of perfusion and of the presence and the orientation of a metal stent on the maximal thermal elevation (ΔTSession,max) in the tissue during an IRE session at fixed IRE settings, and finally, to determine whether the maximum temperature elevation within the IRE-subjected organ during an IRE treatment (single or multiple sessions) is reflected in the organ's surface temperature. METHODS The aims were investigated in 12 case studies conducted in five female Landrace pigs. Several IRE settings were applied for lateral (2), triangular (3), and rectangular (4) electrode configurations in the liver hilum, liver periphery, pancreas head, and pancreas tail. IRE series of 10-90 pulses were applied with pulse durations that varied from 70 μs to 90 μs and electric field strengths between 1,200 V/cm and 3,000 V/cm. In select cases, a metal stent was positioned in the bile duct at the level of the liver hilum. Temperatures were measured before, during, and after IRE in and adjacent to the treatment volumes using fiber optical temperature probes (temperature at the nucleation centers) and digital thermography (surface temperature). The occurrence of thermal damage was assumed to be at temperatures above 50 °C (ΔTSession,max ≥ 13 °C relative to body temperature of 37 °C). The temperature fluctuations at the organ surface (ΔTLocSurf) were compared to the maximum temperature elevation during an IRE treatment in the electroporation zone. In select cases, IRE was applied to tissue volumes encompassing the portal vein (PV) and a constricted and patent superior mesenteric vein (SMV) to determine the influence of the heatsink effect of PV and SMV on ΔTSession,max. RESULTS The median baseline temperature was 31.6 °C-36.3 °C. ΔTSession,max ranged from -1.7 °C to 25.5 °C in moderately perfused parts of the liver and pancreas, and from 0.0 °C to 5.8 °C in highly perfused parts. The median ΔTLocSurf of the liver and pancreas was 1.0 °C and 10.3 °C, respectively. Constricting the SMV in the pancreas head yielded a 0.8 °C higher ΔTSession,max. The presence of a metal stent in the liver hilum resulted in a ΔTSession,max of 19.8 °C. Stents parallel to the electrodes caused a ΔTSession,max difference of 4.2 °C relative to the perpendicular orientation. CONCLUSIONS Depending on IRE settings and tissue type, IRE is capable of inducing considerable heating in the liver and pancreas that is sufficient to cause thermal tissue damage. More significant temperature elevations are positively correlated with increasing number of electrode pairs, electric field strength, and pulse number. Temperature elevations can be further exacerbated by the presence and orientation of metal stents. Temperature elevations at the nucleation centers are not always reflected in the organ's surface temperature. Heat sink effects caused by large vessels were minimal in some instances, possibly due to reduced blood flow caused by anesthesia. RELEVANCE FOR PATIENTS Appropriate IRE settings must be chosen based on the tissue type and the presence of stents to avoid thermal damage in healthy peritumoral tissue and to protect anatomical structures [Table: see text].
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7
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Chan P, McLean C, Chan S, Goh GS. The interaction between irreversible electroporation therapy (IRE) and embolization material using a validated vegetal model: an experimental study. ACTA ACUST UNITED AC 2020; 25:304-309. [PMID: 31199286 DOI: 10.5152/dir.2019.18361] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
PURPOSE Irreversible electroporation (IRE) is a nonthermal tumor ablation technique that induces cell apoptosis while preserving extracellular architecture. Surgical clips and embolic agents may lie adjacent to, or within, the target lesion. It is unknown to date if IRE causes degradation to the embolic agents or surgical clips that may have adverse effects to patients. We aimed to examine the effects of the IRE on the morphology of various embolic agents and the effects of these agents to the ablation field using a previously validated vegetal model. METHODS Metallic surgical clips and various metallic and nonmetallic embolic agents were inserted within the center of the tuber ablation field. Additionally, clips were inserted on the edge and outside the ablation field. One tuber was ablated as a control. Ablation settings were based on previous published experiments. Tubers were imaged with magnetic resonance imaging (MRI) 18-24 hours after ablation and the ablated field dimensions were measured. Nonmetallic embolic agents were examined microscopically by the pathologist. RESULTS Nonmetallic agents did not affect the ablation pattern. Metallic implants, however, caused arcing of the ablation margins. There was no macroscopic or microscopic degradation to the agents after IRE. CONCLUSION The ablation zone arced in the presence of surgical clips at the edge or outside the ablation margins; therefore, nearby critical structures may be susceptible to the effects of IRE. Furthermore, there was no physical degradation of the embolic agents or surgical clips, and this may have importance when considering IRE ablation of previously embolized lesions in vivo.
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Affiliation(s)
- Philip Chan
- Department of Radiology, The Alfred Hospital, Victoria, Australia
| | - Catriona McLean
- Department of Pathology, The Alfred Hospital, Victoria, Australia
| | - Stephen Chan
- Department of Pathology, Sunshine Hospital, Victoria, Australia
| | - Gerard S Goh
- Department of Radiology, The Alfred Hospital, Victoria, Australia; Department of Surgery, Monash University, Melbourne, Australia
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Frey GT, Padula CA, Stauffer JA, Toskich BB. Intraoperative Irreversible Electroporation in Locally Advanced Pancreatic Cancer: A Guide for the Interventional Radiologist. Semin Intervent Radiol 2019; 36:386-391. [PMID: 31798212 DOI: 10.1055/s-0039-1697640] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Efforts to improve mortality associated with locally advanced pancreatic cancer (LAPC) have shown minimal gains despite advances in surgical technique, systemic treatments, and radiation therapy. Locoregional therapy with ablation has not been routinely adopted due to the high risk of complications associated with thermal destruction of the pancreas. Irreversible electroporation (IRE) is an emerging, nonthermal, ablative technology that has demonstrated the ability to generate controlled ablation of LAPC while preserving pancreatic parenchymal integrity. IRE may be performed percutaneously or via laparotomy and will commonly involve multidisciplinary treatment teams. This article will describe the technical aspects of how multidisciplinary IRE is performed during laparotomy at a single tertiary care institution.
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Affiliation(s)
- Gregory T Frey
- Division of Interventional Radiology, Department of Radiology, Mayo Clinic, Jacksonville, Florida
| | - Carlos A Padula
- Division of Interventional Radiology, Department of Radiology, Mayo Clinic, Jacksonville, Florida
| | | | - Beau B Toskich
- Division of Interventional Radiology, Department of Radiology, Mayo Clinic, Jacksonville, Florida
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9
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Cornelis FH, Cindrič H, Kos B, Fujimori M, Petre EN, Miklavčič D, Solomon SB, Srimathveeravalli G. Peri-tumoral Metallic Implants Reduce the Efficacy of Irreversible Electroporation for the Ablation of Colorectal Liver Metastases. Cardiovasc Intervent Radiol 2019; 43:84-93. [PMID: 31385006 DOI: 10.1007/s00270-019-02300-y] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2019] [Revised: 07/21/2019] [Accepted: 07/27/2019] [Indexed: 12/18/2022]
Abstract
PURPOSE To evaluate the effect of peri-tumoral metallic implants (MI) on the safety and efficacy of percutaneous irreversible electroporation (IRE) of colorectal liver metastasis (CRLM). MATERIALS AND METHODS In this retrospective study, 25 patients (12 women, 13 men; MI: 13, no MI: 12) were treated for 29 CRLM. Patient characteristics, tumor location and size, treatment parameters and the presence of MI were evaluated as determinants of local tumor progression (LTP) with the competing risks model (univariate and multivariate analyses). Patient-specific computer models were created to examine the effect of the MI on the electric field used to induce IRE, probability of cell kill and potential thermal effects. RESULTS Patients had a median follow-up of 25 months, during which no IRE-related major complications were reported. Univariate analysis showed that tumor size (> 2 cm), probe spacing (> 20 mm) and the presence of MI (p < 0.05) were significant predictors of time to LTP, but only the latter was found to be an independent predictor on multivariate analysis (sub-hazard ratio = 6.5; [95% CI 1.99, 21.4]; p = 0.002). The absence of peri-tumoral MI was associated with higher progression-free survival at 12 months (92.3% [56.6, 98.9] vs 12.5% [2.1, 32.8]). Computer simulations indicated significant distortions and reduction in electric field strength near MI, which could have contributed to under-treatment of the tumor. CONCLUSIONS Peri-tumoral MI increases the risk of treatment failure following IRE of CRLM.
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Affiliation(s)
- Francois H Cornelis
- Department of Radiology, Memorial Sloan-Kettering Cancer Center, 1275 York Avenue, New York, NY, 10065, USA.,Tenon Hospital, ISCD, Sorbonne Université, 4 Rue de la Chine, 75020, Paris, France
| | - Helena Cindrič
- Faculty of Electrical Engineering, University of Ljubljana, Tržaška 25, 1000, Ljubljana, Slovenia
| | - Bor Kos
- Faculty of Electrical Engineering, University of Ljubljana, Tržaška 25, 1000, Ljubljana, Slovenia
| | - Masashi Fujimori
- Department of Radiology, Memorial Sloan-Kettering Cancer Center, 1275 York Avenue, New York, NY, 10065, USA
| | - Elena N Petre
- Department of Radiology, Memorial Sloan-Kettering Cancer Center, 1275 York Avenue, New York, NY, 10065, USA
| | - Damijan Miklavčič
- Faculty of Electrical Engineering, University of Ljubljana, Tržaška 25, 1000, Ljubljana, Slovenia
| | - Stephen B Solomon
- Department of Radiology, Memorial Sloan-Kettering Cancer Center, 1275 York Avenue, New York, NY, 10065, USA
| | - Govindarajan Srimathveeravalli
- Department of Mechanical and Industrial Engineering, University of Massachusetts, Amherst, MA, 01003, USA. .,Institute for Applied Life Sciences, University of Massachusetts, Amherst, MA, 01003, USA.
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10
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Paiella S, De Pastena M, D’Onofrio M, Crinò SF, Pan TL, De Robertis R, Elio G, Martone E, Bassi C, Salvia R. Palliative therapy in pancreatic cancer-interventional treatment with radiofrequency ablation/irreversible electroporation. Transl Gastroenterol Hepatol 2018; 3:80. [PMID: 30505967 PMCID: PMC6232064 DOI: 10.21037/tgh.2018.10.05] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2018] [Accepted: 10/11/2018] [Indexed: 12/18/2022] Open
Abstract
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.
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Affiliation(s)
- Salvatore Paiella
- General and Pancreatic Surgery Unit, Pancreas Institute, University of Verona, Policlinico GB Rossi, Piazzale L.A. Scuro, Verona, Italy
| | - Matteo De Pastena
- General and Pancreatic Surgery Unit, Pancreas Institute, University of Verona, Policlinico GB Rossi, Piazzale L.A. Scuro, Verona, Italy
| | - Mirko D’Onofrio
- Radiology Unit, Pancreas Institute, University of Verona, Policlinico GB Rossi, Piazzale L.A. Scuro, Verona, Italy
| | - Stefano Francesco Crinò
- Gastroenterology and Digestive Endoscopy Unit, Pancreas Institute, University of Verona, Policlinico GB Rossi, Piazzale L.A. Scuro, Verona, Italy
| | - Teresa Lucia Pan
- General and Pancreatic Surgery Unit, Pancreas Institute, University of Verona, Policlinico GB Rossi, Piazzale L.A. Scuro, Verona, Italy
| | | | - Giovanni Elio
- General and Pancreatic Surgery Unit, Pancreas Institute, University of Verona, Policlinico GB Rossi, Piazzale L.A. Scuro, Verona, Italy
| | - Enrico Martone
- Radiology Unit, Pancreas Institute, University of Verona, Policlinico GB Rossi, Piazzale L.A. Scuro, Verona, Italy
| | - Claudio Bassi
- General and Pancreatic Surgery Unit, Pancreas Institute, University of Verona, Policlinico GB Rossi, Piazzale L.A. Scuro, Verona, Italy
| | - Roberto Salvia
- General and Pancreatic Surgery Unit, Pancreas Institute, University of Verona, Policlinico GB Rossi, Piazzale L.A. Scuro, Verona, Italy
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11
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Yan L, Chen YL, Su M, Liu T, Xu K, Liang F, Gu WQ, Lu SC. A Single-institution Experience with Open Irreversible Electroporation for Locally Advanced Pancreatic Carcinoma. Chin Med J (Engl) 2016; 129:2920-2925. [PMID: 27958223 PMCID: PMC5198526 DOI: 10.4103/0366-6999.195476] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2016] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Locally advanced pancreatic carcinoma (LAPC) is characterized by poor prognosis despite recommended concurrent chemoradiotherapy. Irreversible electroporation (IRE) has emerged as a potential option for the management of unresectable pancreatic cancer. This study was conducted to evaluate the safety and short-term efficacy of open IRE for the treatment of LAPC. METHODS Retrospective data of 25 consecutive patients receiving IRE for T3 lesions from July 2015 to June 2016 at a single center were analyzed. The perioperative and long-term IRE-related complications were reviewed to evaluate the safety of the procedure. The tumor reduction and biological response were analyzed through computed tomography/magnetic resonance imaging; the serum level of CA19-9 was measured as a secondary endpoint to evaluate the short-term efficacy of IRE. RESULTS All patients were successfully treated; the median tumor size was 4.2 cm and the median IRE time was 36 min. Four intraoperative procedure-related complications were observed (16%): two transient hypertensive episodes, one hypotension case, and one transient supraventricular tachycardia case. Nine postoperative complications were described, including three Grade A pancreatic fistulas, three delayed gastric emptying, one acute pancreatitis, one upper gastrointestinal hemorrhage, and one portal vein thrombosis. The overall rate of stable disease was 28%, 36% achieved partial response, and lower serum CA19-9 levels were recorded in all patients at discharge. CONCLUSIONS IRE is feasible for the treatment of LAPC and is a reasonable intervention strategy owing to its combined attributes of safety and efficacy.
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Affiliation(s)
- Li Yan
- Department of Hepatobiliary Surgery, Chinese PLA General Hospital, Beijing 100853, China
| | - Yong-Liang Chen
- Department of Hepatobiliary Surgery, Chinese PLA General Hospital, Beijing 100853, China
| | - Ming Su
- Department of Hepatobiliary Surgery, Chinese PLA General Hospital, Beijing 100853, China
| | - Tian Liu
- Department of Hepatobiliary Surgery, Chinese PLA General Hospital, Beijing 100853, China
| | - Kai Xu
- Department of Hepatobiliary Surgery, Chinese PLA General Hospital, Beijing 100853, China
| | - Feng Liang
- Department of Hepatobiliary Surgery, Chinese PLA General Hospital, Beijing 100853, China
- Department of General Surgery, People's Hospital of Rizhao, Rizhao, Shandong 276800, China
| | - Wan-Qing Gu
- Department of Hepatobiliary Surgery, Chinese PLA General Hospital, Beijing 100853, China
| | - Shi-Chun Lu
- Department of Hepatobiliary Surgery, Chinese PLA General Hospital, Beijing 100853, China
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Ekici Y, Tezcaner T, Aydın HO, Boyvat F, Moray G. Arterial complication of irreversible electroporation procedure for locally advanced pancreatic cancer. World J Gastrointest Oncol 2016; 8:751-756. [PMID: 27795815 PMCID: PMC5064053 DOI: 10.4251/wjgo.v8.i10.751] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2016] [Revised: 06/08/2016] [Accepted: 08/16/2016] [Indexed: 02/05/2023] Open
Abstract
Irreversible electroporation (IRE) is a non-thermal ablation technique used especially in locally advanced pancreatic carcinomas that are considered surgically unresectable. We present the first case of acute superior mesenteric artery (SMA) occlusion secondary to pancreatic IRE procedure that has not been reported before in the literature. A 66-year-old man underwent neoadjuvant chemoradiotherapy for locally advanced pancreatic ductal adenocarcinoma. IRE procedure was applied to the patient during laparotomy under general anesthesia. After finishing the procedure, an acute intestinal ischemia was detected. A conventional vascular angiography was performed and a metallic stent was successfully placed to the SMA and blood flow was maintained. It is important to be careful in such cases of tumor involvement of SMA when evaluating for IRE procedure of pancreatic tumor.
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Wendler JJ, Ganzer R, Hadaschik B, Blana A, Henkel T, Köhrmann KU, Machtens S, Roosen A, Salomon G, Sentker L, Witzsch U, Schlemmer HP, Baumunk D, Köllermann J, Schostak M, Liehr UB. Why we should not routinely apply irreversible electroporation as an alternative curative treatment modality for localized prostate cancer at this stage. World J Urol 2016; 35:11-20. [DOI: 10.1007/s00345-016-1838-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2015] [Accepted: 04/22/2016] [Indexed: 01/05/2023] Open
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Scheffer HJ, Vogel JA, van den Bos W, Neal RE, van Lienden KP, Besselink MGH, van Gemert MJC, van der Geld CWM, Meijerink MR, Klaessens JH, Verdaasdonk RM. The Influence of a Metal Stent on the Distribution of Thermal Energy during Irreversible Electroporation. PLoS One 2016; 11:e0148457. [PMID: 26844550 PMCID: PMC4742246 DOI: 10.1371/journal.pone.0148457] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2015] [Accepted: 01/18/2016] [Indexed: 12/17/2022] Open
Abstract
PURPOSE Irreversible electroporation (IRE) uses short duration, high-voltage electrical pulses to induce cell death via nanoscale defects resulting from altered transmembrane potential. The technique is gaining interest for ablations in unresectable pancreatic and hepatobiliary cancer. Metal stents are often used for palliative biliary drainage in these patients, but are currently seen as an absolute contraindication for IRE due to the perceived risk of direct heating of the metal and its surroundings. This study investigates the thermal and tissue viability changes due to a metal stent during IRE. METHODS IRE was performed in a homogeneous tissue model (polyacrylamide gel), without and with a metal stent placed perpendicular and parallel to the electrodes, delivering 90 and 270 pulses (15-35 A, 90 μsec, 1.5 cm active tip exposure, 1.5 cm interelectrode distance, 1000-1500 V/cm, 90 pulses/min), and in-vivo in a porcine liver (4 ablations). Temperature changes were measured with an infrared thermal camera and with fiber-optic probes. Tissue viability after in-vivo IRE was investigated macroscopically using 5-triphenyltetrazolium chloride (TTC) vitality staining. RESULTS In the gel, direct stent-heating was not observed. Contrarily, the presence of a stent between the electrodes caused a higher increase in median temperature near the electrodes (23.2 vs 13.3°C [90 pulses]; p = 0.021, and 33.1 vs 24.8°C [270 pulses]; p = 0.242). In-vivo, no temperature difference was observed for ablations with and without a stent. Tissue examination showed white coagulation 1mm around the electrodes only. A rim of vital tissue remained around the stent, whereas ablation without stent resulted in complete tissue avitality. CONCLUSION IRE in the vicinity of a metal stent does not cause notable direct heating of the metal, but results in higher temperatures around the electrodes and remnant viable tissue. Future studies should determine for which clinical indications IRE in the presence of metal stents is safe and effective.
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Affiliation(s)
- Hester J. Scheffer
- Department of Radiology and Nuclear Medicine, VU University Medical Center, Amsterdam, The Netherlands
| | - Jantien A. Vogel
- Department of Surgery, Academic Medical Center, Amsterdam, The Netherlands
| | | | - Robert E. Neal
- Department of Radiology, The Alfred Hospital, Melbourne, Australia
| | | | | | - Martin J. C. van Gemert
- Department of Biomedical Engineering and Physics, Academic Medical Center, Amsterdam, The Netherlands
| | - Cees W. M. van der Geld
- Department of Mechanical Engineering, Eindhoven University of Technology, Eindhoven, The Netherlands
| | - Martijn R. Meijerink
- Department of Radiology and Nuclear Medicine, VU University Medical Center, Amsterdam, The Netherlands
| | - John H. Klaessens
- Department of Physics and Medical Technology, VU University Medical Center, Amsterdam, The Netherlands
| | - Rudolf M. Verdaasdonk
- Department of Physics and Medical Technology, VU University Medical Center, Amsterdam, The Netherlands
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Scheffer HJ, Vogel JA, van den Bos W, Meijerink MR, Besselink MGH, Verdaasdonk RM, Klaessens J, van der Geld CWM, van Gemert MJC. Comment to: Månsson C, Nilsson A, Karlson B-M. Severe complications with irreversible electroporation of the pancreas in the presence of a metallic stent: a warning of a procedure that never should be performed. Acta Radiologica Short Reports 2014;3(11):1-3. Acta Radiol Open 2015; 4:2058460115584111. [PMID: 26759723 PMCID: PMC4548731 DOI: 10.1177/2058460115584111] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2015] [Accepted: 04/05/2015] [Indexed: 12/03/2022] Open
Affiliation(s)
- Hester J Scheffer
- Departments of Radiology and Nuclear Medicine, Free University Medical Center, Amsterdam, The Netherlands
| | - Jantien A Vogel
- Department of Surgery, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Willemien van den Bos
- Department of Urology, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Martijn R Meijerink
- Departments of Radiology and Nuclear Medicine, Free University Medical Center, Amsterdam, The Netherlands
| | - Marc GH Besselink
- Department of Surgery, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Rudolf M Verdaasdonk
- Department of Physics and Medical Technology, Free University Medical Center, Amsterdam, The Netherlands
| | - John Klaessens
- Department of Physics and Medical Technology, Free University Medical Center, Amsterdam, The Netherlands
| | - Cees WM van der Geld
- Department of Mechanical Engineering, Eindhoven University of Technology, Eindhoven, The Netherlands
| | - Martin JC van Gemert
- Department of Biomedical Engineering and Physics, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
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Percutaneous Irreversible Electroporation of Unresectable Hilar Cholangiocarcinoma (Klatskin Tumor): A Case Report. Cardiovasc Intervent Radiol 2015; 39:117-21. [PMID: 25994516 PMCID: PMC4689746 DOI: 10.1007/s00270-015-1126-z] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2015] [Accepted: 04/21/2015] [Indexed: 12/15/2022]
Abstract
Irreversible electroporation (IRE) is a novel image-guided ablation technique that is rapidly gaining popularity in the treatment of malignant tumors located near large vessels or bile ducts. The presence of metal objects in the ablation zone, such as Wallstents, is generally considered a contraindication for IRE, because tissue heating due to power conduction may lead to thermal complications. This report describes a 66-year-old female with a Bismuth-Corlette stage IV unresectable cholangiocarcinoma with a metallic Wallstent in the common bile duct, who was safely treated with percutaneous IRE with no signs for relapse 1 year after the procedure.
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Skjennald A. When to do, and when (definitively) not to do an interventional procedure. Acta Radiol Short Rep 2014; 3:2047981614558197. [PMID: 25535574 PMCID: PMC4271710 DOI: 10.1177/2047981614558197] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
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