Radiofrequency ablation - Pancreas Center Italy - Treatment Of Cancer Pancreatic In Italy

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RADIOFREQUENCY ABLATION OF LOCALLY ADVANCED PDAC

Radiofrequency ablation of pancreatic neoplasms is  an experimental technique that has been deveoped by a research  consortium (Unit of Pancreatic Surgery at the Peschiera del Garda  Hospital and Unit of Pancreatic Surgery in Verona). It is currently  employed in patients with locally advanced ductal adenocarcinoma (PDAC).

Radiofrequency ablation (RFA) is a local ablative method that can  destroy the tumour by thermal coagulation and protein denaturation. RFA  has been used successfully in the treatment of unresectable solid  tumours in the liver, lung, kidney, brain, breast, prostate, bone,  adrenal glands and spleen. Application of RFA to the pancreas presents  potential problems related to the properties of the pancreatic  parenchyma (soft and friable) and to the risk of inadvertent thermal  injury to the distal common bile duct, duodenum, transverse colon and  portal vein.

Our group demonstrated in 2010 the feasibility and safety of  pancreatic radiofrequency ablation in a group of 50 patients. Mortality  was 2% and morbidity was 24%. Furhter technical refinements have been  applied, such that mortality has decreased to 1%, and the severity  profile of complications has substantially improved. To date, we have  performed more than 200 procedures, and we are investigating the role of  radiofrequency ablation in the context of a randomized clinical trial.  Figure 1 shows the effects of radiofrequency ablation of a locally  advanced pancreatic head ductal adenocarcinoma as seen on postoperative  perfusion-CT scan.  


Figure 1. Left: Preoperative CT-scan showing a locally advanced  pancreatic head ductal adenocarcinoma. Right:
Postoperative perfusion  CT-scan showing the ablated area, devoid of blood supply. Copyright  Chirurgia del Pancreas Verona.


Radiofrequency is a palliative procedure, the  presence of residual viable tumor at the periphery of the treated area  being an intrinsic aspect of the procedure. Survival data of patients  treated in Verona, calculated from an observational non-randomized  analysis, seem encouraging. Radiofrequency ablation seems to be  a locally effective approach, and may be considered as part of a  multimodal treatment for advanced pancreatic ductal adenocarcinoma.  Current indications to radiofrequency include:

  • Confirmed locally advanced pancreatic ductal adenocarcinoma (radiologic staging + biopsy)
  • Age 18-80 years
  • Stable or locally progressive disease after chemotherapy or chemoradiotherapy
  • Performance status >50% (Karnofsky) or <=2 (ECOG)

Radiofrequency ablation is performed via a laparotomy. Accurate  exploration of the peritoneal cavity is performed and supported by  intraoperative ultrasonography in order to rule out previously  undetected metastases and confirm unresectability of the lesion. The  probe is placed in the centre of the lesion under ultrasonographic  guidance, intraoperative ultrasonography is also used during the  procedure to monitor the coagulative effect. When technically feasible, a  biliary and gastric bypass is performed in patients with tumors of the  pancreatic head. Gastric bypass is performed only if necessary in  patients with tumors of the body-tail.

Raiofrequency ablation is a major surgical procedure  to be carried our in centers with broad experience in pancreatic  surgery. A careful multidisciplinary evaluation (surgeon, radiologist,  oncologist) is necessary to design the best care plan for each patient.
Although in expert hands radiofrequency ablation is safe,  post-operative morbidity (similarly to pancreatic resections) is  substantial. Postoperative complications associated with radiofrequency  ablation of pancreatic solid tumors include:

  • Portal vein/superior mesenteric vein thrombosis
  • Ischemic duodenal ulcers
  • Thermal acute pancreatitis
  • Pancreatic fistula and abdominal collections

CT-scans are performed after 7 and 30 days from the procedure to  monitor the ablated area. The patients are referred to the Oncologist  for possible prosectution of chemotherapy or chemo-radiotherapy, and are  enrolled in a strict surveillance protocol, including a detailed  clinical examination, measurement of serum Ca 19.9, and cross-sectional  imaging.

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