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THERMOABLATION

Thermoablation intervention using radio frequency
 
Thermoablation using radiofrequency of pancreatic wounds is an experimental method developed by an association between Chirurgia Pancreatica Ospedale of Peschiera of Garda and Chirurgia del Pancreas di Verona research groups and used on patients with locally advanced ductal adenocarcinoma.
 
It consists in the application of electromagnetic waves directly on the neoplasia. This causes a rise in the intra-tumoral temperature that destroys the cells by coagulation and denaturation of the proteins. Radiofrequency has been used for some time in the multimodal treatment of an unresectable solid neoplasia (liver, kidney, brain, prostate, suprarenal gland). The application to a pancreas solid neoplasia was always judged as extremely dangerous due to the delicate nature of the pancreas itself and the delicate ties with noble vascular structures, with duodenum and the bile.
 
Our research group on pancreatic radiofrequency demonstrates in 2010 the applicability and the relative safety of ablation using radiofrequency on a group of 50 patients with ductal advanced adenocarcinoma, registering a mortality rate of 2% and a post-surgical complications rate of 24%. With this growing experience the technique gets better and better and, to this day, in the Hospital of Peschiera del Garda and or Unit of Pancreatic Surgery performed over 200 surgeries (highest casuistry worldwide). Picture 1 shows the effects of radiotherapy of pancreatic tumor has seen on a perfusional TAC, that quantifies the blood flow in the region in which new can find the neoplasia after the ablation procedure.
Picture1. Pre-surgical TAC (locally advanced neoplasia on the head of the pancreas, left picture), perfusion-TAC after a thermoablation procedure with radio frequency (on the right). It is clear there is no blood flow on the region of the ablated tissue on the neoplasia level. Copyright Chirurgia del Pancreas Verona.

Radiofrequency remains a procedure with no radical intent, it only produces a partial ablation of the neoplasia. Long-term survival results (which, actually, come from a non-randomized observational analysis) are very encouraging and, this process, might have an important role in a multimodal treatment of ductal adenocarcinoma, with the appropriate timing and cure plan for every single patient. At this moment, we consider radiofrequency thermoablation on patients with:
  • Locally advanced adenocarcinoma (radiological staging) confirmed using preparatory biopsies.
  • Age between 18 and 80 years old.
  • The disease is not in regression after radiotherapy/chemotherapy (regime and number of cycles are at discretion of the Oncologist/Radiotherapist, a minimum of 3 months of therapy).
  • Good general conditions (performance status > 50% sec. Karnofsky or ≤ 2 sec. ECOG).

 
Thermoablation using radiofrequency is performed using a laparotomy (a low abdominal incision). Before a surgeon performs the procedure he will always execute a complete surgical exploration of the abdomen and an ulterior histologic specimen during the operation to confirm diagnose and staging. The localization of the neoplasia and vascular relations is confirmed by an intra-surgery echography, which guides the positioning on the wound of the electrodes medical probe and visualizes the entire tumor necrosis area during the application of electromagnetic waves. If necessary, at the end of the procedure a gastric and/or bilious bypass is performed with a palliative purpose.
 
Thermoablation using radiofrequency is a high level surgery intervention, to execute only in center in which there is a top quality experience on this method and – more in general – with pancreas surgery. A whole team of multidisciplinary experts (radiologists, oncologists) to establish the most appropriate therapeutic plan according to each patient.
 
Even though pancreatic radiofrequency is a safe procedure by now, the insurgence of specific post-surgery complications are still possible, among which:
  • Portal vein/ superior mesenteric vein thrombosis.
  • Duodenal ischemic ulcers.
  • Thermal acute pancreatitis.
  • Pancreatic fistulas.
 
Protocol requires the execution of a TAC at the moment of discharge to evaluate the ablated area, the prosecution of chemotherapy if tolerated, and a close clinical and instrumental follow-up by our center.

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