CIO 2021-26 Review of Percutaneous Irreversible Electroporation in Pancreatic Adenocarcinoma

Purpose: The focus of this educational exhibit is to present a concise review of percutaneous irreversible electroporation (IRE) in the treatment of pancreatic adenocarcinoma.

Material and Methods: We present a review of IRE and its utility in treating pancreatic adenocarcinoma. A concise literature review in both text and figure form will detail the supporting data, patient selection, technique, and potential complications.

Results: Surgical resection with adjuvant chemotherapy is considered as the best option for survival in patients with pancreatic adenocarcinoma, though many patients do not qualify for surgical resection due to their advanced stage of disease at presentation. For these patients, techniques to combine systemic chemotherapy with local ablative therapies are under investigation. Patients should be considered if there is a potential for a previously unresectable tumor to be down-sized to a resectable tumor. While thermal ablation may cause heat-related injury to the adjacent blood supply, bile ducts, and gastrointestinal structures, IRE is a nonthermal ablative technique that uses high-voltage electrical pulses between two needle electrodes within and around the lesion. The electrical pulses create nanopores in cellular membranes which induce apoptosis. A flush catheter is placed transfemoral into the proximal abdominal aorta to allow repeated administration of contrast to visualize the tumor and surrounding vessels. Under general anesthesia, contrast-enhanced computed tomography (CT) is used to establish exact tumor size and shape prior to the insertion of needles under CT guidance. Since the pancreas is retroperitoneal and may be difficult to reach, gantry or virtual gantry tilt is recommended. Needles are inserted according to treatment planning and voltage settings are adjusted following test pulses. Directly following ablation, contrast-enhanced CT is used to assess the ablation coverage and detect bleeding or thrombosis. While mortality from IRE is rare, morbidity is relatively common with patients most frequently complaining of gastrointestinal-related problems, such as pain, diarrhea, and nausea. Severe complications include vessel occlusion or bleeding and pancreatitis.

Conclusions: Local ablative therapies may be used in patients with unresectable pancreatic adenocarcinoma. IRE, especially when combined with adjuvant chemotherapy and/or radiotherapy, has been shown to increase overall survival.