Last week was the annual 2018 meeting of the American Hepatobiliary-PancreaticoBiliary association held in Miami Beach at the Lowe’s Hotel. Altogether 350 lectures and poster sessions; with 10 dedicated NanoKnife. Overall it was rather prosaic with many discussions of marginal relevancy but a few stood out. The Pancreatic meetings focused primarily on prediction of outcome and complication reduction. No new chemotherapy advances were revealed; but some disappointment surrounded excitement by some national leaders about several ongoing trials in the re-configuring of the same 4 agents. Immunotherapy continues to impact 5% of PanCan patients, but induced cell membrane changes stimulating various arms of the immune system may significantly increase that number potentially to 20%!
An entire morning session was held regarding Locally Advanced and Regionally Recurrent Pancreatic Cancer. MED ONC, RAD ONC, SURG ONC, Interventional ONC, each presented where we are and where we will be going during the next 5 years. Chemotherapy options will continue to modify the present first and second line therapies with the addition of immunotherapies in the appropriate setting. RadOnc will be focused on split courses where initial courses are focused on targeted initial IMRT therapy that will allow subsequent SBRT if recurrence occurs. Wider use of Proton therapy is anticipated as favorable Pancreatic Cancer results are anticipated within 5 years.
The surgery of “radical vascular resection” continues to have many devotees with unfortunately high complications and limited long term survival data. The role of Radiation in this subset of Whipples was not well defined because of the risk of death from vascular occlusion.
The interventional oncologists showed they could re-canalize and open the portal vein by stent; yet only minor discussion of how this favorably impacted Portal Hypertension and Ascites. 1 Clearly not all ascites is malignant, and it is my hope further study will better define the transition from benign to malignant.
The greatest excitement came from the discussion of how and when to integrate NanoKnife into the Oncologic paradigm. With Results of 3 trials showing that Open NanoKnife offered single-handedly the longest addition to Overall Survival it was determined it could be incorporated at any point safely and can be repeated as needed, unlike radiation therapy. Although initially felt to a stand alone technology the current prevailing consensus is that it should be used in concert with Chemotherapy and radiation therapy should be withheld until it’s needed toward the end of therapy. The negative impact of prior radiation on later NanoKnife was supported by data and the excitement of immunotherapy post NanoKnife may favorably impact up to 20% of PanCan patients (rather than 4%) even in non-expressors. Lastly, the med oncs supported that No NanoKnife patient should be denied chemotherapy. FFX was favored nevertheless the most effective chemotherapy was felt to be the best and should be reconsidered for use, if side effects profile permits. NanoKnife was associated with stoppage in therapy in less than 5%.
There was universal agreement that we are at a 27-33 month impasse with current multimodality therapy and it was recognized we need better upfront detection of occult metastatic disease. Yours truly met with and consolidated several centers support to participate in MetastaticTrial we are sponsoring using NanoKnife with either TACE vs Y90. More aggressive upfront treatment with Circulating Tumor Cell to detect early recurrence and follow therapy in addition to PET and Ca19-9.
So the role of NanoKnife will expand in Pancreatic and many other cancers. Standardization will be essential in order to enable comparison and a second manufacturer has emerged with a new probe that may prove quite useful in the open procedure. All of these will be published over the next 3 months in the journal HPB- which can be found on PubMed. Stay tuned.
RobertBDonoway, MD, FACS, FSSO
ATLASOncology-The Institute for Pancreas, Liver and Advanced Tumor Ablation
Hollywood • Florida