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Safety of irreversible electroporation treatment for metastatic disease in humans. Silk Mikhail ; Wimmer, Thomas; Getrajdman, George; Durack, Jeremy; Sofocleous, Constantinos T.; Solomon, Stephen B. Interventional Radiology & Image Guided Therapies - PowerPoint PPT Presentation
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Safety of irreversible electroporation treatment for metastatic disease in humans
Silk Mikhail; Wimmer, Thomas; Getrajdman, George; Durack, Jeremy; Sofocleous, Constantinos T.; Solomon, Stephen B.
Interventional Radiology & Image Guided TherapiesMemorial Sloan Kettering Cancer Center. New York, NY
Email:[email protected]
Agenda Agenda
• Background on Ablation Devices
• Physics (RFA, MWA, IRE)
• Pre-Clinical Data
• Clinical Applications
300GHZ
3HZ
Thermal ablation uses Electromagnetic Spectrum
300 MHz
RFA
MWA
Thermal ablation uses the EM frequencies of 3 Hz and 300 GHz.
Irreversible ElectroporationIrreversible Electroporation
• Electroporation– Electric pulses create
tiny holes in the cell – Temporary as long as
the energy is low• 360 V/cm
– Chemotherapy and Genetic therapy delivery
• “Irreversible”– Higher energy
• 680 V/cm1
• Create permanent holes in the cell
• Cell loses essential molecules and internal signals tell the cell to die
ElectroporationElectroporation
• Reversible electroporation is used to allow genes and drugs to enter cells (300-600 V/cm)
• Direct current pulse leads to elevation of transmembrane potentials creating permanent cell membrane pores: ~1,500 V/cm
• Strong electric fields applied across a cell can cause:
Irreversible permeabilizationof the cell membrane: “IRE”
How IRE kills cellsHow IRE kills cells
Advantages of IREAdvantages of IRE
• IRE is non-thermal
– Little to no scar tissue formation– Structural Protein Sparing
• Nerves and bile ducts in the area of ablation have the potential to heal after treatment
– No heat sink effect• Compared to thermal techniques where blood flow dissipates
heat. Electric pulses are not effected by blow flow.
Patient DemographicsPatient Demographics
Table 1. Patient Demographics
Variable Data
Total number of patients included 29
Age range: 42y-81y
Sex:
Male 16
Female 13
Treated tumor lesions 43
Table 2. Tumor characteristics
Variable Data
Total Tumors 43
Tumor Size 2.3cm
<1 cm 6
1-2 cm 13
2.1-3 cm 12
>3 cm 12
Tumor location
Liver 29
Soft Tissue 12
Lung 1
Tumor type (%)
Metastatic Colorectal 26
Metastatic Pancreatic 6
Metastatic Endometrial 3
Metastatic Prostatic 3
Metastatic Leiomyosarcoma 2
Metastatic Hemangiopericytoma 1
Metastatic Ovarian 1
Metastatic Thyroid 1
Multiple IRE electrodes to treat larger Multiple IRE electrodes to treat larger lesions minimum: lesions minimum: 2 parallel electrodes spaced 1.5-2 cm2 parallel electrodes spaced 1.5-2 cm
NO Heat Sink Effect NO Heat Sink Effect
Case close to bile duct and major veinCase close to bile duct and major vein
• Pre-Tx • Tx • Post-Tx• 3 mo. f/u MRI
No tumor for +778 daysNo tumor for +778 days
Perivascular/periductal Liver MetastasesPerivascular/periductal Liver Metastases
28 patients/ 65 tumors: 1 arrhythmia; 1 PV thrombosis (3%) 6 months: 92% Complete Ablation
Kingham P et al: IRE for Perivascular Hepatic Malignant Tumors. J Am Coll Surg 2012; 215(3): 379-87
Applicators
Animal Lung IRE
Post IRE: GGO
1 week 3 weeks
LUNG close to bronchus
Tumor near airway Tumor near airway
• Pre-Tx • Tx • Post-Tx• 3 mo. PET scan
IRE as an Ablation Tool: Potential AdvantagesIRE as an Ablation Tool: Potential Advantages
• Non-Thermal:
-Application in Locations non eligible for Thermal Ablation
-Limit recurrences near vessels by avoiding the “heat sink”
effect
• Cellular Kill Mechanism Avoids Damage to:
- Extracellular Matrix. This may result in fewer complications:
Near Bile Ducts, Intestines, Ureters, Bronchi, Vital structures.
51 year old with rectal cancer recurrence near 51 year old with rectal cancer recurrence near rectumrectum
NO tumor for +565 days NO tumor for +565 days
Transmural Necrosis; No Perforation at 14 days
IRE Rectal Wall
Applications: IREWhere Thermal ablation is NOT feasible
• Pancreas: Locally advanced adenocarcinoma 100% success at 90 days. Martin RC e al J Am Coll Surg 2012; 215(3): 361-9
• Perivascular Liver Tumors. Kingham P et al: IRE for Perivascular Hepatic Malignant Tumors. J Am
Coll Surg 2012; 215(3): 379-87
• Prostate: A potential Therapeutic Paradigm Shift. Ward JF Curr Opin Urol
2012; (2): 104-108
• Intracranial: Canine brain Surgery. Garcia PA Conf Proc IEEE Eng Med Biol Soc 2009:
6513-6. and Technol Cancer Res Treat 2011; 10(1): 73-83
• Blood Brain barrier Disruption: Rat Hjoui M et al. MRI study on reversible and irreversible
electroporation induced blood brain barrier disruption. Plos One. 2012;7(8)
• Small Intenstine: Rat: Complete ablation but recovery of Epithelium in 3 weeks. Phillips MA. Br J Cancer 2012; 31; 106(3): 490-5
Enhancing Irreversible Electroporation
A zone of Reversible electroporation Surrounds the Area of IRE
A lethal agent can be targeted to the reversible zone:
ElectrochemotherapyGene Electrotransfer
Electrochemotherapy : A new technological approach in treatment of Liver Metastases. Edhemovic et al Technol Cancer Res Treat 2011 Oct; 10(5):475-85
Treatment Planning of Electroporation-Based medical Interventions: electrochemotherapy, gene electrotransfer and IRE Phys Med Biol 2012; 7;57(17)5425-40
Model assumes 360 V/cm threshold for reversible and 680 V/cm threshold for irreversible
Reversible
Irreversible
ConclusionConclusion
• Unlike Thermal Ablation, IRE, can be performed in close proximity to bile ducts, major vessels, bladder, rectum, and nerves, with an acceptable safety profile.
• Longer term follow up is performed to determine efficacy.
• Further research will determine the potential of this new ablation technology