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Emerging strategies augment surgery in pancreatic cancer

OCTOBER 25, 2017
Clinical Congress Daily Highlights, Wednesday First Edition

Advanced pancreatic cancer is a therapeutic battleground, where significant victories are measured in months, not years, of added survival. Most patients die within a year of diagnosis, and the five-year survival rate is less than 5 percent. Only about one in five patients present with resectable tumors, the kind most amenable to treatment.

“As I often tell my trainees, we currently don’t actually have a standard of care for neoadjuvant therapy, let alone for radiotherapy, in the context of locally advanced pancreatic cancer (LAPC),” said Theodore Hong, MD, Massachusetts General Hospital, Boston, MA, a radiation oncologist and cancer researcher. “Where we’re going is probably more important than where we are.”

That itinerary comprised the agenda for a Wednesday session that featured a mix of surgeons and other specialists like Dr. Hong, who observed that “the biggest win” in the category will be to increase the pool of patients eligible for surgery and thus potentially extended survival. Candidate approaches include chemotherapy/radiation, electroporation (applying an electrical field to tumor cells in order to increase their permeability to drugs) and a new technique, scheduled to be first tried in humans next year, that involves drug delivery into the tumor via electrical charge.

Tony Reid, MD, PhD, University of California San Diego Health, La Jolla, CA, reported on progress in the use of multidrug chemotherapy to downstage the disease for surgical resection. He said the optimal regimen of FOLFIRINOX and gemcitabine/abraxane in combination with radiation has not been determined, though trials are in progress. He also noted significant survival improvements with adjuvant chemotherapy after macroscopic resection of pancreatic cancer.

Reversible electroporation has been a basic lab tool for loading cell membranes, DNA molecules or forging cell fusion for decades. But in the clinic of Robert C.G. Martin. MD, PhD, University of Louisville, Louisville, KY, a surgical oncologist, they’re doing it irreversibly, subjecting tumor cells to 3,000-volt pulses from multiple probes that induce permanent porosity, causing electrolyte imbalances and underlying cell death. Unlike radiofrequency, microwave, or cryo techniques, which are thermal-based and affect surrounding connective tissue, irreversible electroporation (IRE) spares connective tissue. 

Significant overall survival benefits in LAPC can be achieved with optimized chemotherapy, IRE, and radiation therapy, he concluded.

Next year, Phase I human trials are scheduled to begin with a new modality, iontophoresis, which involves using electrical charge to pull medication directly into tumor. Panelist Jen Jen Yeh, MD, University of North Carolina, Chapel Hill, NC, the chief executive of the startup company developing and testing the technology, described its function and presented preclinical animal results.

Additional Information:
The Panel Session, Novel Approaches to the Management of Advanced Pancreatic Cancer, was held October 25, at the 2017 Clinical Congress of the American College of Surgeons in San Diego, CA. Program, webcast and audio information is available online at FACS.org/clincon2017.

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