Assessment of Ablation Therapy in Pancreatic Cancer: The Radiologist's Challenge

Vincenza Granata, Roberta Grassi, Roberta Fusco, Sergio Venanzio Setola, Raffaele Palaia, Andrea Belli, Vittorio Miele, Luca Brunese, Roberto Grassi, Antonella Petrillo, Francesco Izzo, Vincenza Granata, Roberta Grassi, Roberta Fusco, Sergio Venanzio Setola, Raffaele Palaia, Andrea Belli, Vittorio Miele, Luca Brunese, Roberto Grassi, Antonella Petrillo, Francesco Izzo

Abstract

This article provides an overview of imaging assessment of ablated pancreatic cancer. Only studies reporting radiological assessment on pancreatic ablated cancer were retained. We found 16 clinical studies that satisfied the inclusion criteria. Radiofrequency ablation and irreversible electroporation have become established treatment modalities because of their efficacy, low complication rates, and availability. Microwave Ablation (MWA) has several advantages over radiofrequency ablation (RFA), which may make it more attractive to treat pancreatic cancer. Electrochemotherapy (ECT) is a very interesting emerging technique, characterized by low complication rate and safety profile. According to the literature, the assessment of the effectiveness of ablative therapies is difficult by means of the Response Evaluation Criteria in Solid Tumors (RECIST) criteria that are not suitable to evaluate the treatment response considering that are related to technique used, the timing of reassessment, and the imaging procedure being used to evaluate the efficacy. RFA causes various appearances on imaging in the ablated zone, correlating to the different effects, such as interstitial edema, hemorrhage, carbonization, necrosis, and fibrosis. Irreversible electroporation (IRE) causes the creation of pores within the cell membrane causing cell death. Experimental studies showed that Diffusion Weigthed Imaging (DWI) extracted parameters could be used to detect therapy effects. No data about functional assessment post MWA is available in literature. Morphologic data extracted by Computed Tomography (CT) or Magnetic Resonance Imaging (MRI) do not allow to differentiate partial, complete, or incomplete response after ECT conversely to functional parameters, obtained with Position Emission Tomography (PET), MRI, and CT.

Keywords: ablation treatment; computed tomography; functional imaging; magnetic resonance imaging; pancreatic cancer.

Conflict of interest statement

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Copyright © 2020 Granata, Grassi, Fusco, Setola, Palaia, Belli, Miele, Brunese, Grassi, Petrillo and Izzo.

Figures

Figure 1
Figure 1
Included and excluded studies in systematic review.
Figure 2
Figure 2
Patient 1 with Body-Tail Pancreatic Cancer. Morphological MRI assessment post-RFA treatment. In (A) (VIBE T1-W post-contrast sequence during portal phase in axial plane) pre-treatment evaluation of lesion (arrow). In (B) (VIBE T1-W post-contrast sequence during portal phase in axial plane) arrow shows ablated area. Qualitative assessment shows significant differences in SI in pre- and post-treatment sequences.
Figure 3
Figure 3
Patient 2 with Body-Tail Pancreatic Cancer. Morphological MRI assessment post-ECT treatment. In (A) (VIBE T1-W post-contrast sequence during portal phase in axial plane) pre-treatment evaluation of lesion (arrow). In (B) (VIBE T1-W post-contrast sequence during portal phase in axial plane) arrow shows ablated area. Qualitative assessment shows significant differences in SI in pre- and post-treatment sequences.
Figure 4
Figure 4
Patient 3 with head pancreatic cancer. Morphological MRI and CT assessment post-ECT treatment. In (A) (VIBE T1-W post-contrast sequence during portal phase in axial plane) and (C) (CT scan during pancreatic phase of contrast study) the arrow shows lesion. In (B) (VIBE T1-W post-contrast sequence during portal phase in axial plane) and (D) (CT scan during pancreatic phase of contrast study) the arrow shows ablated area. Qualitative assessment shows no significant differences in SI in pre- and post-treatment sequences and no significant differences in density in pre- and post-CT images.
Figure 5
Figure 5
Patient 3 with head pancreatic cancer (the same of Figure 4). Functional (DW-MRI and PET) assessment post-ECT treatment. In (A) (pre treatment) and (D) (post treatment) (b 800 s/mm2) the lesion (arrow) shows restricted signal so as in ADC map (B: pre treatment; and E: post treatment) the lesion shows hypointense signal (arrow). This qualitative analysis is indicative of non-responder lesion. The PET (C: pre treatment; and F: post treatment) assessment shows (arrow) a responder lesion.

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