nanoknife IRE for pancreatic cancer

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RE: nanoknife IRE for pancreatic cancer

by ricketty on Wed Apr 04, 2018 02:58 AM

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cisplatin can be very hard on kidneys and thyroid own ntroduces a heavy metal into your system that your system is not designed to handle very well in my opinion. platinum

RE: nanoknife IRE for pancreatic cancer

by PhilipJax on Wed Apr 04, 2018 01:55 PM

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Cisplatin & Cytotoxic Agent Harshness
In the Context of Life & Death

          It is correct that many cytotoxic agents (including Cisplatin) beat up the body substantially.  But, those agents must be considered in the context of life and death.  The overriding question is: Will they get the patient closer to surgical resection, generally considered the only avenue for cure?
          Certainly, Cisplatin is not among the “precious bodily fluids.”  Neither is Irinotecan. Nevertheless, Cisplatin can be managed.  A key is pre and post hydration.  To learn hydration details use Google to search the terms: cisplatin hydration guidelines.  You’ll get documents like the following: .
          Since hydration may be undertaken intravenously (IV) be sure to review the advantages of “balanced crystalloid fluids” compared to the typical saline IV fluids.
          Researchers found that for every 100 patients on “balanced” fluids there was one fewer death or severe kidney problem.  Get more details in these articles:
          There is justification for the strategy: Hit hard and early.  If the patient discards the Cisplatin opportunity now, it may not be available later when the patient is too weak and Nab-Paclitaxel + Gemcitabine has failed.  There are no second chances with this disease.  Time is lost; mutations proceed; micro-metastases propagate.
          There is some evidence for Cisplatin efficacy.  See the following prior posts near these pages:,6312,6312
          However, there is little evidence for Paricalcitol (Vitamin D).  It is true that Cornell oncologist Allyson Ocean espouses Paricalcitol.  If she can prove good results, then she should publish her documentation supporting Paricalcitol efficacy to allow peer review.  That is how in science claim is separated from fact.
          Vitamin D proponents suggest that Paricalcitol (a synthetic derivative of Vitamin D) could normalize the barrier of cells that shield pancreatic tumors from chemotherapeutic drugs.  That could alter the stroma.
          Researcher Tanios Bekaii-Saab points out: “Stroma has been characterized as both a friend and a foe. Stroma contains the cancer from spreading out, it prevents things from going in, and keeps the center of the cancer very immunosuppressive . . . [If we break down that stroma] Can we break it enough to be able to kill the cancer?  If we break it too much are we releasing those cancer cells?”  Find the Bekaii-Saab interview herer:
          One final note: There is an index of PhilipJax posts here:

RE: nanoknife IRE for pancreatic cancer

by PhilipJax on Sat Apr 07, 2018 02:26 AM

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Metastases Removal May Become Accepted Practice
Advantage For Patients with<3 Metastases in 1 Organ

          Surgeons usually refuse pancreatic resection to metastatic patients, at least currently.  However, new 2018 (and earlier) research suggests that sturdy metastatic patients, having 3 or fewer (<3) metastases COULD be candidates for BOTH secondary tumor removal AND primary tumor removal, performed in two surgical sessions.
          New Paradigm?  The new therapy sequence is Chemotherapy, then Metastatic Tumor Removal, then More Chemotherapy, then Primary Tumor Therapy (IRE or knife surgery).
          The 2018 report, of which Robert CG Martin is an author, states: “An aggressive surgical approach for a once thought non-operative metastatic pancreatic patient is, in fact, feasible and safe with favorable survival benefit.”  In this study metastases were confined primarily to the liver.
          Potential candidates must have 3 or fewer metastases to a single organ.  They are considered oligometastatic, meaning few (oligo) metastases.
          The patient results of this very small study are not themselves important – what is important is the change in surgeon thinking, favoring oligometastasectomy (removal of few metastases) in very select cases.
          And, the report cites 12 other research efforts (Table 5) agreeing with its view.  In those 12 studies secondary and primary tumor removal yielded 6 to 14 months median Overall Survival.  In the 2018 and earlier studies the liver was the metastatic site.
          Lung Metastases.  For lung metastases the benefits of this same approach are described in two other research reports.
          Linked below they address pulmonary metastases due to pancreatic cancer.  Median Overall Survival (OS) is given.  But, readers should not compare their performance numbers, because the sample sizes are small, and patient selection criteria and therapy histories are different.
          The first article reports on a very informative 2016 German study, which found that metastatic patients lived months longer (a) if the metastases developed solely in the lung (22 patients studied) following prior resection of the primary site (that is, if the lung metastases were not present at initial PC diagnosis), (b) if the metastases were 10 or fewer, and (c) if the metastases were confined to one lung.
          The researchers conclude that “patients with solitary lung recurrence after resection of PC might also benefit from surgical intervention or stereotactic radiosurgery.”  “Solitary” means in the lung only, not the liver or elsewhere.  See
          The second, thoughtful 2016 Moffitt report on 16 patients offers a similar recommendation: “Pancreaticobiliary cancer . . . may derive therapeutic benefit from pulmonary metastasectomy [surgical removal of metastases] when they meet the standard criteria, especially if they have a low preoperative serum CA 19-9 level.  “Pancreaticobiliary” means cancer of the pancreas or biliary system.
          The researchers noted: “Not all new lung masses in pancreatic cancer patients are metastases, and resection should be considered, [because] a potentially curable, second primary lung cancer is often found.”
          They added: “Most oncologists think that any pancreatic cancer patient who has or develops a lung mass is most likely to have stage IV pancreatic cancer, and only palliative chemotherapy is recommended.  Even if the lung lesion is known to be a [primary] lung cancer, surgery is generally not recommended, based on the reasoning that the pancreatic cancer will kill the patient long before the stage I lung cancer will harm the patient.  Fortunately, this reasoning seems to be flawed . . . ”  The Moffitt article is here:
          Further, the authors conclude that pulmonary metastasis, as the first site of PC dissemination, is a rare event and might define a biologically distinct subgroup in metastatic PC (Liver metastasis represents the first site of dissemination in over 80% of metastatic pancreatic cancer patients).  “Dissemination” means metastasis.
          The Moffitt article identifies physicians favoring pulmonary metastasectomy.
          A third article, from Japan, describes the results of such surgery in 4 cases, describing them as “favorable outcomes”:
          Ablation Methods.  The following article describes several lung ablation technologies:
          IRE is not suitable for lung application.  The saclike structure of the lung allows excessive conductivity differences between lung and tumor tissues.
          Radiation.  To the extent that radiation can manage lung metastases, PROTON therapy is superior to photon (X-ray) because it is less damaging to healthy organs and spinal cord.  Both Massachusetts General and the University of Florida Proton Therapy Institute at Jacksonville have programs for primary lung cancer (some of the other 15 proton facilities may have such programs as well).  They may be persuaded to treat lung metastases, especially if you acquaint them with the related journal articles.  Regarding proton facilities:
          These are enormously expensive, $170M facilities.  So, they may have an incentive to help you gain insurance coverage.
          It should be emphasized that oligometastasectomy (few metastases removal) is likely to take place ONLY at major and academic cancer centers – those in the top-ranking by US News.

RE: nanoknife IRE for pancreatic cancer

by PhilipJax on Sun Apr 08, 2018 03:15 AM

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Chemotherapy-First Better Than Surgery-First?
Chemo Better For Those Initially Eligible For Surgery

          In my previous posting I failed to link Dr Martin’s article which favors metastasis removal when they are few in one organ (oligometastatic).  The article can be downloaded from

          Now, the following essay applies ONLY to those early-stage patients who would usually be sent to surgery immediately upon diagnosis.  The essay does not apply to “unresectable” patients whose typical first-therapy is chemotherapy.
          For early-surgery patients, Italian researchers have found that Chemotherapy-First (neoadjuvant chemotherapy followed by surgery) produces better results than initial surgery.  In their Phase 2-3 clinical trial researchers enrolled 88 patients, randomly assigning them to three therapy modes:
1. Group A (26 patients): Immediate surgery followed by Gemcitabine as adjuvant therapy.
2. Group B (30 patients): Immediate surgery followed by the PEXG regimen (Cisplatin, Epirubicin, Capecitabine, Gemcitabine.
3. Group C (32 patients): PEXG (3 cycles) before surgery (neoadjuvant) plus 3 cycles after surgery.
          The results.  The neoadjuvant patients (Group C) fared significantly better.  For Group A the median Progression Free Survival (PFS) was 4.7 months; Group B 12.4 months; Group C 16.9 months.  PFS is the elapsed time before tumors begin to grow again.
          The median Overall Survival (OS) was Group A 20.4 months, Group B 26.4 months, Group C 38.2 months.  ESTIMATES of 5-year survival are Group A 13%, Group B 24% and Group C 49%.  The report is downloadable here:
          And, the clinical trial details reveal the chemo agent dosages, here:
          It should be noted that in the USA Gemcitabine alone is too often chosen as an adjuvant to surgery, as in Group A.  PEXG is not a frequent chemo regimen in the USA and is mentioned only in passing in the NCCN guidelines.  It is often use in countries where Nab-Paclitaxel is not available.
          An analysis of patient records, reported by New Zealand researchers in 2014, showed that PEXG had “similar median OS and response rate to that reported for Gemcitabine-Nab-Paclitaxel.”  A link to the report is here:

          Similar Chemotherapy-First results were found by Spanish researchers, detailed in the following report:
          The Chemotherapy-First vs Surgery-First question was also addressed via the 2018 Gastrointestinal Cancers Symposium in Abstract 406, titled: Resection of pancreatic cancer following induction chemotherapy
          Researchers at five USA institutions sought to learn whether Resectable, Borderline Resectable and Locally Advanced patients fared better if they went directly to surgery or first underwent neoadjuvant (pre-surgery) chemotherapy.  The study of 415 patients helps to resolve the Surgery-First vs. Neoadjuvant-First controversy.
          The investigators began with 144 Resectable (R), 158 Borderline Resectable (BR) and 108 Locally Advanced (LA) patients; some received neoadjuvant chemotherapy; others went directly to surgery.
>> For Surgery-First patients, the median Overall Survival was R 16.9 months, BR 14.6 months, and LA 10.9 months.
>> Of the Neoadjuvant-First patients, the Overall Survival was 31.5 months for BR patients who undertook FOLFIRINOX first, more than twice the 14.6 months of BR Surgery-First patients.
          Some Surgery-First vs. Neoadjuvant-First comparisons could not be made because sample sizes were too small.  For example, of 144 R patients, only 3 received neoadjuvant therapy.  And, the Locally Advanced (LA) data was not presented in the abstract.
          Key 2018 symposium abstracts are downloadable here:
          Finally, two older articles make a case for Chemotherapy-First (neoadjuvant chemotherapy), even when surgery would typically be undertaken first.
          A shortcoming of the Chemotherapy-First strategy is that some initially surgery-eligible patients will lose their opportunities for resection, if the disease progresses during the chemotherapy period (that is, if they are not responders).

RE: nanoknife IRE for pancreatic cancer

by PhilipJax on Sun May 20, 2018 02:34 AM

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BRCA Mutations & Platinum Agents
Help for 20% of Pancreatic Cancer Victims

          A new finding: Platinum drugs perform well in BRCA-based pancreatic cancer.  In May 2018 Johns Hopkins researchers reported that, when pancreatic patients have BRCA1/2 mutations in their DNA, there tend to be two notable outcomes from chemotherapy following surgical resection:
>> BRCA patients, if treated with platinum-based chemotherapy after surgery, are likely to have better Overall Survival rates – an average of 31 months compared to 17.8 months.
>> But, if BRCA patients are treated with non-platinum agents following surgery, they are more likely to suffer a worse Overall Survival than other pancreatic patients, 20.2 months versus 27.8 months.
          In the research the helpful platinum therapy was most often FOLFIRINOX, although one patient was treated with a Cisplatin regimen – this background was learned by direct communications with the report author, since it is not revealed in the report.
          BRCA is the defect often implicated in breast cancer and less than 20% of pancreatic cancer patients.
          The lesson: Undertake genetic testing.  If the patient has the BRCA defect, select FOLFIRINOX following surgery (or perhaps add Cisplatin to a Gemcitabine-based regimen).
          As a corollary of this research, the following might be speculated for the non-BRCA patient: (1) that FOLFIRINOX may offer no greater benefit than Gemcitabine+Nab-Paclitaxel and (2) that FOLFIRI (Oxaliplatin omitted) may work as well as FOLFIRINOX. 
          To learn about FOLFIRI see research Abstract 370, which compares the performances of FOLFIRINOX, FOLFIRI and FOLFOX.  Abstract 370 is located here,6312
          And the new Johns Hopkins BRCA report is here:
          Be sure to study my new website EndPC, which offers guidance on all pancreatic cancer topics, including the latest therapy, care management and clinical trials.  It is located here:

RE: nanoknife IRE for pancreatic cancer

by PhilipJax on Sun May 20, 2018 07:14 PM

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NCCN 2018 Guidelines
Minor Revisions

          The new 2018 NCCN guidelines, released today, contain several noteworthy changes:
>> Genetic testing and counseling are encouraged as part of the oncologist’s workup.
>> Neoadjuvant chemotherapy is now an option for those “high-risk patients” who are eligible for immediate surgical resection.  This recognizes the new Neoadjuvant-First vs Surgery-First debate.
>> Radiation (SBRT) has been added as an option for locally advanced disease, if the primary site (pancreas) is the sole site of disease progression.
>> Irreversible Electroporation (IRE) has been addressed for the second year.  Refer to the Footnote for more on NCCN’s IRE opinion.
          The new NCCN guidelines can be downloaded here:

How to Use the NCCN Guidelines
          NCCN guidelines are used by medical oncologists to make treatment decisions.  However, more than half of all treating physicians ignore these guidelines.  Read about the detrimental consequences to patients here:
          These guidelines (link below) will all you to determine whether your physician is applying the best available therapy.  It takes a few days of real work to study them, but they reduce suffering in the long run.
          Every care manager MUST study the document carefully (and study the last two years of posts on this website).
          The following is a list of NCCN features by page number.  You should study the guide in the following order:
> Pg-4, The new Evidence Block system.
> Pg-43, The ranking of chemo regimens using Evidence Blocks.  Focus on the far-left column: Efficacy.
> Pg-47, Staging code.  Coding to this detail should appear in the overall-condition and biopsy reports.
> Pg-48, Details of the disease and therapies.  And, note well the Categories of Evidence and Consensus, upper left, Page 48.  Using this code the authors rank the reliability of therapies.  Category-1 is, of course, the best.
> Pg 100, Genetic Syndromes and Risk.
> Pg-101, Indications for specific therapies.
> Pg-108, References.  Here you will find research leaders AND physicians you may wish to seek for treatment.
> Pg-2, Oncology leaders who authored this guideline.  They are physicians you may wish to consult for treatment.
> Pg-6, Physician decision tree.  With the exception of IRE, your physicians should be following this decision tool.
          Be sure to study my new website EndPC, which offers guidance on all pancreatic cancer topics, including the latest therapy, care management and clinical trials.  It is located here:

Footnote.  The NCCN panel irrationally recommends against IRE for locally advanced disease “due to concerns about complications and technical expertise.”
          NCCN bases its absurd recommendation on the 2016 musings of several non-IRE practitioners – statements selectively chosen by freelance writer Susan Jenks.  Those physicians never address IRE’s unique application: The removal of tumors which encase blood vessels and ducts, thus making surgical resection (and cure) possible.
          NCCN’s unfounded concern about “complications” is based on the first 10 IRE patients at the inexperienced Roswell Park Cancer Institute.  In 2016 Roswell’s Steven Hochwald said: “What’s unclear is whether IRE really makes a difference in patient outcomes.” 
          Now, two years and only 15 patients later, a still-inexperienced Roswell Park thinks differently, insisting: “We have had some success in extending survival using IRE.”  Yet, NCCN keeps it irresponsible recommendation.  See the 2018 Roswell statement here:
          And the 2-page 2016 interview which nixed a favorable IRE recommendation is downloadable here:

RE: nanoknife IRE for pancreatic cancer

by Barbara19 on Mon May 21, 2018 11:50 AM

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@PhilipJax Looking for that study you posted How bacteria can block gemcitabine from working My bro may have lung inflammation from gemcitabine Waiting for CT scan to determine if that or pneumonia is cause of high fevers & pneumonia like symptoms

RE: nanoknife IRE for pancreatic cancer

by PhilipJax on Mon May 21, 2018 01:51 PM

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Find all past posts at pancreatic(dot)altervista(dot)org where there is a catalog and links to all my postings.

RE: nanoknife IRE for pancreatic cancer

by Upiatoni on Tue May 22, 2018 09:59 AM

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@PhilipJax, First, I would like to thank you for your devotion regarding this particular cancer. Your work is spectacular! Big thanks!

Let me to explain you our history:

My father (71 years old) & I are french (Paris and Dijon based) and since July 2017, my father was diagnosed LAPC (stage 3) non operable because of invasion of blood vessel (artery).

He followed 9 FOLFIRINOX and 9 FOLFORI cures to control the tumor who slightly decreased (from 3.8cm to 3.3cm).

As he supports very will those chimio and french doctors decided to continue this protocol.

In parallel, I spotted a french study named IRECAP in France who is the first IRE study in our country. I asked to his current doctor to involve my father in the IRE protocol but study's critera are very strict, he is not eligible at that time (I'm very desapointed). 

I would like to push in order to include my father in this study where I see a real benefit for him.

Here my requests:

I saw in the historical discussion Dr Martin (in Louisville) as IRE specialist, could you please let me know if it's easy to contact him? Do you have others very well known doctors names to recommand (tricky question)? Do you know if they operates foregein patients? 

If you have a list of names, I will be very gratefull.

When you will revert, I will contact all (with ma father's lastest scan) to get their point of view regarding my father case and if needed, we will travel to US to follow IRE in your country.

He is currently in good shape : eating well, hiking and I would like to maximize his quality of life.

Thanks all in advance for him to share your experiences.

RE: nanoknife IRE for pancreatic cancer

by PhilipJax on Wed May 23, 2018 03:29 AM

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IRE & Chemotherapy
in Europe

Dear Upiatoni,
          This message may be delayed several days due to its links.
          Assuming that the patient is undertaking his first (induction) chemotherapy regimen and that there are no metastases, the patient has a chance.  However, an opportunity may have been squandered.  Your oncologist is wasting time on FOLFIRINOX which has merely stabilized the disease.
          You should consider shifting immediately to Nab-Paclitaxel + Gemcitabine.  You can always return to FOLFIRINOX or 5FU+MM-398 later.  If Nab-Paclitaxel is not available in France, consider the regimens PEFG or PDFG.
          PEFG is Cisplatin (Platinum), Epirubicin, 5-FU and Gemcitabine.  The F is 5FU, sometimes administered as oral 5FU (Xeloda X), creating PEXG.  PDFG replaces Epirubicin E with Docetaxel D.  See
          And, more importantly, review the highlighted text and Table 2 of this creative report
          In addition, review other potential regimens at my website.  See " target="_blank" rel="nofollow">
          Regarding IRE, tumor size limitation depends considerably on the skill and experience of the surgeon.
          I do not know of the competence of European IRE practitioners.  No one has such objective information.  Surgeon Matthias Birth of Straslund Germany is sometimes used by Europeans and Canadians whose insurance won’t cover American surgeons.  You might find him by starting at these websites:
          UK’s Edward Leen is an interventional radiologist experienced in percutaneous IRE (through the skin).  However, open surgery and endoscopic IRE applications are better, to examine the site and to assure the critical placement of the ablation needles.  Contact information is at
          IRE is practiced by the following German institutions, principally percutaneous IRE of the liver:
1. University Medical Center Regensburg of Regensburg Germany; Surgeon H. J. Schlitt and interventional radiologists Marco Dollinger ( and Christoph Niessen (
2. Institut fur Bildgebende Diagnostik, Offenbach am Main, Germany; physician Nina Klein (
          Somewhat dated lists of IRE facilities are given here, and two of the lists do not indicate whether the practitioner is a surgeon or an interventional radiologist.  See
          Robert CG Martin is certainly the leading practitioner.  His contact info may be in this document.
          In the USA state academic facilities such as his tend to be less expensive and tend to work hard to find cost-reducing methods for cash customers.
          When communicating with distant physicians be sure to assemble all recent reports into ONE pdf document: General condition report, surgery, PET / MRI / CT, biopsy, bloodwork – all clean, properly-oriented, easy to read pages and in the recipient’s native language
          As you mentioned, the French IRE trial wants chemotherapy naïve patients although it will accept tumors of 7cm.
          Although you are not trial-eligible, you may find some IRE experience at the trial facility.
          Be sure to review other materials at my website.  See " target="_blank" rel="nofollow">

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