nanoknife IRE for pancreatic cancer

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RE: nanoknife IRE for pancreatic cancer

by PhilipJax on Thu Aug 24, 2017 01:38 PM

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Care Management

Dear Dessmo,
          As you may know, many victims of lethal disease act as if all treatment facilities and all physicians possess equal competence.  Not so.  As in every profession (whether athletics, engineering or law) there are vast differences in imagination and skill.
          And, strategy preparation should not wait for physician meetings.  The patient should be so well-informed about his condition and the available therapies that he knows BEFORE the meeting what the physicians will recommend.
          The patient or his family care manager should know specifics on all therapies.  And, the paths to each therapy (including communications with physicians) should be so well prepared that the patient can jump to a new therapy with no loss of time.  This is called: Having Many Irons In The Fire.  Your physicians will not do this for you.  Time is an enemy.  It must not be wasted.
          In addition, were I an ACC victim, I would seek the best facility and best physicians on earth, if my fortunes or my insurance would cover them.
          Families don’t like the inconvenience of travel.  However, select a lesser facility, and there will be more complications, more suffering, more delays and worse outcomes.  Death is far more inconvenient than travel.
          If IRE is performed imperfectly, there will be an inferior outcome.  Even placement of the IRE probes 5mm out of standard will result in incomplete ablation.
          The following publications describe IRE ablation of the liver, and may identify suitable IRE practitioners nearby and worldwide.
http://jaxelection.altervista.org/pancreatic/IRE_PercutLiver
http://jaxelection.altervista.org/pancreatic/IRE_PercutLiver
http://jaxelection.altervista.org/pancreatic/IRE_LiverMetsCT
http://jaxelection.altervista.org/pancreatic/IRE_LiverMets20
http://jaxelection.altervista.org/pancreatic/IRE_LiverRecurr
http://jaxelection.altervista.org/pancreatic/Martin2013Liver
          For colon cancer with many metastases to the liver, frequently half the liver is removed (it will regenerate quickly), and the remaining metastases are ablated.
          In your case, I don’t know whether liver surgery / ablation is suitable.  You must not interrupt systemic chemotherapy for long.  And, if you undertake the surgery, you still must return to systemic therapy quickly.  There are still hidden micrometastases which must be treated.
          The patient can inquire of the outside world quickly without travel.  Many distinguished physicians will reply to inquiries, if presented with medical details in a courteous, concise email.  The email should contain ONE clean, properly-oriented pdf file, which contains the following reports: Overall condition, Surgery report, PET/MRI/CT report, Biopsy report, Medical oncology report, Bloodwork, etc, in logical order.
         The letter should get right to the point, something like the following:

Dear Dr xxxx:
          I would be very grateful for your thoughts on whether I might be a candidate for xxxxxxxxx.
          On xxxxx 2016 I was diagnosed with xxxxxxxxxx, Stage xx (xx metastases to the liver – the largest of which is xxx mm).
          I underwent xxxxxxxx surgery in xxx 2016 with xxxxxxxxx results.  And, I have undertaken xx rounds of xxxx (name the chemo regimen) with xxxxxxxxxxx results.
          I also suffer from diabetes mellitus (or whatever major conditions ails you).  I am well insured.
          I cannot thank you enough for your help.
          Sincerely
         Dessmo xxxxxxx

         PhilipJax

 

RE: nanoknife IRE for pancreatic cancer

by dessmo on Fri Aug 25, 2017 08:41 AM

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PhillipJax,

Thank you very much for your thoughts and advise which I very much share. I try to learn as much as possible about my disease and treatment options so I can meet well prepared and challenge my medical team. I find this especially important since I am diagnosed with a rare version of PC that there is not developed specific treatment protocols for. Norway has also a small population with only around 800 PC patients/year, and that sets limitations wrt experience. I also agree that traveling and getting treatment abroad is a relatively low price to pay when your life is at stake. The challenge as I see it is to be able to identify the best treatment provider for my diagnosis. I have already sent out a lot of emails to medical experts that have wrote articles about ACC  searching for some expertise in treating this rare version of PC. I have got a lot of answer, but have yet to find experts with experience treating ACC. Encouraged by your advise I will continue my search iot find the best treatment that is available. Thank you very much PhillipJax, I really appreciate your assistance and advise.

Magnus    

RE: nanoknife IRE for pancreatic cancer

by PhilipJax on Fri Aug 25, 2017 02:17 PM

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Dear Dessmo (Mangus)
          As you mentioned, you have identified SURGICAL oncologists, perhaps using journal articles recently posted.  So, the identities of imaginative MEDICAL oncologists will be helpful.
          Medical oncologists Margaret A. Tempero and Tanios Bekaii-Saab fit the definition of very creative.  Dr Tempero practices at UCSF Diller Comprehensive Cancer Center, USA.  And, Dr Bekaii-Saab may be found at Mayo Clinic, Phoenix Arizona, or at Ohio State University Comprehensive Cancer Center in Columbus Ohio.
          Of course, there are other oncologists, but I cannot be certain of them.  Dr Tempero is the chair of NCCN’s pancreatic cancer guidelines committee and has an enormous reputation.  The guidelines are here:
http://jaxelection.altervista.org/pancreatic/NCCN2.2017Pancr
          At every ASCO conference, the highly-regarded Dr Bekaii-Saab is sought for his insightful opinions on gastric cancers.  His recent paper on colorectal cancer displays considerable creativity.
http://jaxelection.altervista.org/pancreatic/CheckpointInCRC
          If they treat you in clinical practice, you will get carefully-considered therapy.  Be wary, however, of a clinical trial, if the experimental agent has not shown good performance in an earlier human trial.  Success in a non-human trial doesn’t count.  All failed human trials (of which there have been hundreds) began with a successful non-human trial.
         PhilipJax

 

RE: nanoknife IRE for pancreatic cancer

by dessmo on Sat Aug 26, 2017 03:05 PM

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Dear PhilipJax,

Thanks again for your advise and information. Both very useful. I have not seen the NCCN guidelines before, and found them very interesting. I would though like to see guidelines specific for ACC, it is frustrating to be treated for Adeno when you have Acinar.

RE: nanoknife IRE for pancreatic cancer

by GinaGB on Wed Aug 30, 2017 09:33 PM

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Dear Ladies and Gentleman:

I am overwhelmed by the amount of information here on this discussion. Thanks so much for sharing your experience and knowledge. Please bear with me as my post is a bit long. I need your advice on a nanoknife procedure that we are offered. 

My husband has been approved by Dr. Leen in England for the nanoknife (laparoscopically) procedure . He also has metastases on his liver and Dr. Leen has suggested microwave ablation procedure for the liver metastases. Dr. Leen will ablate the whole tumor on the pancreas. My first question is what are the cons/risks associated with ablation of the whole tumor? Why other physicians (e.g., Dr. Martin) do not consider this procedure for the patients that do not want to have an open surgery?

My other question is that Dr. Vogl (of Germany) has recommended chemoembolization for the metastases on the liver. Based on your experience what method is better for liver metastases? or basically which one is less damaging to the liver especially if one wants to continue the chemo right after?
I also appreciate if you know any practitioner in the USA that offers the same procedure when metastases are present. 

PS-1: I have contacted Dr. Martin and I have not heard back from him and it has been more a week already
PS-2: laparoscopic procedure is preferred because we want to be able to continue the systemic chemo right after

RE: nanoknife IRE for pancreatic cancer

by GinaGB on Wed Aug 30, 2017 09:33 PM

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Dear Ladies and Gentleman:

I am overwhelmed by the amount of information here on this discussion. Thanks so much for sharing your experience and knowledge. Please bear with me as my post is a bit long. I need your advice on a nanoknife procedure that we are offered. 

My husband has been approved by Dr. Leen in England for the nanoknife (laparoscopically) procedure . He also has metastases on his liver and Dr. Leen has suggested microwave ablation procedure for the liver metastases. Dr. Leen will ablate the whole tumor on the pancreas. My first question is what are the cons/risks associated with ablation of the whole tumor? Why other physicians (e.g., Dr. Martin) do not consider this procedure for the patients that do not want to have an open surgery?

My other question is that Dr. Vogl (of Germany) has recommended chemoembolization for the metastases on the liver. Based on your experience what method is better for liver metastases? or basically which one is less damaging to the liver especially if one wants to continue the chemo right after?
I also appreciate if you know any practitioner in the USA that offers the same procedure when metastases are present. 
Thanks so much in advance,

PS-1: I have contacted Dr. Martin and I have not heard back from him and it has been more a week already
PS-2: laparoscopic procedure is preferred because we want to be able to continue the systemic chemo right after

RE: nanoknife IRE for pancreatic cancer

by PhilipJax on Thu Aug 31, 2017 11:55 AM

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Dear GinaGB:
          The forum system usually delays my replies by one day, due to the links.
          Some of your questions can be answered.  But, others cannot, because we don’t have all the data.  For them we can only speculate.
1. For the liver, IRE likely produces less morbidity than microwave ablation.  See the following journal articles.  However, it is possible that Prof Leen, Imperial College London, is more skilled at microwave ablation.
http://jaxelection.altervista.org/pancreatic/Chap98Microwave
http://jaxelection.altervista.org/pancreatic/IREvsMicrowave2
2. According to his biography at Princess Grace Hospital, Prof Leen is an interventional radiologist, not a surgeon.  He “runs the clinical percutaneous ablative therapies” activity of the London system – no laparoscopy is cited.  In the USA a laparoscopic procedure is usually performed by a surgeon.  Perhaps Prof Leen works with a surgeon.
3. Of course, I do not know why Dr Martin did not reply.  Perhaps your email insisted too much on an approach that YOU prefer.  Of course, I do not know.  I suggest you use the letter form which I posted recently, sent with the records in one pdf file.  Stick to the facts; offer no judgments; skip all emotion, and get to the point in as few words as possible.  Make no reference to the previous letter you sent.
          Surgeons may undertake IRE in any form (percutaneous, laparoscopic, open surgery); so, if highly competent, will select the method likely to produce the most thorough, durable results.  Keep in mind: The difference between the resectability and non-resectability of a patient is often the skill of the surgeon.
          Dr Martin is chief of the medical school’s surgical oncology division, and the leading IRE practitioner.  Don’t presume that he is missing something, if he selects a non-percutaneous approach.  He may not agree that the “benefits” of your preferred approach are real.  He knows that the battle does not end with the first surgery or the first IRE ablation.
          On the other hand, Prof Leen (and other interventional radiologists) cannot undertake surgery, even if open surgery would be better for the patient in the long term.
          You might also contact surgeon Christopher Lee Wolfgang, MD, PhD of Johns Hopkins.  See
http://jaxelection.altervista.org/pancreatic/10_IRE_JHopkins
3. There are many articles at PubMed on management of liver metastases by embolization (a procedure which seeks to block blood supply to tumors).  Review of a few will give you the answer on chemo-embolization.  I also posted an article recently on the various ablation techniques used to treat liver metastases. 
4. Govindarajan Narayanan, MD, an interventional radiologist at the U of Miami Sylvester Cancer Center, once used percutaneous IRE to treat pancreatic metastases to the liver.  He may or may not still do that.  He may be the most experienced percutaneous IRE practitioner in the USA.
         PhilipJax

RE: nanoknife IRE for pancreatic cancer

by Esrph on Thu Aug 31, 2017 05:54 PM

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FYI we has been trying to get Dr.Martin s office to call us back or answer an e mail for almost 2-3 weeks. No reply at all. Keep emailing and leaving messages to no avail. We are not in a rush as have scan next Thursday . Have no idea what is wrong with his office.

RE: nanoknife IRE for pancreatic cancer

by cdaley2 on Thu Aug 31, 2017 06:22 PM

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RE: Dr. Martin, same here. I sent the whole package, including CDs of scan a couple of weeks ago and have heard nothing. I'm just dotting my i's as I am sure that he is going to refuse me for nano on my lung mets - so I haven't been chasing him. I'm sure it's just late August/Labor Day vacations etc.

RE: nanoknife IRE for pancreatic cancer

by PhilipJax on Fri Sep 01, 2017 03:20 AM

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Esrph & cdaley2:
          Time is an enemy.  All pc victims must have many irons in the fire.  So that, if one avenue fails, he can jump to another at a moment’s notice (truly at a moment’s notice, meaning tomorrow).  All arrangements should have already been made with other physicians for the same or other therapies.
          You should have made inquiries of other physicians already.  You are not obligated to tell one about the other, or to reveal any physician preferences.
          Time is fleeting.  You should be able to say: If my current therapy doesn’t work (most often it won’t), then I have already made arrangements to begin therapy X with physician Y, who has already accepted me.  And, it that doesn’t work, I have been accepted for therapy Z.
          Such research and planning requires a lot of work, but you will use the fruits of your work, sooner than later.
          Pancreatic cancer is a swiftly moving parade.  One misstep, and one cannot go back and take a road previously forsaken.
          PhilipJax
PS:    It is entirely possible that Dr Martin is exhausted. Each procedure can last 5-6 hours. Do that 3-4 time per week; add the duties of chief of surgical oncology and research director, and you get very fatigued.

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