Nanoknife for pancreatic cancer

@hopefulandpositive
Assuming you are at a pancreas center of excellence… please visit with one more for a second opinion.

I suggest this because:
1) people react differently to different chemo concoctions and there are more than what he is on, incl. a newly approved one
2)nano knife is not widely used for this
3)this must be a very experienced surgeon to work in this area

If you cannot travel, I know there are clinics that will do virtual second opinions. One is Dr Doug Evans at Univ of Wisconsin

The NanoKnife procedure is also known as Irreversible Electroporation (IRE). If you search this forum for "electroporation" a couple discussions will turn up. The procedure can be done, open, laparoscopically, or percutaneously (each less invasive than the previous, but all done under a heavy general anesthesia that requires full paralysis to prevent the patient from convulsing during the electric shocks). There is some risk of organ puncture during electrode insertion, so it's definitely important to find a surgeon who is very experienced with this.

I would give serious consideration to IRE for a tumor that's not currently resectable, especially if you can do the percutaneous procedure. I haven't been able to speak to a surgeon about it yet, but it seems the percutaneous approach would be "non-invasive enough" that you might not need the usual 4-week chemo washout before surgery, or a long abstinence from chemo while healing after surgery.

By "freezing the tumor" I think it's important to clarify that means arresting its development rather than applying cold temperatures. The NanoKnife doesn't cause any appreciable heating or cooling of tissue.

I'm surprised your docs were dismissive of a different chemo regimen. I'm one of those who didn't get much benefit at all from Folfirinox, but had a much better response to Gemcitabine + Abraxane + Cisplatin. It doesn't work for everyone, but seems an easy enough route to try. One nice thing is that you could still try that after the NanoKnife.

Please let us know if you get more information about this, and if you don't mind sharing which institution/surgeon has done more than 200 of these procedures, that would be awesome to know. I'm "researching this procedure for a friend." 😉

Hello hopefulandpositive,
I had the Nanoknife procedure eleven months ago. Like your husband, I was not a candidate for Whipple because of atrial involvement. My surgery was done at the University of Iowa Hospital by Dr. Carlos Chan. I had eight rounds of Folfirinox chemo and 25 rounds of chemo radiation prior to my surgery. The chemo and radiation shrank my tumor from about 3 cm to just under 2.

My surgery was an open procedure, and they also moved where my bowel connects to my stomach to avoid future blockages due to narrowing or scarring of the bowel (the tumor was very close to it). My surgery was on a Friday, and I went home the following Wednesday. I was definitely sore afterwards, but it wasn’t terrible. I used pain meds for maybe a week, mainly to help me sleep, then Tylenol was fine. My doctor did not recommend any chemo after the surgery, but some doctors do.

I’ve had PET and CT scans every three months. The most recent one was about a month ago. So far, so good! No signs of any active cancer cells and my CA 19-9 is at 18 (the lowest it’s ever been). I feel great, and dairy is the only food that gives me any minor issues.

I know not everyone is on board with this procedure, but I am very grateful that I was able to have it done. There is a Facebook page called Nanoknife Surgery Warriors. It is run by a doctor in Florida, Dr. Robert Donoway. He is a big proponent of Nanoknife and performs many of them. He thoroughly answers questions and in my opinion it’s worth checking out.

I’m more than happy to answer any questions you have. Best of luck!!

@hopefulandpositive, have you and your husband decided to go ahead with NanoKnife (irreversible electroporation [IRE]) treatment?

@tiffboss Thank you so much for responding! So inspiring to hear a positive outcome!.

@colleenyoung and all others:
It has been a rollercoaster ride of up and down emotions and very confusing times & information & conflicting opinions so I apologize for my delayed response.
Short answer: We don't know yet. Have a few more appointments next week. Hope to have a game plan soon.

Long answer:
We live in Chicago so we started with Northwestern Memorial Hospital (his cancer was diagnosed here after a CT his internal medicine doctor ordered after upset stomach symptoms which she thought might be related to ulcer) and then got second opinion from University of Chicago. The diagnosis, prognosis and course treatment plan was the same and decided to go with Northwestern Memorial to start chemotherapy right away. And we do like our oncologist there. A month into his treatment, we went to see Dr. Bilimoria (who did his medical school & residency at Northwestern Memorial and fellowship at MD Anderson and is now at Arlington Heights) who came highly recommended by doctor friends as the lead pancreatic surgeon and was told that he has more experience than any other pancreatic surgeon in the area. In fact, he was the only surgeon we talked to that gave us hope about potential surgery after chemo and if chemo doesn't work, potentially being eligible for nanoknife where others have basically said "there is nothing we can do here, get your affairs in order".

So, we decided to continue to work with our oncologist at Northwestern Memorial Hospital and Dr. Bilimoria as the surgeon if and when he became a candidate. We saw him every few months to get scanned and talked about his progress and next steps. So, now after 12 chemo sessions, he is now recommending nanoknife as surgery is not an option as chemo didn't shrink the tumor. We asked to get some statistics on nanoknife but his office recommended we reach out to Angiodynamics (the company who makes nanoknife) as they would have the most comprehensive stats. (I will get to it sometime this week hopefully)

On the other hand, our oncologist and now another new oncology surgeon we talked to yesterday at are "very strongly recommending against it". Our oncologist said, if we choose to do nanoknife, she would highly recommend continuing chemo regardless and said his lab results are good and no reason why he can't continue chemo as is. (in fact, we had our pre-scheduled 13th session on Thursday so if we do nanoknife, have to wait another 4 weeks). Our reason of wanting to go with nanoknife now was so that he wouldn't have to do chemo anymore so if that's not an option, would it be worth doing nanoknife and if we do, do we choose to go against oncologist's wishes on chemo.

Our oncologist at Northwestern is hopeful with clinical trials that are in works (she mentioned RMC-6236 monotherapy and potentially others that are specifically for KRAS mutation. His tumor does) though he won't be eligible for it unless he gets worse or when the clinical trial becomes available for him and others in 2+ years if it continues to show such positive results. Her thinking is to continue with chemo as is and if things get worse, there are promising trials we can tap into.

This other oncology surgeon at Northwestern we talked to yesterday wants us to see a radiation oncologist as he said he is seeing very promising results with "proton radiation therapy (vs. photon radiation therapy) and he referenced "dose escalation therapy 2024" clinical trial and if I understand correctly, is available to patients outside the clinical trial as well. Appointments being scheduled to discuss further and meet with radiation oncologist next week.

So, we are at a crossroads:
-Stop chemo now and do nanoknife in 4 weeks with scans every 3 months after and hope that there is no spread, no new growth...etc.
-Stop chemo and try radiation therapy and if it works, could we do surgery? and if it doesn't work, try nanoknife then if he is still eligible (no spread)?
-Skip nanoknife and continue to do chemo as he is stable and hope to be eligible for surgery (more complicated than nanoknife but as I understand it is the gold standard for "being cancer free") when a successful clinical trial is available to shrink the tumor enough.

Thank you for reading (it was somewhat therapeutic to write)...

This is the wonderful world of multiple opinions, of which I am strongly in favor of! But it does leave us with questions.

I am stage IV since diagnosis 11/2021. NED/not NED, etc etc

What I do believe is unless caught very early and small in size, there are very few one and done surgeries. My insight from many doctors, studies, and now patients I meet and talk with us this-it’s very likely to be in the bloodstream once it is attached to arteries or even elsewhere near ducts. I would not work with a doctor that does not project chemo after surgery. Unless it’s due to co-morbidities, why would someone advise a “what and see” attitude vs insurance?
My thoughts only. Definitely not a medical professional of any kind. This is where my sorting process would begin!

hopeful,

Not a medical professional, but after my sister's illness and reading thousands of threads, a clear takeaway for me is to consider continuing chemo - before surgery, after surgery, during any other treatment where permitted, etc. It may never make one cancer free, but it will continue to beat tumor growth down, as well as potentially limit the spread.

The above said, there are several types of chemotherapy - changing types, strengths, etc is pretty common - has this occurred for your husband?

Can you please elaborate about the treatment options you are under since diagnosis??!! It would be really helpful

I don't know anything about Nanoknife except what I've read on this board, and I'm certainly no medical expert of any type, just a patient. But I noticed that you mentioned that your husband's oncologist was stopping the modified Folfirinox chemo after 12 cycles because of concerns about bone marrow. I have stage 4 adenocarcinoma, inoperable due to blood vessel involvement. I just completed chemo cycle 23 last week. Why are they stopping his after 12? I will say that my oncologist discontinued oxaliplatin after cycle 8 in order to avoid neuropathy. I've also been on a reduced dosage the entire time. But we have continued because we're getting results and because otherwise it might give the cancer a stronger toehold. So it might be worth asking. Here's the other thing I wanted to ask: Has your husband been given injections to activate and boost the bone marrow and prevent infection? There are several versions. One is Neulasta; the one I get is Udenyca. It's given a minimum of 24 hours after the 5FU pump shuts off. Depending on what the bone marrow concern is, that injection might help him. Again, it might be worth asking if you haven't already.

FWIW, we were talking with my palliative MD today about these sorts of issues. I currently have some options to discuss as well. He said that there really is no clear-cut one-size-fits-all pathway for pancreatic cancer therapy. It is such an individual disease, with all sorts of variations. And it's extremely virulent as well, which makes treatment challenging. He said that it requires a lot of back and forth conversations, hallway exchanges between MDs, tumor boards, debates, etc., to arrive at the best plan for each patient. It's frustrating to me, and I'm sure it is for you as well because it's hard to make decisions. But we just have to keep asking questions, doing our research and hopefully getting our MDs together to assess and discuss so they can come up with a plan. I hope all works well for you all!

Morning Everyone,

Just a "different perspective" on everyone is different.

I had Folfirnox ( with very little side effects) pre Whipple procedure for 3 months (March to May 2023); had the Whipple procedure (with complications); tried to get back on Folfirnox again after surgery. After only one treatment, it put me in the hospital with rapid weight loss, dehydration and lots of pain. After being bedridden for 3 weeks after the hospital and taking four months to get my strength back, it took me til 5 months before I tried chemo the 2nd time. This time with G&A. The results were the same, dehydration, 20 pound weight loss and bedridden - and I'm in the process of trying to recover (yet again) the strength that I had before chemo.

My only thought to pass on to everyone; chemo is wonderful when it can help prolong your life in a productive way. As we always say, this really is an individual cancer that impacts everyone in different ways.

My only suggestion on future comments; try to be a little gentler with people when recommending they try different types of chemo at different levels. Sometimes, even when people would like to be on chemo, the negative impact it may have on some individuals is way too much of a burden to carry. (Knowing you are stage 4)

We're all trying to help one another here. Sometimes, not continuing on with chemo is a tough enough choice by itself. Each individual needs to make their best choice. "Gentle" suggestions can be helpful. Other times, trying to push someone a certain way to "help themselves" is difficult to read when you have already made a tough choice.

Prayers for everyone......