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Irreversible electroporation (IRE)

Post by: Dr. Ali Asgar Sabir

IRE is a novel treatment approach that employs high-voltage pulses to induce cell membrane porosity, leading to slow cell death over time. It is a type of non thermal ablation and therefore does not demonstrate heat sink effect. During the procedure, a total of 70 high-voltage DC current pulses, ranging from 1,500 to 3,000 volts, are delivered between the probes to complete the treatment for one pair of probes. Depending on the number of probe pairs involved, the generator automatically switches to the next pair(s) to continue the treatment. Each treatment cycle between a pair of probes lasts for 70 seconds. Following the procedure, a post-procedure CT scan is performed to check for any immediate complications. Contrast is utilized in patients with intact renal function to evaluate vascular structures.

TNM staging for Pancreatic Adenocarcinoma (8th edition):

Stage GroupingsDescription
Stage 0Tis N0 M0
Stage IaT1 N0 M0
Stage IbT2 N0 M0
Stage IIaT3 N0 M0
Stage IIbT1, T2, or T3 with N1 M0
Stage IIIN2 M0 with any T or T4 with any N M0
Stage IVM1 with any T and N
T1 = Tumor ≤ 2 cm in greatest dimension
T2 =Tumor >2 cm in greatest dimension but less than ≤ 4 cm
T3 =Tumor >4 cm in greatest dimension
T4 = Involvement of superior mesenteric artery or coeliac axis
Nx = Nodes cannot be assessed
N0 = No evidence of nodal involvement
N1 = 1-3 regional node metastases present
N2 = 4 or more regional node metastases present
Mx = Presence of metastases cannot be assessed
M0 = No evidence of metastases
M1 = Distant metastases present


  1. As most of the diagnosis is made in advanced disease stages ~ 52% (III and IV), only a small percentage of pancreatic adenocarcinoma patients are eligible for surgical resection.
  2. Locally advanced unresectable pancreatic cancer has a poor prognosis (median survival ~12 months) despite chemotherapy and conventional radiation therapy.
  3. Palliative options for staged locally advanced pancreatic cancer include systemic chemotherapy, radiation therapy (IMRT, cyberknife, proton therapy), and surgical therapy (e.g., celiac axis alcohol ablation, thoracoscopic thoracic splanchnicectomy)
  4. IRE is predominantly used in locally advanced stage III pancreatic adenocarcinoma without metastasis.
  5. A single CT image at one time point is insufficient to confirm recurrence in patients with locally advanced pancreatic cancer, given the heterogeneity of the imaged tissue, the ongoing IRE effects, and the limitations of this modality

Contraindications:

  1. Identification of varices on pretreatment imaging, which is particularly important due to the high incidence of portal vein and splenic vein thrombosis in patients with pancreatic adenocarcinoma. Not all patients with LAPC (locally advanced pancreatic cancer) may be suitable candidates for percutaneous IRE due to the absence of a safe treatment “window.”

  2. The presence of a nearby metallic stent is another significant contraindication.

  3. A history of cardiac arrhythmias represents a third important contraindication for this procedure.

Complications:

Major Complications:

  • Death
  • Severe pancreatitis
  • Biliary obstruction
  • Fistula formation
  • Portal vein thrombosis
  • Bile leak
  • GI perforation

Minor Complications:

  • Abscess formation
  • Post-procedural pneumonia