Our new treatments  for stage 3 pancreatic cancer
In stage 3 pancreatic cancer, the tumor is still in the pancreas and has not spread to other organs. However, surgery cannot be performed because the tumor is attached to the liver and intestinal vessels and radiotherapy has not been shown to be effective. Therefore, local treatment options such as surgery and radiotherapy is not suitable at this stage, although the tumor tends to remain local in which case local treatments must be applied first.
Because of the unsuitability of surgery and radiotherapy, the only remaining treatment option for Stage 3 pancreatic cancer is systemic chemotherapy. Unfortunately however, it has been proven in many studies that the effect of systemic chemotherapy is very limited in stage 3 patients.

Could percutaneous ablation be a good local treatment option?
In stage 3 pancreatic cancer, which tends to progress locally, the biggest problem is the lack of a good local treatment option. Percutaneous ablation may have the potential to address this important problem and improve patients' life expectancy and quality.

Our Varisson Radiology Clinics are among the most experienced centers in the world in the field of pancreatic cancer ablation.  All ablation methods have been used in Stage 3 pancreatic cancer in our clinics since 2012. Among these methods, in our experience, the most successful and safest one is cryoablation (freezing) treatment. 

Why do we prefer cryoablation in stage 3 pancreatic cancer?
1. Cryoablation is performed through a needle puncture under local anesthesia, the procedure only takes 1-2 hours.
2. There is very little pain during and after the procedure. The natural local anesthetic effect of cold prevents pain.
3. During the procedure, the frozen area is clearly seen on ultrasound and tomography. This area can be reduced or enlarged as desired to achieve maximum effect without damaging the surrounding tissue.
4. The patient can return to normal life on the same day or after an overnight stay in our center. 
5. Cryoablation is one of the most effective methods for relieving pain due to pancreatic cancer. After cryoablation, the patient's pain decreases, making it easier for the patient to receive other treatments such as chemotherapy.
6. Approximately 80-90% of the mass in the pancreas can be killed with cryoablation in a single session. If necessary, long-term local control can be further improved by additional radiotherapy and intratumoral immunotherapy. 
7. If the cancer recurs, unlike radiotherapy, cryoablation can be repeated as many times as necessary in the same area.


















How do we perform cryoablation?
In our clinics, all pancreatic cryoablations are performed under ultrasound and computed tomography (CT) guidance, with local anesthesia and sedation. Before the cryoablation, we first perform a celiac ganglion block to prevent pain during and after the procedure. Then, under ultrasound and CT guidance, we insert the cryoablation needle into the pancreatic tumor. When the device is activated, an ice ball is formed at the tip of the needle, which is seen as an elliptic-shaped black area on ultrasound and CT. If necessary, the ice ball can be enlarged by changing the location of a single needle or using more than one needle until the ice ball completely covers the tumor. 


















In stage 3 patients, pancreatic cryoablation usually takes approximately 1.5 hours. After the procedure, the patient is kept under surveillance for 3-4 hours and can go home if he has no serious complaints. Does cryoablation damage the vessels surrounding the cancer during the procedure? No, cryoablation will not damage the veins as long as the needle does not go directly into the veins. Because the blood flowing rapidly through the veins at +37.5 degrees takes away the cold, the vein wall can never get cold enough to be damaged. Due to this feature, cryoablation does not damage the vessels.  As a result, with the cryoablation method, it is possible to freeze and kill 80-90% of the tumor in this region at once without damaging the vessels in the pancreas. With the celiac banglion blockade we perform together with cryoablation, the pain felt by the patient during and after the procedure is minimized.

The combination of blockade + cryoablation is the most effective local treatment for pancreatic cancer pain. We prefer to apply 2 more treatment methods because they create synergy (increasing each other's effect) with cryoablation in most stage 3 pancreas patients. These are intratumoral immunotherapy and radiotherapy:


















1. Intratumoral (within the tumor) immunotherapy: Cryoablation is the ablation method that increases the effect of immunotherapy the most. For this reason, about 2 weeks after cryoablation treatment, we aim to better introduce cancer cells to the immune system by injecting immune checkpoint suppressor drugs (such as Nivolumab) into the frozen area. We repeat this treatment at least several times.

2. Radiotherapy: The highest effect in ablations occurs in the middle parts of the tumor and in the areas around the needle. The effect of ablation decreases as you move further away from the needle and closer to the outer region of the tumor. In radiotherapy, the situation is exactly the opposite. Radiotherapy is more effective on the outer parts of the tumor and less effective on the inner parts. Therefore, applying radiotherapy after cryoablation may increase the amount of tissue killed and reduce the likelihood of tumor recurrence.