Insights on Chinese and European consensus for USgHIFU treatment of pancreatic cancer

The article “US-guided high-intensity focused ultrasound in pancreatic cancer treatment: a consensus initiative between Chinese and European HIFU centers” by Zhou et al. provides a valuable overview of the application of ultrasound-guided high-intensity focused ultrasound (USgHIFU) in treating pancreatic cancer (1).

Pancreatic cancer remains one of the most challenging major tumours, with median survival under 12 months for inoperable patients (2). Even for those who undergo surgery, only about one-fourth achieve a cure. Patients with inoperable or recurrent disease rely solely on chemotherapy, with little advancement in targeted therapy or immunotherapy compared to other cancers. Therefore, any progress in controlling pancreatic cancer growth is highly significant.

One of the notable strengths of this work is the multinational collaboration that brings together expertise from leading high-intensity focused ultrasound (HIFU) centers across China and Europe. This cross-continental partnership is crucial for harmonizing treatment standards and protocols, enabling the pooling of resources and knowledge to enhance the efficacy of USgHIFU. Such collaboration is particularly important in the context of non-invasive treatments like USgHIFU, which offers a promising alternative to traditional surgical methods for patients with unresectable, locally advanced, or metastatic pancreatic cancer. The ability to alleviate pain and reduce tumour volume without invasive procedures represents a significant advancement in palliative care.

The article meticulously delineates the criteria for patient selection, ensuring that those most likely to benefit from USgHIFU are identified. This targeted approach maximizes therapeutic benefits while minimizing unnecessary risks, which is essential for optimizing patient outcomes. However, case selection should focus on patients with locally advanced disease, as metastases, particularly hepatic metastases, often lead to treatment failure. Hence, for stage IV patients, selection should prioritize those with pain as a primary symptom. Furthermore, the management of anaesthesia is crucial, as many pancreatic cancer patients experience intolerable pain during HIFU treatment, potentially diminishing treatment intensity. Therefore, collaboration with anaesthesiologists is essential, and sedation or preventive low-level analgesia may be insufficient for some patients.

The choice of patient positioning during treatment is another aspect that requires attention. While prone positioning is commonly used and advantageous for HIFU treatment, some devices support supine positioning, which may facilitate anaesthesia administration or long-durational positioning fixation. The consensus should accommodate these different equipment options. Additionally, due to the close proximity of pancreatic tumours to hollow organs such as the stomach, duodenum, intestines, and bile ducts, special attention is needed. Particularly, tumours encircling the superior mesenteric artery (SMA) or superior mesenteric vein (SMV) causing significant vessel narrowing require caution, as occlusion of these vessels can lead to fatal complications like bowel necrosis, unlike the less critical risk of gastrointestinal perforation.

Currently, HIFU treatment relies on experience and real-time ultrasound grayscale changes to determine the treatment dose, which is often inadequate. Given the poor vascular supply of pancreatic tumours, intraoperative ultrasound contrast imaging also lacks precision. Therefore, developing a treatment dose calculation based on energy, temperature, and time could simplify the procedure for operators, especially those new to the technique.

Evaluation of treatment efficacy should be comprehensive, considering imaging, tumour markers, and patient symptoms. The challenging nature of pancreatic cancer necessitates close integration of HIFU treatment with systemic therapies to extend survival and enhance quality of life. With over 1,000 cases treated over 20 years, our experience demonstrates the benefits of HIFU in treating pancreatic cancer (3-6). Future high-quality clinical studies should focus on identifying the optimal patient stage for HIFU, its integration with systemic cancer treatments, and its potential to overcome pancreatic cancer’s immune resistance, thereby advancing treatment for pancreatic cancer patients.

In conclusion, the initiative by Zhou et al. is a pioneering effort in the field of pancreatic cancer treatment. By fostering international cooperation and establishing clear guidelines, this consensus paves the way for broader adoption and standardization of USgHIFU. Continued research and collaboration will be vital in realizing the full potential of this innovative treatment modality, ultimately improving outcomes for patients with pancreatic cancer.

Acknowledgments

Funding: None.

Footnote

Provenance and Peer Review: This article was commissioned by the editorial office, HepatoBiliary Surgery and Nutrition. The article did not undergo external peer review.

Conflicts of Interest: Both authors have completed the ICMJE uniform disclosure form (available at https://hbsn.amegroups.com/article/view/10.21037/hbsn-24-341/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

References

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