Annals of Surgical Oncology

, Volume 26, Issue 3, pp 800–806 | Cite as

Evaluating the Regulatory Immunomodulation Effect of Irreversible Electroporation (IRE) in Pancreatic Adenocarcinoma

  • Harshul Pandit
  • Young K. Hong
  • Yan Li
  • Jack Rostas
  • Zachary Pulliam
  • Su Ping Li
  • Robert C. G. MartinEmail author
Pancreatic Tumors



Irreversible electroporation (IRE) has been demonstrated as an effective local method for locally advanced (stage 3) pancreatic adenocarcinoma. Immune regulatory T cells (Tregs) induce immunosuppression of tumors by inhibiting patients’ anti-tumor adaptive immune response. This study aimed to evaluate the immunomodulation effect of IRE to identify an ideal time point for potential adjuvant immunotherapy.


This study prospectively evaluated an institutional review board-approved study of patients undergoing either in situ IRE or pancreatectomy. Patient blood samples were collected at different time points (before surgery [preOP] and on postoperative day [POD] 1, POD3, and POD5). Peripheral blood mononuclear cells (PBMCs) were isolated and evaluated for three different CD4 + Treg subsets (CD25 + CD4 +, CD4 + CD25 + FoxP3 +, CD4 + CD25 + FoxP3 −) by flow cytometry and analyzed for median fold change (MFC) between each two consecutive time points (MFC = log2(T2/T1)).


The study analyzed 15 patients with in situ IRE (n = 11) or pancreatectomy (PAN) (n = 4). In both groups, CD25 + CD4 + Tregs decreased on POD1 followed by a steady increase in pancreatectomy, whereas the trend in the IRE group reversed between D3 and D5 (MFC: IRE [− 0.01], PAN [+ 0.39]). For each period, CD4 + CD25 + FoxP3 + Tregs showed the most dramatic inverse effect, with D3 to D5 showing the most change (MFC: IRE [− 0.18], PAN [+ 0.39]). Also, CD4 + CD25 + FoxP3 − Tregs showed an inverse effect between D3 and D5 (MFC: IRE [− 0.25], PAN [+ 0.49]). Altogether, the Treg trend was inversely affected by the in situ IRE procedure, with the greatest cumulative significant change for all three Treg subsets between D3 and D5 (MFC ± SEM: IRE [− 0.24 ± 0.05], PAN [+ 0.37 ± 0.02]; p = 0.016).


The study data suggest that in situ IRE procedure-mediated Treg attenuation between POD3 and POD5 can provide a clinical window of opportunity for potentiating clinical efficacy in combination with immunotherapy.



This study was funded by the Division of Surgical Oncology, Hiram C. Polk Jr, MD Department of Surgery, University of Louisville School of Medicine, Louisville, KY 40202. No outside funding was received.

Conflict of interest

Robert C. G. Martin is a paid consultant for AngioDynamics. The remaining authors have no conflicts of interest.

Supplementary material

10434_2018_7144_MOESM1_ESM.docx (104 kb)
Levels of different subsets of CD4 + regulatory T cells: Box plot showing levels of different regulatory T cells subsets (Tregs) at different time points i.e. PreOP, D1, D3 and D5. All 4 time point specimens for each patient were processed and analyzed together, at the same time, using flowcytometry. PreOP = before surgery, D1 = POD1, D3 = POD3, D5 = POD5. Solid line represent median and dotted line represent mean. Supplementary material 1 (DOCX 104 kb)


  1. 1.
    United States Cancer Statistics: 1999–2010 Incidence and Mortality Web-Based Report. 2013. Retrieved January 15, 2018 from
  2. 2.
    SEER Cancer Statistics Review, 1975–2010. 2013. Retrieved April 2013 at
  3. 3.
    Balaban EP, Mangu PB, Khorana AA, et al. Locally advanced, unresectable pancreatic cancer: American Society of Clinical Oncology Clinical Practice Guideline. J Clin Oncol. 2016;34:2654–68.CrossRefGoogle Scholar
  4. 4.
    O Kane GM, Knox JJ. Locally advanced pancreatic cancer: an emerging entity. Curr Prob Cancer. 2018;42:12–25.CrossRefGoogle Scholar
  5. 5.
    Martin RC II, Kwon D, Chalikonda S, et al. Treatment of 200 locally advanced (stage III) pancreatic adenocarcinoma patients with irreversible electroporation: safety and efficacy. Ann Surg. 2015;262:486–94.CrossRefGoogle Scholar
  6. 6.
    Bower M, Sherwood L, Li Y, Martin R. Irreversible electroporation of the pancreas: definitive local therapy without systemic effects. J Surg Oncol. 2011;104:22–8.CrossRefGoogle Scholar
  7. 7.
    Bhutiani N, Agle S, Li Y, Li S, Martin RC II. Irreversible electroporation enhances delivery of gemcitabine to pancreatic adenocarcinoma. J Surg Oncol. 2016;114:181–6.CrossRefGoogle Scholar
  8. 8.
    Dunki-Jacobs EM, Philips P, Martin Ii RC. Evaluation of thermal injury to liver, pancreas and kidney during irreversible electroporation in an in vivo experimental model. Br J Surg. 2014;101:1113–21.CrossRefGoogle Scholar
  9. 9.
    Philips P, Hays D, Martin RC. Irreversible electroporation ablation (IRE) of unresectable soft tissue tumors: learning curve evaluation in the first 150 patients treated. PloS One. 2013;8:e76260.CrossRefGoogle Scholar
  10. 10.
    Lawrence MS, Stojanov P, Polak P, et al. Mutational heterogeneity in cancer and the search for new cancer-associated genes. Nature. 2013;499:214–8.CrossRefGoogle Scholar
  11. 11.
    Winograd R, Byrne KT, Evans RA, et al. Induction of T-cell immunity overcomes complete resistance to PD-1 and CTLA-4 blockade and improves survival in pancreatic carcinoma. Cancer Immunol Res. 2015;3:399.CrossRefGoogle Scholar
  12. 12.
    Clark CE, Hingorani SR, Mick R, Combs C, Tuveson DA, Vonderheide RH. Dynamics of the immune reaction to pancreatic cancer from inception to invasion. Cancer Res. 2007;67:9518–27.CrossRefGoogle Scholar
  13. 13.
    Sharma P, Allison JP. The future of immune checkpoint therapy. Science. 2015;348:56–61.CrossRefGoogle Scholar
  14. 14.
    Vonderheide RH, Bayne LJ. Inflammatory networks and immune surveillance of pancreatic carcinoma. Curr Opin Immunol. 2013;25:200–5.CrossRefGoogle Scholar
  15. 15.
    Shitara K, Nishikawa H. Regulatory T cells: a potential target in cancer immunotherapy. Ann N Y Acad Sci. 2018;1417:104–15.CrossRefGoogle Scholar
  16. 16.
    Nishikawa H, Sakaguchi S. Regulatory T cells in cancer immunotherapy. Curr Opin Immunol. 2014;27:1–7.CrossRefGoogle Scholar
  17. 17.
    Yamamoto T, Yanagimoto H, Satoi S, et al. Circulating CD4 + CD25 + regulatory T cells in patients with pancreatic cancer. Pancreas. 2012;41:409–15.CrossRefGoogle Scholar
  18. 18.
    Jang JE, Hajdu CH, Liot C, Miller G, Dustin ML, Bar-Sagi D. Crosstalk between regulatory T cells and tumor-associated dendritic cells negates anti-tumor immunity in pancreatic cancer. Cell Rep. 2017;20:558–71.CrossRefGoogle Scholar
  19. 19.
    Yao X, Ahmadzadeh M, Lu YC, et al. Levels of peripheral CD4(+)FoxP3(+) regulatory T cells are negatively associated with clinical response to adoptive immunotherapy of human cancer. Blood. 2012;119:5688–96.CrossRefGoogle Scholar
  20. 20.
    Clavien PA, Barkun J, de Oliveira ML, et al. The Clavien-Dindo classification of surgical complications: five-year experience. Ann Surg. 2009;250:187–96.CrossRefGoogle Scholar
  21. 21.
    Martin RC II. Irreversible electroporation of locally advanced pancreatic neck/body adenocarcinoma. J Gastrointest Oncol. 2015;6:329–35.Google Scholar
  22. 22.
    Martin RC II, Durham AN, Besselink MG, et al. Irreversible electroporation in locally advanced pancreatic cancer: a call for standardization of energy delivery. J Surg Oncol. 2016;114:865–71.CrossRefGoogle Scholar
  23. 23.
    Martin RC. Irreversible electroporation of locally advanced pancreatic head adenocarcinoma. J Gastrointest Surg. 2013;17:1850–6.CrossRefGoogle Scholar
  24. 24.
    ACK Lysis Buffer. Cold Spring Harbor Protocols. 2014; 2014:pdb.rec083295.Google Scholar
  25. 25.
    Dunki-Jacobs EM, Philips P, Martin RC II. Evaluation of resistance as a measure of successful tumor ablation during irreversible electroporation of the pancreas. J Am Coll Surg. 2014;218:179–87.CrossRefGoogle Scholar
  26. 26.
    Johansson H, Andersson R, Bauden M, Hammes S, Holdenrieder S, Ansari D. Immune checkpoint therapy for pancreatic cancer. World J Gastroenterol. 2016;22:9457–76.CrossRefGoogle Scholar
  27. 27.
    Guo S, Contratto M, Miller G, Leichman L, Wu J. Immunotherapy in pancreatic cancer: unleash its potential through novel combinations. World J Clin Oncol. 2017;8:230–40. Scholar
  28. 28.
    Tafti BA, Kee ST. Immunological response during electroporation. In: Miklavcic D (ed) Handbook of Electroporation. Springer International Publishing, Cham, 2016:1–13.Google Scholar
  29. 29.
    Neal RE II, Rossmeisl JH Jr, Robertson JL, et al. Improved local and systemic anti-tumor efficacy for irreversible electroporation in immunocompetent versus immunodeficient mice. PloS One. 2013;8:e64559.CrossRefGoogle Scholar
  30. 30.
    Li X, Xu K, Li W, et al. Immunologic response to tumor ablation with irreversible electroporation. PloS one. 2012;7:e48749. Scholar
  31. 31.
    Al-Sakere B, Bernat C, André F, et al. A study of the immunological response to tumor ablation with irreversible electroporation. Tech Cancer Res Treat. 2007;6:301–5.CrossRefGoogle Scholar

Copyright information

© Society of Surgical Oncology 2019

Authors and Affiliations

  • Harshul Pandit
    • 1
    • 2
  • Young K. Hong
    • 1
  • Yan Li
    • 1
  • Jack Rostas
    • 1
  • Zachary Pulliam
    • 1
  • Su Ping Li
    • 1
  • Robert C. G. Martin
    • 1
    • 2
    Email author
  1. 1.Division of Surgical Oncology, Hiram C. Polk Jr. M.D. Department of SurgeryUniversity of Louisville School of MedicineLouisvilleUSA
  2. 2.Department of Pharmacology & ToxicologyUniversity of Louisville School of MedicineLouisvilleUSA

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