Posted on Mon, Jul. 16, 2012

Dominga Ungaro was diagnosed with inoperable pancreatic cancer in January 2010. The Margate grandmother had suffered from stomach pain for months before doctors discovered the root of her ailment.

Today, after undergoing chemotherapy, radiation, a NanoKnife procedure and finally surgery, doctors say she shows no signs of cancer. Ungaro has gained back some of the weight she lost, and feels like she is getting back to normal.

“I am a very positive person,” said Ungaro, 64, who has five children and 16 grandchildren. “I just accepted it and we acted on it, and I never really looked back.”

Without question, Ungaro is one of the lucky ones. Pancreatic cancer is among the deadliest of cancers. Doctors say its somewhat vague symptoms make it difficult to diagnose before it has either advanced locally or metastasized to other organs.

Those symptoms include pain (usually abdominal or back pain), weight loss, yellowing of the skin and eyes, loss of appetite, nausea, changes in stool and sudden or worsening diabetes.

The fourth leading cause of cancer death in the United States, pancreatic cancer is expected this year to strike an estimated 43,920 people nationwide, and about 37,390 will die from the disease, according to the Pancreatic Cancer Action Network, citing statistics from the American Cancer Society.

Pancreatic cancer also has the lowest survival rate of all cancers tracked by both the American Cancer Society and the National Cancer Institute: with just 6 percent of patients surviving five years after diagnosis, and 74 percent of patients dying within the first year of diagnosis. Among the most well-known figures to succumb to the disease are Patrick Swayze, Luciano Pavarotti and Steve Jobs, who died from metastatic pancreatic cancer, though his was a less common and far less aggressive type of tumor, known as a neuroendocrine tumor.

In South Florida, doctors can help diagnose pancreatic cancer using endoscopic ultrasound and other methods, and are working hard to combat the disease.

The University of Miami’s Sylvester Comprehensive Cancer Center is the only facility in South Florida offering the NanoKnife, which uses high voltage electricity to destroy cancer cells, used on patients who are deemed inoperable.

Dr.Govindarajan Narayanan, chief of vascular and interventional radiology at the University of Miami, and two of his colleagues, have performed the NanoKnife procedure on 19 pancreatic cancer patients since November 2010, with two going on to have successful surgery, including Ungaro.

During the minimally invasive procedure, which uses “irreversible electroporation” technology, the patient is placed under general anesthesia. Two to four probes, with needles, are placed into the tumor, using imaging guidance. The needles are connected to a generator device, which, when turned on, delivers 3,000 volts of DC current, Narayanan said.

“When you deliver that high level of energy, it creates multiple holes in the cell membrane,” he said. “It riddles the cell membrane with holes and the cells die.”

The actual treatment time is a matter of minutes, but it can take two to four hours for the procedure to be completed, including putting the patient under anesthesia and placing up to six probes.

The NanoKnife can also be used on other cancers, mostly liver cancer, and the University of Miami has performed 150 of the procedures since 2010 — more than any other medical center worldwide, Narayanan said.

The technique has received Food & Drug Administration 501(k) medical device approval for use in soft tissue, and is considered “off label” for use on organs, he said.

“What we have established is the safety and the ability to treat pancreatic cancer without surgery, and early results are promising,” Narayanan said. “But we really have to conduct a trial to establish the complete potential of this technology.”

Aside from the Nanoknife, about 20 percent of pancreatic cancer patients may be candidates for a complex surgical procedure called the Whipple procedure.

The five-to six-hour operation involves removing the “head’’ of the pancreas, (an area involved in the vast majority of pancreatic cancers), the duodenum and the gallbladder, said surgical oncologist Dr. Omar Llaguna, who has performed at least 25 Whipple procedures since joining Baptist Health Medical Group last July.

“It’s such a tight quarters where the head of the pancreas is, that you can’t just take it out. You have to take out the adjacent quarters,” he said.

Then, the surgeon must make several reconnections of the remaining organs.

“The best outcome is always in someone who can undergo resection, recover, and then go on to complete their chemotherapy,” Llaguna said.

Meanwhile, a clinical trial of a novel chemotherapy drug for advanced pancreatic cancer is underway nationwide, and being done at Mount Sinai Medical Center in Miami Beach.

The hospital is still enrolling patients who have been newly diagnosed with Stage IV, metastatic pancreatic cancer, and have received no prior chemotherapy. The trial is randomized, so one-third of patients will receive regular chemotherapy instead of the new drug, said Dr. Mike Cusnir, an oncologist at Mount Sinai Comprehensive Cancer Center.

The study is examining a promising new drug, ON 01910.Na.

“What is important is that it’s a drug that has a fairly novel mechanism of action — it works in a different pathway than has been done in the past,” Cusnir said.

The drug damages the division of cells, so hopefully they cannot divide, he said.

“Research offers hope,” Cusnir said. “So anytime we have a research over the standard of care, it offers hope.”