Joey Wahler (Host): It's an advanced way of treating cancer, so we're discussing the NanoKnife procedure. Our guest is Dr. Michelle Fillion, specializing in complex general surgical oncology. This is Meaningful Medicine, a Novant Health Podcast, bringing you access to leading doctors who answer questions they wish you would ask. From routine care to rare conditions, our physicians offer tips to navigate medical decisions and build a healthier future. Thanks so much for joining us. I'm Joey Wahler. Hi, Doctor. Welcome.

Michelle Fillion, MD: Thank you for having me.

Host: Great to have you aboard. I appreciate the time. So first, being a surgical oncologist, you naturally work alongside other specialists treating cancer patients could include radiation oncologists, medical oncologists. So, can you discuss a little bit about that multidisciplinary approach?

Michelle Fillion, MD: Yeah, that really is the cornerstone for any kind of treatment for the cancer patient. Especially patients who have more complex disease, processes or intraabdominal tumors that are either in the liver, the pancreas, we really have to work as a team in order to best determine the treatment modality and the sequencing of that treatment modality for those patients.

Host: So as mentioned, we're focusing here on a treatment modality you're now offering in the Wilmington area. It's called NanoKnife irreversible electroporation. So in a nutshell, how does this technology work?

Michelle Fillion, MD: To break it down with you, it's a way that we can ablate or destroy the cancer cells, but not using a heat source. So, it's called a non-thermal ablation that we can kill the cells without having to actually cut out that organ. It's used complementary. We can either use it with surgery or without surgery. But it's offering a different treatment that we didn't have in this region before, which is not using heat or a non-thermal ablative technology where we have some of those thermal technologies that we can already use.

Host: So, speaking of which doctor, part of the goal here, of course, is to spare that surrounding healthy tissue. So, can you talk a little bit about the importance of such preciseness here?

Michelle Fillion, MD: Yeah. And so when we use these technologies, we use image guidance. And so, you can use ultrasound guidance to help find the lesions. You can also use CT scan guidance. And if we're using it in the operating room as an adjunct or in assistance with surgery, we're using ultrasound guidance to help place the probes or their little antennas that are either at the tumor or adjacent to the tumor, so then we can conduct the electroporation and kill those cells. Real time, we can watch with the ultrasound the tumor get disrupted. And we can see it necrose, kind of in front of our eyes. We can then go back. If there needs to be a touchup or a second or a third treatment, we can do that real time based on what we're seeing with the image guidance.

Host: Gotcha. So that being said, what types of conditions, what kinds of tumor specifically can surgeons like you use the NanoKnife technology treat?

Michelle Fillion, MD: Yeah. So right now, there's pretty strong indications for using it in the liver. And that can be done with primary liver cancer. For example, if it's unresectable due to its location or if they have significant cirrhosis and a not just a good surgical candidate, we can use this to ablate, and especially if it's near adjacent blood vessels or bile ducts that we didn't want to use the thermal methods for. It can also be used for colon and rectal metastasis or spread to the liver so we can treat cancers that have spread to the liver as well.

There's also ways—it's a little bit more emerging—is to treat pancreatic cancer tumors to help kind of treat the margins so we can make sure we get complete tumor clearance and decrease the risk of it coming back. There are urologists that specialize in prostate cancer that can also be using this for tumors that are very adjacent to the urethra to help prevent some stenosis or having men having difficulty passing their urine. So, that's another area that we could use this technique.

Host: So while the NanoKnife uses electrical pulses, there are also those thermal ablations you've touched on. Can you explain a little bit about the main difference between those two? And are there any benefits in certain cases to using one or the other?

Michelle Fillion, MD: Yeah. And so, the big thing to add to our region is that we have a non-thermal ablative technology. And so, when these electrical pulses shoot together, they disrupt the cell's membrane to the point where we're literally just shooting holes in the cell's membrane to the point that it can't repair and those cells end up dying.

So again, you want to be very specific on treating those cells, but they don't penetrate the extracellular matrix of, say, blood vessels, bile ducts, nerves. So, those tissues do get spared. So, that's where it really comes into a benefit. If you did an ablative technology such as a microwave ablation or a radiofrequency ablation, you have to be very careful due to the surrounding blood vessels or bile ducts, urethra, because you can get thermal damage and cause long-term damage to those structures.

Host: Now, you also use ablations as a primary treatment or in conjunction with a tumor removal. So, can you explain that, including the importance of negative margins as they're known?

Michelle Fillion, MD: Yes, our first goal is to always try to remove the cancer. So, that's the main principle. If we can always remove it, that's the best treatment. If we can't remove it, then we can start to use these ablative technologies. And it's not one or the other. So, there's also a middle ground is if we want to remove it, but we're concerned about having close margins, and the key to a good resection is having negative margins, because you don't want that tumor to come back, you can use these technologies to help augment or get a wider margin that maybe would be difficult surgically due to those vascular structures or bile ducts that would be in the way. So, this would allow us to treat that margin that couldn't safely be removed, but while killing the cancer cells to ultimately get us to have that negative margin. And for patients that are unresectable, then we would principally treat them with the IRE, the irreversible electroporation. But the goal is always, if we can resect it, is to physically remove it.

Host: How about are there any cancers for which NanoKnife is not an option?

Michelle Fillion, MD: Probably a whole host of cancers that can't. Like the strong indications would be in the liver, in the pancreas, and in the prostate, where there are approval to be using those type of modalities. I believe kidney cancer may be one that's coming down the pike as well. So, there's more cancers that are out there. But those specific organs, there is FDA clearance to be using this technology in those organs.

Host: All right. Couple of other things for you, since you've been using this technique, what kind of feedback have you gotten from patients and how rewarding is it to be able to offer this in the first place?

Michelle Fillion, MD: Well, it's a whole 'nother modality. It gives us more options. So if we need to pivot real-time, say, we're in the operating room, we've planned resection. And if we can't go forward with it, we have an option to real-time pivot and still get the cancer treated on the table without having to have the patient come back, schedule a different treatment, or be referred out of the area to get this cancer treated. So, it's offering us abilities to stay in the area. And most of the time, the patients tolerate it quite well. Very, very low risk. Biggest risk is obviously bleeding because we're putting in probes into the organs. And then, we also just work with our anesthesia docs, because these are procedures that would require anesthesia as well.

Host: And of course, as you know, well, as anyone, Doctor, cancer patients, when they're going through it, they're going through a lot more than just the cancer, right? There are all kinds of distractions and other issues that need to be dealt with in someone's life as a result of cancer, perhaps losing a job, family care, et cetera, et cetera. The list goes on and on. So to be able to make the procedure itself of removing the cancer as quick and easy as possible, that's got to be very comforting for people, right?

Michelle Fillion, MD: Oh my gosh. Of course, if we can do things as minimally invasive as possible, that would be ideal. And for those patients that wouldn't be a surgical candidate that we knew upfront, these probes can be done what we call percutaneously, kind of going through the skin, so they can be treated as well. So, that's really limiting kind of that downtime. But it's great to see the patients. Our goal is to get them back in a good functional status so they can be enjoying their lives.

Host: And then, in summary here, Doctor, what would you say you and yours at Novant Health in your department and this specialty, what do you really hang your hat on that you're most proud of, that you want to convey to those joining us in case they do have to go through this procedure?

Michelle Fillion, MD: It's just that we care. We really truly care. And we want to see you succeed. Like, that's where I get the most joy, is that if I can get your cancer treated, and I'm seeing you years later and I'm learning more about your stories—where have you traveled, have you visited your grandkids, that you have gotten meaningful life—just growth and life experiences that gives me joy. And so, the goal is to get there and to get patients a new lease on life by getting their cancer treatment completed.

Host: Absolutely. Well, folks, we trust you are now more familiar with the NanoKnife procedure. Dr. Fillion, keep up all your great, in this case, groundbreaking work. And thanks so much again.

Michelle Fillion, MD: Thank you so much for having me.

Host: Absolutely. And to find a physician, please visit novanthealth.org. For more health and wellness information from our experts, please visit healthyheadlines.org. If you found this podcast helpful, we ask that you please share it on your social media. I'm Joey Wahler. And thanks so much again for being part of Meaningful Medicine, a Novant Health Podcast.