**6. Future directions of IRE in pancreatic cancer**

Given the severity and decreased overall survival of patients diagnosed with locally advanced pancreatic cancer, there is a driving need for treatment alternatives to conventional chemo/radiation therapy. The minimally invasive application of IRE shows potential regarding an increase of the progression-free survival time and quality of life [48]. However, these interventions require highly experienced medical professionals as needles need to be navigated close to multiple structures at risk. Computer assistance plays a major role in all types of procedures where spatial accuracy needs to be delivered in order to achieve a successful treatment outcome. As mentioned in Morris et al. [22] there is a need for multicenter, randomized, prospective trials to determine the efficacy of IRE treatment in the pancreatic use case. To conduct IRE treatments on the pancreas, computer assistance holds the potential to standardize the workflow and to enable highly accurate needle placement independent on outstanding multidisciplinary skills, which are typically found in high expert centers.

#### **6.1 Patient screening**

The evaluation of suitable patients for IRE is a crucial step to achieve a positive treatment outcome. The Miami Protocol lists patients' criteria including among others the performance status, lesion size, and access path [24]. An important criterion is stated by the access path, which requires an excellent radiological understanding

due to the difficulty of planning multiple trajectories solely on tomographic images. This coincides with the opinions of the MDs who consider conventional 2D planning to be insufficient. A dedicated planning tool would enhance the preoperative procedure as multiple access paths can be planned relative to the patient's anatomy and structures at risk better identified. This requires precise anatomical segmentations from the radiological department, which is, especially for the pancreatic use case, a time-consuming task.
