Importance of tumour coverage by sufficiently high local electric field for effective electrochemotherapy

Electrochemotherapy as palliative care in patients with local or metastatic recurrence of head and neck cancer: review of state of the art

Head and neck cancers are mostly represented by squamous cell carcinoma. Despite effective treatment of primary tumours, local recurrences and metastases are frequent, with up to a 60% risk of local and 30% of distant failure. Moreover, second primary tumours sometimes occur in these patients (2-3% per year). Treatment of recurrences, metastases, and second primary tumours can be extremely challenging for Otorhinolaryngologists, especially in patients who have already been treated with radiotherapy, previous surgery, or both. Electrochemotherapy represents an effective and valid option in these cases.

Novel tetrapolar single-needle electrode for electrochemotherapy in bone cavities: Modeling, design and validation

Electrochemotherapy is a cancer treatment in which local pulsed electric fields are delivered through electrodes. The effectiveness of the treatment depends on exposing the tumor to a threshold electric field. Electrode geometry plays an important role in the resulting electric field distribution, especially in hard-to-reach areas and deep-seated tumors. We designed and developed a novel tetrapolar single-needle electrode for proper treatment in bone cavities. In silico and in vitro experiments were performed to evaluate the electric field and electric current produced by the electrode. In addition, tomography images of a real case of nasal cavity tumor were segmented into a 3D simulation to evaluate the electrode performance in a bone cavity. The proposed electrode was validated and its operating range was set up to 650 V. In the nasal cavity tumor, we found that the electrode can produce a circular electric field of 3 mm with an electric current of 14.1 A at 500 V, which is compatible with electrochemotherapy standards and commercial equipment.

The equivalence of different types of electric pulses for electrochemotherapy with cisplatin - an in vitro study

BACKGROUND

Electrochemotherapy (ECT) is a treatment involving the administration of chemotherapeutics drugs followed by the application of 8 square monopolar pulses of 100 μs duration at a repetition frequency of 1 Hz or 5000 Hz. However, there is increasing interest in using alternative types of pulses for ECT. The use of high-frequency short bipolar pulses has been shown to mitigate pain and muscle contractions. Conversely, the use of millisecond pulses is interesting when combining ECT with gene electrotransfer for the uptake of DNA-encoding proteins that stimulate the immune response with the aim of converting ECT from a local to systemic treatment. Therefore, the aim of this study was to investigate how alternative types of pulses affect the efficiency of the ECT.

MATERIALS AND METHODS

We performed in vitro experiments, exposing Chinese hamster ovary (CHO) cells to conventional ECT pulses, high-frequency bipolar pulses, and millisecond pulses in the presence of different concentrations of cisplatin. We determined cisplatin uptake by inductively coupled plasma mass spectrometry and cisplatin cytotoxicity by the clonogenic assay.

RESULTS

We observed that the three tested types of pulses potentiate the uptake and cytotoxicity of cisplatin in an equivalent manner, provided that the electric field is properly adjusted for each pulse type. Furthermore, we quantified that the number of cisplatin molecules, resulting in the eradication of most cells, was 2-7 × 107 per cell.

CONCLUSIONS

High-frequency bipolar pulses and millisecond pulses can potentially be used in ECT to reduce pain and muscle contraction and increase the effect of the immune response in combination with gene electrotransfer, respectively.

Finite Element Evaluation of the Electric Field Distribution in a Non-Homogeneous Environment

Finite element analysis is used in this study to investigate the effect of media inhomogeneity on the electric field distribution in a sample composed of cells and their extracellular matrix. The sample is supposed to be subjected to very high pulsed electric field. Numerically computed electric field distribution and transmembrane potential at the cell membrane in electroporation conditions are considered in order to study cell behavior at different degrees of inhomogeneity. The different inhomogeneity grade is locally obtained using a representative model of fixed volume with cell-cell distance varying in the range of 1-283 um. The conductivity of the extracellular medium was varied between plain collagen and a gel-like myxoid matrix through combinations of the two, i.e., collagen and myxoid. An increase in the transmembrane potential was shown in the case of higher aggregate. The results obtained in this study show the effect of the presence of the cell aggregates and collagen on the transmembrane potential. In particular, by increasing the cell aggregation in the two cases, the transmembrane potential increased. Finally, the simulation results were compared to experimental data obtained by culturing HCC1954 cells in a hyaluronic acid-based scaffold. The experimental validation confirmed the behavior of the transmembrane potential in presence of the collagen: an increase in electroporation at a lower electric field intensity was found for the cells cultured in the scaffolds where there is the formation of collagen areas.

Irreversible Electroporation in Pancreatic Cancer-An Evolving Experimental and Clinical Method

Pancreatic cancer has no symptoms until the disease has advanced and is aggressive cancer with early metastasis. Up to now, the only curative treatment is surgical resection, which is possible in the early stages of the disease. Irreversible electroporation treatment offers new hope for patients with unresectable tumors. Irreversible electroporation (IRE) is a type of ablation therapy that has been explored as a potential treatment for pancreatic cancer. Ablation therapies involve the use of energy to destroy or damage cancer cells. IRE involves using high-voltage, low-energy electrical pulses to create resealing in the cell membrane, causing the cell to die. This review summarizes experiential and clinical findings in terms of the IRE applications. As was described, IRE can be a non-pharmacological approach (electroporation) or combined with anticancer drugs or standard treatment methods. The efficacy of irreversible electroporation (IRE) in eliminating pancreatic cancer cells has been demonstrated through both in vitro and in vivo studies, and it has been shown to induce an immune response. Nevertheless, further investigation is required to assess its effectiveness in human subjects and to comprehensively understand IRE's potential as a treatment option for pancreatic cancer.

Invasive and non-invasive electrodes for successful drug and gene delivery in electroporation-based treatments

Electroporation is an effective physical method for irreversible or reversible permeabilization of plasma membranes of biological cells and is typically used for tissue ablation or targeted drug/DNA delivery into living cells. In the context of cancer treatment, full recovery from an electroporation-based procedure is frequently dependent on the spatial distribution/homogeneity of the electric field in the tissue; therefore, the structure of electrodes/applicators plays an important role. This review focuses on the analysis of electrodes and in silico models used for electroporation in cancer treatment and gene therapy. We have reviewed various invasive and non-invasive electrodes; analyzed the spatial electric field distribution using finite element method analysis; evaluated parametric compatibility, and the pros and cons of application; and summarized options for improvement. Additionally, this review highlights the importance of tissue bioimpedance for accurate treatment planning using numerical modeling and the effects of pulse frequency on tissue conductivity and relative permittivity values.

Optimization of Transpedicular Electrode Insertion for Electroporation-Based Treatments of Vertebral Tumors

Electroporation-based treatments such as electrochemotherapy and irreversible electroporation ablation have sparked interest with respect to their use in medicine. Treatment planning involves determining the best possible electrode positions and voltage amplitudes to ensure treatment of the entire clinical target volume (CTV). This process is mainly performed manually or with computationally intensive genetic algorithms. In this study, an algorithm was developed to optimize electrode positions for the electrochemotherapy of vertebral tumors without using computationally intensive methods. The algorithm considers the electric field distribution in the CTV, identifies undertreated areas, and uses this information to iteratively shift the electrodes from their initial positions to cover the entire CTV. The algorithm performs successfully for different spinal segments, tumor sizes, and positions within the vertebra. The average optimization time was 71 s with an average of 4.9 iterations performed. The algorithm significantly reduces the time and expertise required to create a treatment plan for vertebral tumors. This study serves as a proof of concept that electrode positions can be determined (semi-)automatically based on the spatial information of the electric field distribution in the target tissue. The algorithm is currently designed for the electrochemotherapy of vertebral tumors via a transpedicular approach but could be adapted for other anatomic sites in the future.

Veterinary Guidelines for Electrochemotherapy of Superficial Tumors

Electrochemotherapy (ECT) consists in the application of electric pulses to increase chemotherapeutic drug intake (bleomycin, cisplatin, or calcium) into the tumor cells. It has become a very valuable treatment option in veterinary oncology. It is an effective and safe treatment modality, which is not only beneficial as a palliative treatment, but also for a curative approach. Performing the treatment adequately will ensure the best results possible, in the minimum number of sessions, and reduce complications. Usually, only one session is enough to achieve excellent results, but the treatment can be repeated. Several sessions can be necessary in the case of incompletely treated or very extended lesions, as well as in the occurrence of new lesions. ECT is effective for superficial or oral tumors of any histology that are accessible to the electrodes. Intravenous bleomycin is the preferred drug and route of administration, leaving other ways of administration and drugs for selected cases. The guidelines presented here are destined to veterinarians who want to develop their understanding of the basis of ECT and wish to perform it adequately and effectively. In this paper, we also discuss common problems and how to solve them, and we include practical tips to improve the treatment results based on common questions and mistakes of beginner users.

Impact of electrochemotherapy in metastatic cutaneous melanoma: a contemporary systematic review and meta-analysis

BACKGROUND

Electrochemotherapy (ECT) harnesses electric pulses to enhance cytotoxic drug delivery into tumors and has entered the armamentarium to treat superficially metastatic melanoma. We performed a systematic review and meta-analysis to assess treatment patterns and patient outcomes.

METHODS

PubMed, Medline, Embase, and the Cochrane Library databases were queried for publication from inception to September 2020. Primary outcome measures were overall and complete response rate (ORR and CRR); secondary outcomes included local control rate (LCR) and overall survival (OS).

RESULTS

Twenty-seven studies met the selection criteria for a total of 1161 individuals (mean age 71 years) and 5308 tumors (weighted mean size 14 mm). The majority of patients (n = 1124) underwent bleomycin-ECT. Aggregate ORR was 77.6% (95% confidence interval [CI] 71.0 - 83.2%) and CRR 48% (95% CI 42 - 54%), with no significant difference between the route of bleomycin administration (ORR, 69.2 vs. 81.9% following intravenous or intratumoral bleomycin, p = .37) and tumor size (p = .69). When reported (n = 8 studies), 1- and 2-year LCR ranged from 54 to 89% and 72 to 74%, respectively, and 1-year OS (n = 3 studies) from 67 to 89%.

CONCLUSIONS

ECT with either intratumoral or intravenous bleomycin confers a high therapeutic response in cutaneous metastatic melanoma. Moderate evidence supports its low toxicity and durability of local control.HighlightsElectrochemotherapy (ECT) is associated with a 77% overall response rate (ORR).Intravenous and intratumoral bleomycin are equally effective.There are no relevant toxicity concerns.One-year local tumor control rate ranges from 54 to 89%.Current literature has significant variation in reporting.

Numerical mesoscale tissue model of electrochemotherapy in liver based on histological findings

Electrochemotherapy (ECT) and irreversible electroporation (IRE) are being investigated for treatment of hepatic tumours. The liver is a highly heterogeneous organ, permeated with a network of macro- and microvasculature, biliary tracts and connective tissue. The success of ECT and IRE depends on sufficient electric field established in whole target tissue; therefore, tissue heterogeneity may affect the treatment outcome. In this study, we investigate electroporation in the liver using a numerical mesoscale tissue model. We numerically reconstructed four ECT experiments in healthy porcine liver and computed the electric field distribution using our treatment planning framework. We compared the computed results with histopathological changes identified on microscopic images after treatment. The mean electric field threshold that best fitted the zone of coagulation necrosis was 1225 V/cm, while the mean threshold that best fitted the zone of partially damaged liver parenchyma attributed to IRE was 805 V/cm. We evaluated how the liver macro- and microstructures affect the electric field distribution. Our results show that the liver microstructure does not significantly affect the electric field distribution on the level needed for treatment planning. However, major hepatic vessels and portal spaces significantly affect the electric field distribution, and should be considered when planning treatments.

Revisiting the role of pulsed electric fields in overcoming the barriers to in vivo gene electrotransfer

Gene therapies are revolutionizing medicine by providing a way to cure hitherto incurable diseases. The scientific and technological advances have enabled the first gene therapies to become clinically approved. In addition, with the ongoing COVID-19 pandemic, we are witnessing record speeds in the development and distribution of gene-based vaccines. For gene therapy to take effect, the therapeutic nucleic acids (RNA or DNA) need to overcome several barriers before they can execute their function of producing a protein or silencing a defective or overexpressing gene. This includes the barriers of the interstitium, the cell membrane, the cytoplasmic barriers and (in case of DNA) the nuclear envelope. Gene electrotransfer (GET), i.e., transfection by means of pulsed electric fields, is a non-viral technique that can overcome these barriers in a safe and effective manner. GET has reached the clinical stage of investigations where it is currently being evaluated for its therapeutic benefits across a wide variety of indications. In this review, we formalize our current understanding of GET from a biophysical perspective and critically discuss the mechanisms by which electric field can aid in overcoming the barriers. We also identify the gaps in knowledge that are hindering optimization of GET in vivo.

Computer optimization of conductive gels for electrochemotherapy

Electrochemotherapy (ECT) requires covering the entire tumor and safe margins with a suitable pulsed electric field (PEF). The PEF distribution depends on the biological and electrical parameters. The biological tissue may have diffractive geometry with non-linear conductivity behavior due to electroporation. That characteristic may provoke ECT-insufficient electric field regions, also known as blind spots. The conductive gels can fill holes and bumps, being a tool to homogenize the electric field. We executed an in vitro vegetal tissue experiment to validate a numerical model under different gels conditions. We used a study case in silico experiment to investigate gel influence on PEF distribution and electrical current. We propose a case-oriented methodology to optimize the gel during the ECT pre-treatment. Results show that the optimized gel completely treats a region of interest while avoiding unnecessary current increase and damage to healthy tissue by over treatment. The optimized gel conductivity may be lower than the previously reported (0.5 to 1 S/m) and may be in the range of the commercially available gels. For a veterinary mastocytoma exophytic nodule ECT case study, using needles electrode, the 0.2 S/m gel is the optimum gel.

Electrochemotherapy and Other Clinical Applications of Electroporation for the Targeted Therapy of Metastatic Melanoma

Electrochemotherapy (ECT) is an effective bioelectrochemical procedure that uses controlled electrical pulses to facilitate the increase of intracellular concentration of certain substances (electropermeabilization/ reversible electroporation). ECT using antitumor drugs such as bleomycin and cisplatin is a minimally invasive targeted therapy that can be used as an alternative for oncologic patients not eligible for surgery or other standard therapies. Even though ECT is mainly applied as palliative care for metastases, it may also be used for primary tumors that are unresectable due to size and location. Skin neoplasms are the main clinical indication of ECT, the procedure reporting good curative results and high efficiency across all tumor types, including melanoma. In daily practice, there are many cases in which the patient’s quality of life can be significantly improved by a safe procedure such as ECT. Its popularity must be increased because it has a safe profile and minor local adverse reactions. The method can be used by dermatologists, oncologists, and surgeons. The aim of this paper is to review recent literature concerning electrochemotherapy and other clinical applications of electroporation for the targeted therapy of metastatic melanoma.

Electroporation as the Immunotherapy Strategy for Cancer in Veterinary Medicine: State of the Art in Latin America

Electroporation is a technology that increases cell membrane permeability by the application of electric pulses. Electrochemotherapy (ECT), the best-known application of electroporation, is a very effective local treatment for tumors of any histology in human and veterinary medicine. It induces a local yet robust immune response that is responsible for its high effectiveness. Gene electrotransfer (GET), used in research to produce a systemic immune response against cancer, is another electroporation-based treatment that is very appealing for its effectiveness, low cost, and simplicity. In this review, we present the immune effect of electroporation-based treatments and analyze the results of the vast majority of the published papers related to immune response enhancement by gene electrotransfer in companion animals with spontaneous tumors. In addition, we present a brief history of the initial steps and the state of the art of the electroporation-based treatments in Latin America. They have the potential to become an essential form of immunotherapy in the region. This review gives insight into the subject and helps to choose promising research lines for future work; it also helps to select the adequate treatment parameters for performing a successful application of this technology.

A numerical study on the effect of conductivity change in cell kill distribution in irreversible electroporation

Introduction: irreversible electroporation (IRE) is a tissue ablation technique and physical process used to kill the undesirable cells. In the IRE process by mathematical modelling we can calculate the cell kill probability and distribution inside the tissue. The purpose of the study is to determine the influence of electric conductivity change in the IRE process into the cell kill probability and distribution.

Methods: cell death probability and electric conductivity were calculated with COMSOL Multiphysics software package. 8 pulses with a frequency of 1 Hz, pulse width of 100 µs and electric field intensity from 1000 to 3000 V/Cm with steps of 500 V/Cm used as electric pulses.

Results: significantly, the electrical conductivity of tissue will increase during the time of pulse delivery. According to our results, electrical conductivity increased with an electric field intensity of pulses. By considering the effect of conductivity change on cell kill probability, the cell kill probability and distribution will change.

Conclusion: we believe that considering the impact of electric conductivity change on the cell kill probability will improve the accuracy of treatment outcome in the clinic for treatment with IRE.

The role of 217-Hz ELF magnetic fields emitted from GSM mobile phones on electrochemotherapy mechanisms

Electrochemotherapy (ECT), the combination of electric pulses (EPs) and an anticancer drug, is a type of cancer treatment method. We investigated the effect of 217-Hz magnetic fields (MFs) similar to that generated by GSM900 mobile phones, as intervening factors, on proposed mechanisms of ECT including permeability, tumor hypoxia and immune system response. The 4T1 cells were exposed to extremely low-frequency (ELF)-MFs at 93, 120 or 159 µT intensities, generated by Helmholtz coils 10 min, and then put in individual groups, comprising no treatment, chemotherapy, EPs or ECT. The cell viability was evaluated. Then, two treatment protocols were selected for in vivo experiments. The mice with 4T1 tumor cells were exposed to ELF-MFs 10 min/day until the day their tumors reached 8 mm in diameter. Then, the tumors were treated to ECT. Tumor hypoxia and immune system response were analyzed through immunohistochemistry assay and enzyme-linked immunosorbent assay technique, respectively. The results in vitro indicated a significant decreased ECT efficacy of 60 V/cm, 5 kHz at the flux density of 93 µT. The results in vivo showed that pre-exposure to ELF-MFs could increase tumor hypoxia induced by ECT. In addition, exposure to ELF-MFs before ECT caused a significant increase in interferon-γ/interleukin-4 in comparison with ECT alone. More studies, including studies on the effect of ELF-MFs emitted from mobile phones on tumor volume changes induced by ECT, are needed to elucidate how the process of ECT is influenced by the MFs.

Palliative electrochemotherapy in primary or recurrent vulvar cancer

OBJECTIVE

Since vulvar cancer is such a rare disease, the international experience with electrochemotherapy has been derived from only a few centers. The aim of this study was to evaluate clinical outcome and side effects profile with the use of electrochemotherapy in patients with primary or recurrent vulvar cancer.

METHODS

Data were retrospectively collected from November 2017 to November 2019 in two major Italian oncologic institutes: Regina Elena Institute and Fondazione Policlinico Universitario Agostino Gemelli IRCCS. Electrochemotherapy was offered in a palliative setting to patients with a primary or recurrent vulvar cancer who were not candidates for surgery or any other treatment, because of poor performance status or previous delivered treatments. All patients underwent general anesthesia. Electrical pulses were delivered using a pulse generator. Intravenous bleomycin was administered in conjunction with electrochemotherapy. Follow-up examinations were performed at 1, 3, and 6 months. Primary endpoint was to assess the response rate of electrochemotherapy as palliative treatment in patients with vulvar cancer.

RESULTS

A total of 15 patients were included in the study. Fourteen patients (93.3%) had a squamous cell carcinoma and one patient had vulvar carcinosarcoma. Ten patients (66.7 %) had a single lesion and 5 patients (33.3%) had multiple lesions. Median number of electrical pulses was 22 (range 3-42) and median operative time was 13 (range 7-20) min. No intra-procedure complications occurred. One patient had pneumonia during their post-operative stay. Overall response rate after 1 month was 80%. At the 3-month follow-up, 3 patients (20%) had disease progression, 3 patients (20%) had died from ongoing disease, 1 patient (6.7%) died for other reasons, whereas the other patients maintained their 1-month clinical response. A total of 8/13 patients (61.5%) were alive at 6-month follow-up, whereas 6/12 patients (50%) were alive at 1-year follow-up.

CONCLUSIONS

Electrochemotherapy is a feasible, easy to perform, and reproducible procedure in patients with primary or recurrent vulvar cancer who are unable to undergo surgery. Survival after 1 year in this population was 50%. Electrochemotherapy may have a role in the management of vulvar cancer, especially as palliative treatment when other therapies are no longer applicable.

Feasibility of Electroacoustic Tomography: A Simulation Study

The feasibility of electroacoustic tomography (EAT) was investigated for in situ monitoring the electric field distribution in soft tissue. EAT exploits the phenomenon that the amplitude of acoustic emission generated by an electric field is proportional to the electrical energy deposition in tissue. After detecting these acoustic waves with ultrasound transducers, an image of the electric field distribution can be reconstructed in real-time. In our computer simulations, the electric field distribution in soft tissue was generated by solving general partial differential equations (PDEs) using finite element analysis (FEA). The electric field distributions were converted into initial pressure distributions, and the propagation of the induced acoustic waves was simulated using K-Wave simulation. A circular array of 128 ultrasound transducers was placed around the target to detect the acoustic waves, and a time reversal reconstruction algorithm was used to reconstruct the EAT image. A different number of electrodes set at different distances with different voltage inputs on the electrodes were performed to simulate different electric field distributions during electroporation. It was found that the electrical energy deposition in reconstructed EAT imaging is decreased as the distance of the electrodes increases. We also have investigated the sensitivity of the EAT imaging with different voltage inputs. The minimal voltage we can detect with EAT is 970 V at the pulsewidth of 180 ns. The results of this study demonstrated that EAT is a feasible technique for monitoring the electric field distribution and guiding the electrotherapy in future clinical practice.

The Efficiency of Gene Electrotransfer in Breast-Cancer Cell Lines Cultured on a Novel Collagen-Free 3D Scaffold

Gene Electro-Transfer (GET) is a powerful method of DNA delivery with great potential for medical applications. Although GET has been extensively studied in vitro and in vivo, the optimal parameters remain controversial. 2D cell cultures have been widely used to investigate GET protocols, but have intrinsic limitations, whereas 3D cultures may represent a more reliable model thanks to the capacity of reproducing the tumor architecture. Here we applied two GET protocols, using a plate or linear electrode, on 3D-cultured HCC1954 and MDA-MB231 breast cancer cell lines grown on a novel collagen-free 3D scaffold and compared results with conventional 2D cultures. To evaluate the electrotransfer efficiency, we used the plasmid pEGFP-C3 encoding the enhanced green fluorescent protein (EGFP) reporter gene. The novel 3D scaffold promoted extracellular matrix deposition, which particularly influences cell behavior in both in vitro cell cultures and in vivo tumor tissue. While the transfection efficiency was similar in the 2D-cultures, we observed significant differences in the 3D-model. The transfection efficiency in the 3D vs 2D model was 44% versus 15% (p < 0.01) and 24% versus 17% (p < 0.01) in HCC1954 and MDA-MB231 cell cultures, respectively. These findings suggest that the novel 3D scaffold allows reproducing, at least partially, the peculiar morphology of the original tumor tissues, thus allowing us to detect meaningful differences between the two cell lines. Following GET with plate electrodes, cell viability was higher in 3D-cultured HCC1954 (66%) and MDA-MB231 (96%) cell lines compared to their 2D counterpart (53% and 63%, respectively, p < 0.001). Based on these results, we propose the novel 3D scaffold as a reliable support for the preparation of cell cultures in GET studies. It may increase the reliability of in vitro assays and allow the optimization of GET parameters of in vivo protocols.

Functional Requirements and Quality Assurance Necessary for Successful Incorporation of Electroporation-Based Therapies Into Clinical Practice

Electroporation-based therapies have a huge potential for implementation into clinical practice in socioeconomically disadvantaged populations. Currently, the price of electroporators and electrodes is relatively high, but custom low budget devices can be developed. In the paper, we describe three most established applications in medicine, with the focus on the basic mechanisms, which should be taken into account during the development process of a clinical electroporator. Also, typical pulse parameters used in each of the described applications are defined. In the second part of the paper, we describe technical functional requirements for a clinical electroporator and safety guidelines, with the focus on medical device standard. At the end of the paper, the focus moves to a more general problematic, such as quality assurance and the importance of measurement during the pulse delivery, which we firmly believe is necessary for successful electroporation.

New Deployable Expandable Electrodes in the Electroporation Treatment in a Pig Model: A Feasibility and Usability Preliminary Study

The aim of the study is to evaluate the usability aspects of new deployable, expandable, electrode prototypes, in terms of suitability solutions for laparoscopic applications on the liver, endoscopic trans-oral and trans-anal procedures, electroporation segmentation in several steps, mechanical functionality (flexibility, penetrability), visibility of the electrode under instrumental guidance, compatibility of the electrode with laparoscopic/endoscopic accesses, surgical instruments, and procedural room and safety compatibility. The electroporation was performed on an animal model (Sus Scrofa Large White 60 kg) both in laparoscopy and endoscopy, under ultrasound guidance, and in open surgery. Electrodes without divergence, with needles coming out straight, parallel to each other, and electrodes with peripheral needles (four needles), diverging from the electrode shaft axis (electrode with non-zero divergence) have been tested. To cause an evaluable necrosis effect, the number of electrical pulses was increased to induce immediate liver cell death. Histological samples were analyzed by staining with Haematoxylin/Eosin or by immunohistochemical staining to confirm complete necrosis. The prototypes of expandable electrodes, tested in laparoscopy and endoscopy and in open surgery, respectively, are suitable in terms of usability, electroporation segmentation in several steps, mechanical functionality (flexibility, penetrability), visibility under instrumental guidance, compatibility with laparoscopic/endoscopic accesses, surgical instruments and procedural room safety, patient safety (no bleeding and/or perforation), and treatment efficacy (adequate ablated volume). Electroporation treatment using new deployable expandable electrode prototypes is safe and feasible. Moreover, electrode configurations allow for a gradual increase in the ablated area in consecutive steps, as confirmed by histology and immunohistochemistry.

Cancellation effect is present in high-frequency reversible and irreversible electroporation

It was recently suggested that applying high-frequency short biphasic pulses (HF-IRE) reduces pain and muscle contractions in electrochemotherapy and irreversible ablation treatments; however, higher amplitudes with HF-IRE pulses are required to achieve a similar effect as with monophasic pulses. HF-IRE pulses are in the range of a microseconds, thus, the so-called cancellation effect could be responsible for the need to apply pulses of higher amplitudes. In cancellation effect, the effect of first pulse is reduced by the second pulse of opposite polarity. We evaluated cancellation effect with high-frequency biphasic pulses on CHO-K1 in different electroporation buffers. We applied eight bursts of 1-10 µs long pulses with inter-phase delays of 0.5 µs - 10 ms and evaluated membrane permeability and cell survival. In permeability experiments, cancellation effect was not observed in low-conductivity buffer. Cancellation effect was, however, observed in treatments with high-frequency biphasic pulses looking at survival in all of the tested electroporation buffers. In general, cancellation effect depended on inter-phase delay as well as on pulse duration, i.e. longer pulses and longer interphase delay cause less pronounced cancellation effect. Cancellation effect could be partially explained by the assisted discharge and not by the hyperpolarization by the chloride channels.

A Novel 3D Scaffold for Cell Growth to Asses Electroporation Efficacy

Tumor electroporation (EP) refers to the permeabilization of the cell membrane by means of short electric pulses thus allowing the potentiation of chemotherapeutic drugs. Standard plate adhesion 2D cell cultures can simulate the in vivo environment only partially due to lack of cell–cell interaction and extracellular matrix (ECM). In this study, we assessed a novel 3D scaffold for cell cultures based on hyaluronic acid and ionic-complementary self-assembling peptides (SAPs), by studying the growth patterns of two different breast carcinoma cell lines (HCC1569 and MDA-MB231). This 3D scaffold modulates cell shape and induces extracellular matrix deposit around cells. In the MDA-MB 231 cell line, it allows three-dimensional growth of structures known as spheroids, while in HCC1569 it achieves a cell organization similar to that observed in vivo. Interestingly, we were able to visualize the electroporation effect on the cells seeded in the new scaffold by means of standard propidium iodide assay and fluorescence microscopy. Thanks to the presence of cell–cell and cell–ECM interactions, the new 3D scaffold may represent a more reliable support for EP studies than 2D cancer cell cultures and may be used to test new EP-delivered drugs and novel EP protocols.

Calcium electroporation: The bioelectrochemical treatment of spontaneous equine skin tumors results in a local necrosis

Electrochemotherapy (ECT) is an anticancer bioelectrochemical therapy where electrical field pulses (electropermeabilization) increase intracellular concentration of antitumor drugs. The procedure is very effective against skin tumors. The restrictive regulations concerning anticancer drugs in veterinary medicine limit use of ECT. Electroporation with calcium (Electroporation Calcium Therapy)(ECaT) was proved to be effective in vivo on induced tumors in laboratory animals. This study evaluated the effects of ECaT in equine sarcoids (spontaneous skin tumors) on an animal cohort. Pulse parameters for ECaT were choosen for using skin contact electrodes. ECaT was applied under general anesthesia. The tumors were removed at different days after the treatment and analyzed by histology. The study assessed the volume fraction of necrosis that was >50% for 9 of 13 sarcoids. Sixteen sarcoids in 10 horses were treated with ECaT. Macroscopic changes (a crust) were observed in 14/16 tumors. The main microscopic changes were necrosis, ulceration,hemorrhages, calcifications and thrombosis. The adverse effect was an inflammatory local reaction. Surrounding tissues were not affected. This targeted effect can be explained by its control by the field distribution in the tissue and on the interstitial diffusion of the injected Ca²⁺.

Electrochemotherapy of superficial tumors - Current status:: Basic principles, operating procedures, shared indications, and emerging applications

Treatment of superficial tumors with electrochemotherapy (ECT) has shown a steep rise over the past decade and indications range from skin cancers to locally advanced or metastatic neoplasms. Based on reversible electroporation, which is a physical method to achieve transient tumor cell membrane permeabilization by means of short electric pulses, ECT increases cellular uptake of bleomycin and cisplatin and their cytotoxicity by 8,000- and 80-fold, respectively. Standard operating procedures were established in 2006 and updated in 2018. Ease of administration, patient tolerability, efficacy across histotypes, and repeatability are peculiar advantages, which make standard ECT (ie, ECT using fixed-geometry electrodes) a reliable option for controlling superficial tumor growth locally and preventing their morbidity. Consolidated indications include superficial metastatic melanoma, breast cancer, head and neck skin tumors, nonmelanoma skin cancers, and Kaposi sarcoma. In well-selected patients with oropharyngeal cancers, ECT ensures appreciable symptom control. Emerging applications include skin metastases from visceral or hematological malignancies, vulvar cancer, and some noncancerous skin lesions (keloids and capillary vascular malformations). Repeatability and integration with other oncologic therapies allow for consolidation of response and sustained tumor control. In this review, we present the basic principles of ECT, recently updated operating procedures, anesthesiological management, and provide a synthesis of the efficacy of standard ECT across histotypes.

Electrochemotherapy of Spinal Metastases Using Transpedicular Approach-A Numerical Feasibility Study

Vertebral column is the most frequent site for bone metastases. It has been demonstrated in previous studies that bone metastases can be efficiently treated by electrochemotherapy. We developed a novel approach to treat spinal metastases, that is, transpedicular approach that combines electrochemotherapy with already established technologies for insertion of fixation screws in spinal surgery. In the transpedicular approach, needle electrodes are inserted into the vertebral body through pedicles and placed around the tumor. The main goal of our study was to numerically investigate the feasibility of the proposed treatment approach. Three clinical cases were used in this study—1 with a tumor completely contained within the vertebral body and 2 with tumors spread also to the pedicles and spinal canal. Anatomically accurate numerical models were built for all 3 cases, and numerical computations of electric field distribution in tumor and surrounding tissue were performed to determine the treatment outcome. Complete coverage of tumor volume with sufficiently high electric field is a prerequisite for successful electrochemotherapy. Close to 100% tumor coverage was obtained in all 3 cases studied. Two cases exhibited tumor coverage of >99%, while the coverage in the third case was 98.88%. Tumor tissue that remained untreated was positioned on the margin of the tumor volume. We also evaluated hypothetical damage to spinal cord and nerves. Only 1 case, which featured a tumor grown into the spinal canal, exhibited potential risk of neural damage. Our study shows that the proposed transpedicular approach to treat spinal metastases is feasible and safe if the majority of tumor volume is contained within the vertebral body. In cases where the spinal cord and nerves are contained within the margin of the tumor volume, a successful and safe treatment is still possible, but special attention needs to be given to evaluation of potential neural damage.

Electrochemotherapy: A Review of Current Status, Alternative IGP Approaches, and Future Perspectives

The efficiency of electroporation (EP) has made it a widely used therapeutic procedure to transfer cell killing substances effectively to the target site. A lot of researches are being done on EP-based cancer treatment techniques. Electrochemotherapy (ECT) is the first EP-based application in the field of drug administration. ECT is a local and nonthermal treatment of cancer that combines the use of a medical device with pharmaceutical agents to obtain local tumor control in solid cancers. It involves the application of eight, 100µs, pulses at 1 or 5000 Hz frequency and specified electric field (V/cm) with a median duration of 25 minutes. The efficacy of chemotherapeutic drugs increases by applying short and intense electrical pulses. Several clinical studies proposed ECT as a safe and complementary curative or palliative treatment option (curative intent of 50% to 63% in the treatment of Basal Cell Carcinoma (BCC)) to treat a number of solid tumors and skin malignancies, which are not suitable for conventional treatments. It is used currently for treatment of cutaneous and subcutaneous lesions, without consideration of their histology. On the contrary, it is also becoming a practical method for treatment of internal, deep-seated tumors and tissues. A review of this method, needed instruments, alternative image-guided procedures (IGP) approaches, and future perspectives and recommendations are discussed in this paper.

Ultrasonographic changes in the liver tumors as indicators of adequate tumor coverage with electric field for effective electrochemotherapy

Background

The aim of the study was to characterize ultrasonographic (US) findings during and after electrochem-otherapy of liver tumors to determine the actual ablation zone and to verify the coverage of the treated tumor with a sufficiently strong electric field for effective electrochemotherapy.

Patients and methods

US findings from two representative patients that describe immediate and delayed tumor changes after electrochemotherapy of colorectal liver metastases are presented.

Results

The US findings were interrelated with magnetic resonance imaging (MRI). Electrochemotherapy-treated tumors were exposed to electric pulses based on computational treatment planning. The US findings indicate immediate appearance of hyperechogenic microbubbles along the electrode tracks. Within minutes, the tumors became evenly hyperechogenic, and simultaneously, an oedematous rim was formed presenting as a hypoechogenic formation which persisted for several hours after treatment. The US findings overlapped with computed electric field distribution in the treated tissue, indicating adequate coverage of tumors with sufficiently strong electric field, which may predict an effective treatment outcome.

Conclusions

US provides a tool for assessment of appropriate electrode insertion for intraoperative electrochemo-therapy of liver tumors and assessment of the appropriate coverage of a tumor with a sufficiently strong electric field and can serve as predictor of the response of tumors.

Connecting the in vitro and in vivo experiments in electrochemotherapy - a feasibility study modeling cisplatin transport in mouse melanoma using the dual-porosity model

In electrochemotherapy two conditions have to be met to be successful - the electric field of sufficient amplitude and sufficient uptake of chemotherapeutics in the tumor. Current treatment plans only take into account critical electric field to achieve cell membrane permeabilization. However, permeabilization alone does not guarantee uptake of chemotherapeutics and consequently successful treatment. We performed a feasibility study to determine whether the transport of cisplatin in vivo could be calculated based on experiments performed in vitro. In vitro, a spectrum of parameters can be explored without ethical issues. Mouse melanoma B16-F1 cell suspension and inoculated B16-F10 tumors were exposed to electric pulses in the presence of chemotherapeutic cisplatin. The uptake of cisplatin was measured by inductively coupled plasma mass spectrometry. We modeled the transport of cisplatin with the dual-porosity model, which is based on the diffusion equation, connects pore formation with membrane permeability, and includes transport between several compartments. In our case, there were three compartments - tumor cells, interstitial fraction and peritumoral region. Our hypothesis was that in vitro permeability coefficient could be introduced in vivo, as long as tumor physiology was taken into account. Our hypothesis was confirmed as the connection of in vitro and in vivo experiments was possible by introducing a transformation coefficient which took into account the in vivo characteristics, i.e., smaller available area of the plasma membrane for transport due to cell density, presence of cell-matrix in vivo, and reduced drug mobility. We thus show that it is possible to connect in vitro and in vivo experiments of electrochemotherapy. However, more experimental work is required for model validation.

Electrochemotherapy in head and neck cancer: A review of an emerging cancer treatment

Patients affected by aggressive neoplasms with a high propensity to metastasize to the skin, including some types of head and neck cancer, may benefit from electrochemotherapy, a modality that combines the electroporation of cell membranes and chemotherapy to facilitate the transport of non-permeant molecules into cells; the host immune response consequently participates in achieving the abolition of tumors. Electrochemotherapy can be successfully used for skin metastases of head and neck tumors and, with some limitations, for primary and relapsing neoplasms; it can also be applied on an outpatient basis with a favorable cost-benefit ratio and it is a repeatable treatment that, if necessary, can be followed by traditional antineoplastic therapies. Although still a palliative treatment, the good level of tolerability and the high success rates of electrochemotherapy make it worth consideration among treatment options in selected patients.

Electrochemotherapy Effectiveness Loss due to Electric Field Indentation between Needle Electrodes: A Numerical Study

Electrochemotherapy is an anticancer treatment based on applying electric field pulses that reduce cell membrane selectivity, allowing chemotherapy drugs to enter the cells. In parallel to electrochemotherapy clinical tests, in silico experiments have helped scientists and clinicians to understand the electric field distribution through anatomically complex regions of the body. In particular, these in silico experiments allow clinicians to predict problems that may arise in treatment effectiveness. The current work presents a metastatic case of a mast cell tumor in a dog. In this specific treatment planning study, we show that using needle electrodes has a possible pitfall. The macroscopic consequence of the electroporation was assessed through a mathematical model of tissue electrical conductivity. Considering the electrical and geometrical characteristics of the case under study, we modeled an ellipsoidal tumor. Initial simulations were based on the European Standard Operating Procedures for electrochemotherapy suggestions, and then different electrodes' arrangements were evaluated. To avoid blind spots, multiple applications are usually required for large tumors, demanding electrode repositioning. An effective treatment electroporates all the tumor cells. Partially and slightly overlapping the areas increases the session's duration but also likely increases the treatment's effectiveness. It is worth noting that for a single application, the needles should not be placed close to the tumor's borders because effectiveness is highly likely to be lost.

Electroporation in veterinary oncology

Cancer treatments in veterinary medicine continue to evolve beyond the established standard therapies of surgery, chemotherapy and radiation therapy. New technologies in cancer therapy include a targeted mechanism to open the cell membrane based on electroporation, driving therapeutic agents, such as chemotherapy (electro-chemotherapy), for local control of cancer, or delivery of gene-based products (electro-gene therapy), directly into the cancer cell to achieve systemic control. This review examines electrochemotherapy and electro-gene therapy in veterinary medicine and considers future directions and applications.

Histological and Mathematical Analysis of the Irreversibly Electroporated Liver Tissue

Irreversible electroporation has clinically been used to treat various types of cancer. A plan on how to apply irreversible electroporation before practicing is very important to increase the ablation area and reduce the side effects. Several electrical models have been developed to predict the ablation area with applied electric energy. In this experiment, the static relationship between applied electric energy and ablated area was mathematically and experimentally investigated at 10 hours after applying irreversible electroporation. We performed the irreversible electroporation on the liver tissue of Sprague Dawley rats (male, 8 weeks, weighing 250-350 g). The ablated area was measured based on histological analysis and compared with the mathematical calculation from the electric energy, assuming that the tissue is homogeneous. The ablated area increased with the increase in applied electric energy. The numerically calculated contour lines of electric energy density overlapped well with the apoptotic area induced by the irreversible electroporation. The overlapped area clearly showed that the destructive threshold of apoptosis between electrodes is electric energy density level of 5.9 × 10⁵ J/m³. The results of the present study suggested that the clinical results of the irreversible electroporation on a liver tissue could be predicted through mathematical calculation.

Recommendations for improving the quality of reporting clinical electrochemotherapy studies based on qualitative systematic review

BACKGROUND

Electrochemotherapy is becoming a well-established treatment for malignancies of skin and non-skin origin and its use is widening across Europe. The technique was developed and optimized from solid experimental and clinical evidence. A consensus document is now warranted to formalize reporting results, which should strengthen evidence-based practice recommendations. This consensus should be derived from high quality clinical data collection, clinical expertise and summarizing patient feedback. The first step, which is addressed in this paper, aims to critically analyze the quality of published studies and to provide the recommendations for reporting clinical trials on electrochemotherapy.

METHODS

The quality of reporting in published studies on electrochemotherapy was analyzed in order to produce procedure specific reporting recommendations. A comprehensive literature search of studies published from 2006 to 2015 was performed followed by qualitative analysis of manuscripts assessing for 47 quality criteria grouped into four major clusters: (1) trial design, (2) description of patient population, (3) description of treatment delivery and patient outcome, (4) analysis of results and their interpretation. The summary measure during literature assessment was the proportion of studies fulfilling each manuscript quality criteria.

RESULTS

A total of 56 studies were screened, from the period 2006 to 2015, of which 33 were included in the qualitative analysis, with a total of 1215 patients. Overall, the quality of reporting was highly variable. Twenty-four reports (73%) were single-center, non-comparative studies, and only 15 (45%) were prospective in nature (only 2 of them were entered into a clinical trials registry). Electrochemotherapy technique was consistently reported, with most studies (31/33) adhering closely to published standard operating procedures. The quality of reporting the patient population was variable among the analyzed studies, with only between 45% and 100% achieving dedicated quality criteria. Reporting of treatment delivery and patient outcome was also highly variable with studies only fulfilling between 3% and 100%. Finally, reporting study results critically varied, fulfilling from 27% to 100% of the quality criteria. Based on the critical issues emerging from this analysis, recommendations and minimal requirements for reporting clinical data on electrochemotherapy were prepared and summarized into a checklist.

CONCLUSIONS

There is an increasing body of published clinical data on electrochemotherapy, but more high quality clinical data are needed. Published papers often lack accurate description of study population, treatment delivery as well as patient outcome. Our recommendations, provided in the form of a summary checklist, are intended to ameliorate data reporting in future studies on electrochemotherapy and help researchers to provide a solid evidence basis for clinical practice.

Electrochemotherapy of tumors as in situ vaccination boosted by immunogene electrotransfer

Electroporation is a platform technology for drug and gene delivery. When applied to cell in vitro or tissues in vivo, it leads to an increase in membrane permeability for molecules which otherwise cannot enter the cell (e.g., siRNA, plasmid DNA, and some chemotherapeutic drugs). The therapeutic effectiveness of delivered chemotherapeutics or nucleic acids depends greatly on their successful and efficient delivery to the target tissue. Therefore, the understanding of different principles of drug and gene delivery is necessary and needs to be taken into account according to the specificity of their delivery to tumors and/or normal tissues. Based on the current knowledge, electrochemotherapy (a combination of drug and electric pulses) is used for tumor treatment and has shown great potential. Its local effectiveness is up to 80 % of local tumor control, however, without noticeable effect on metastases. In an attempt to increase systemic antitumor effectiveness of electrochemotherapy, electrotransfer of genes with immunomodulatory effect (immunogene electrotransfer) could be used as adjuvant treatment. Since electrochemotherapy can induce immunogenic cell death, adjuvant immunogene electrotransfer to peritumoral tissue could lead to locoregional effect as well as the abscopal effect on distant untreated metastases. Therefore, we propose a combination of electrochemotherapy with peritumoral IL-12 electrotransfer, as a proof of principle, using electrochemotherapy boosted with immunogene electrotransfer as in situ vaccination for successful tumor treatment.

Electrical resistance of human soft tissue sarcomas: an ex vivo study on surgical specimens

This paper presents a study about electrical resistance, which using fixed electrode geometry could be correlated to the tissue resistivity, of different histological types of human soft tissue sarcomas measured during electroporation. The same voltage pulse sequence was applied to the tumor mass shortly after surgical resection by means of a voltage pulse generator currently used in clinical practice for electrochemotherapy that uses reversible electroporation. The voltage pulses were applied by means of a standard hexagonal electrode composed by seven, 20-mm-long equispaced needles. Irrespective of tumor size, the electrode applies electric pulses to the same volume of tissue. The resistance value was computed from the voltage and current recorded by the pulse generator, and it was correlated with the histological characteristics of the tumor tissue which was assessed by a dedicated pathologist. Some differences in resistance values, which could be correlated to a difference in tissue resistivity, were noticed according to sarcoma histotype. Lipomatous tumors (i.e., those rich in adipose tissue) displayed the highest resistance values (up to 1700 Ω), whereas in the other soft tissue sarcomas, such as those originating from muscle, nerve sheath, or fibrous tissue, the electrical resistance measured was between 40 and 110 Ω. A variability in resistance was found also within the same histotype. Among lipomatous tumors, the presence of myxoid tissue between adipocytes reduced the electrical resistance (e.g., 50-100 Ω). This work represents the first step in order to explore the difference in tissue electrical properties of STS. These results may be used to verify whether tuning electric field intensity according to the specific STS histotype could improve tissue electroporation and ultimately treatment efficacy.

Modeling the positioning of single needle electrodes for the treatment of breast cancer in a clinical case

Background

Breast cancer is the most common cancer in women worldwide and is the second most common cause of cancer death in women. Electrochemotherapy (ECT) used in early-phase clinical trials for the treatment of primary breast cancer resulted in a not complete tumor necrosis in most cases. The present study was undertaken to analyze the feasibility to use ECT to treat patients with histologically proven unifocal ductal breast cancer. In particular, results of ECT treatment in a clinical case are compared with the ones of a simplified 3D dosimetric model.

Methods

This clinical study was conducted with the pulse generator Cliniporator Vitae (IGEA, Carpi, Italy). ECT procedures were performed according to ESOPE standard operating procedures. Five single needle electrodes were used with one positioned in the center of the tumor, and the other four distributed around the nodule. Histological images of the resected tumor are compared with the maps of the electric field obtained with a simplified 3D model in Comsol Multiphysics v 4.3.

Results

The results of the clinical case demonstrated a reduced efficacy of the ECT treatment described. The proposed simple numerical model of the breast tumor located in a low conductive tissue suggests that this is due to the reduced electric field induced inside the tumor with such 5 electrodes placement. However, where the electric field is predicted higher than the reversible electroporation threshold (E>400 V/cm), also the histological images confirm the necrosis of the target with a good agreement between the modeled and clinical results.

Conclusions

The results suggest the dependence of the effectiveness of the treatment on the careful placement of the electrodes. A detailed planned procedure for the tumor analysis after the treatment is also needed in order to better correlate the single electrode positions and the histological images. Simulation models could be used to identify better electrodes configuration in planning the experimental protocol for ECT treatment of breast tumors.

Web-based tool for visualization of electric field distribution in deep-seated body structures and planning of electroporation-based treatments

BACKGROUND

Treatments based on electroporation are a new and promising approach to treating tumors, especially non-resectable ones. The success of the treatment is, however, heavily dependent on coverage of the entire tumor volume with a sufficiently high electric field. Ensuring complete coverage in the case of deep-seated tumors is not trivial and can in best way be ensured by patient-specific treatment planning. The basis of the treatment planning process consists of two complex tasks: medical image segmentation, and numerical modeling and optimization.

METHODS

In addition to previously developed segmentation algorithms for several tissues (human liver, hepatic vessels, bone tissue and canine brain) and the algorithms for numerical modeling and optimization of treatment parameters, we developed a web-based tool to facilitate the translation of the algorithms and their application in the clinic. The developed web-based tool automatically builds a 3D model of the target tissue from the medical images uploaded by the user and then uses this 3D model to optimize treatment parameters. The tool enables the user to validate the results of the automatic segmentation and make corrections if necessary before delivering the final treatment plan.

RESULTS

Evaluation of the tool was performed by five independent experts from four different institutions. During the evaluation, we gathered data concerning user experience and measured performance times for different components of the tool. Both user reports and performance times show significant reduction in treatment-planning complexity and time-consumption from 1-2 days to a few hours.

CONCLUSIONS

The presented web-based tool is intended to facilitate the treatment planning process and reduce the time needed for it. It is crucial for facilitating expansion of electroporation-based treatments in the clinic and ensuring reliable treatment for the patients. The additional value of the tool is the possibility of easy upgrade and integration of modules with new functionalities as they are developed.

Current density imaging sequence for monitoring current distribution during delivery of electric pulses in irreversible electroporation

Background

Electroporation is gaining its importance in everyday clinical practice of cancer treatment. For its success it is extremely important that coverage of the target tissue, i.e. treated tumor, with electric field is within the specified range. Therefore, an efficient tool for the electric field monitoring in the tumor during delivery of electroporation pulses is needed. The electric field can be reconstructed by the magnetic resonance electric impedance tomography method from current density distribution data. In this study, the use of current density imaging with MRI for monitoring current density distribution during delivery of irreversible electroporation pulses was demonstrated.

Methods

Using a modified single-shot RARE sequence, where four 3000 V and 100 μs long pulses were included at the start, current distribution between a pair of electrodes inserted in a liver tissue sample was imaged. Two repetitions of the sequence with phases of refocusing radiofrequency pulses 90° apart were needed to acquire one current density image. For each sample in total 45 current density images were acquired to follow a standard protocol for irreversible electroporation where 90 electric pulses are delivered at 1 Hz.

Results

Acquired current density images showed that the current density in the middle of the sample increased from first to last electric pulses by 60%, i.e. from 8 kA/m² to 13 kA/m² and that direction of the current path did not change with repeated electric pulses significantly.

Conclusions

The presented single-shot RARE-based current density imaging sequence was used successfully to image current distribution during delivery of short high-voltage electric pulses. The method has a potential to enable monitoring of tumor coverage by electric field during irreversible electroporation tissue ablation.

Effect of blood vessel segmentation on the outcome of electroporation-based treatments of liver tumors

Electroporation-based treatments rely on increasing the permeability of the cell membrane by high voltage electric pulses applied to tissue via electrodes. To ensure that the whole tumor is covered with sufficiently high electric field, accurate numerical models are built based on individual patient anatomy. Extraction of patient's anatomy through segmentation of medical images inevitably produces some errors. In order to ensure the robustness of treatment planning, it is necessary to evaluate the potential effect of such errors on the electric field distribution. In this work we focus on determining the effect of errors in automatic segmentation of hepatic vessels on the electric field distribution in electroporation-based treatments in the liver. First, a numerical analysis was performed on a simple 'sphere and cylinder' model for tumors and vessels of different sizes and relative positions. Second, an analysis of two models extracted from medical images of real patients in which we introduced variations of an error of the automatic vessel segmentation method was performed. The results obtained from a simple model indicate that ignoring the vessels when calculating the electric field distribution can cause insufficient coverage of the tumor with electric fields. Results of this study indicate that this effect happens for small (10 mm) and medium-sized (30 mm) tumors, especially in the absence of a central electrode inserted in the tumor. The results obtained from the real-case models also show higher negative impact of automatic vessel segmentation errors on the electric field distribution when the central electrode is absent. However, the average error of the automatic vessel segmentation did not have an impact on the electric field distribution if the central electrode was present. This suggests the algorithm is robust enough to be used in creating a model for treatment parameter optimization, but with a central electrode.

Evaluation of the Electroporation Efficiency of a Grid Electrode for Electrochemotherapy: From Numerical Model to In Vitro Tests

Electrochemotherapy (ECT) is a local anticancer treatment based on the combination of chemotherapy and short, tumor-permeabilizing, voltage pulses delivered using needle electrodes or plate electrodes. The application of ECT to large skin surface tumors is time consuming due to technical limitations of currently available voltage applicators. The availability of large pulse applicators with few and more spaced needle electrodes could be useful in the clinic, since they could allow managing large and spread tumors while limiting the duration and the invasiveness of the procedure. In this article, a grid electrode with 2-cm spaced needles has been studied by means of numerical models. The electroporation efficiency has been assessed on human osteosarcoma cell line MG63 cultured in monolayer. The computational results show the distribution of the electric field in a model of the treated tissue. These results are helpful to evaluate the effect of the needle distance on the electric field distribution. Furthermore, the in vitro tests showed that the grid electrode proposed is suitable to electropore, by a single application, a cell culture covering an area of 55 cm(2). In conclusion, our data might represent substantial improvement in ECT in order to achieve a more homogeneous and time-saving treatment, with benefits for patients with cancer.

Optimization of a gene electrotransfer procedure for efficient intradermal immunization with an hTERT-based DNA vaccine in mice

DNA vaccination consists in administering an antigen-encoding plasmid in order to trigger a specific immune response. This specific vaccine strategy is of particular interest to fight against various infectious diseases and cancer. Gene electrotransfer is the most efficient and safest non-viral gene transfer procedure and specific electrical parameters have been developed for several target tissues. Here, a gene electrotransfer protocol into the skin has been optimized in mice for efficient intradermal immunization against the well-known telomerase tumor antigen. First, the luciferase reporter gene was used to evaluate gene electrotransfer efficiency into the skin as a function of the electrical parameters and electrodes, either non-invasive or invasive. In a second time, these parameters were tested for their potency to generate specific cellular CD8 immune responses against telomerase epitopes. These CD8 T-cells were fully functional as they secreted IFNγ and were endowed with specific cytotoxic activity towards target cells. This simple and optimized procedure for efficient gene electrotransfer into the skin using the telomerase antigen is to be used in cancer patients for the phase 1 clinical evaluation of a therapeutic cancer DNA vaccine called INVAC-1.

Electrochemotherapy in non-melanoma head and neck cancers: a retrospective analysis of the treated cases

Electrochemotherapy increases the permeability of tumours to drugs by electric voltages applied locally. Its value in tumours of the head and neck is unknown. We retrospectively reviewed a 2-centre database, and found 39 patients with squamous cell carcinoma (SCC) of the oral cavity or oropharynx (n=12) or non-melanoma skin tumours (n=27) who had been treated with bleomycin electrochemotherapy with needle electrodes. A further 3 patients were given cisplatin electrochemotherapy (n=2), or bleomycin electrochemotherapy by plate electrodes (n=1). Local toxicity was mild. The complete response rate was 38% and was associated with whether the tumour was primary or recurrent (p<0.001), its size (p=0.02), and the route by which the drug was given (p=0.02). We did not study enough patients with basal cell carcinomas to say whether the response was significantly better or not (p=0.07). Skin tumours and SCC of the oral cavity or oropharynx showed comparable complete responses (41% and 33%, p=0.73) and local control (1-year local progression-free survival, 51% compared with 59%, p=0.89), particularly if they were small (p=0.001), primary (p=0.002), chemonaive (p=0.03). Patients treated with cisplatin were unresponsive. Electrochemotherapy with bleomycin is an effective option for skin tumours of the head and neck and is a feasible alternative in highly selected (small, primary, and not previously treated by chemotherapy) SCC of the oral cavity and oropharynx.

In situ monitoring of electric field distribution in mouse tumor during electroporation

PURPOSE

To investigate the feasibility of magnetic resonance (MR) electric impedance tomography ( EIT electric impedance tomography ) technique for in situ monitoring of electric field distribution during in vivo electroporation of mouse tumors to predict reversibly electroporated tumor areas.

MATERIALS AND METHODS

All experiments received institutional animal care and use committee approval. Group 1 consisted of eight tumors that were used for determination of predicted area of reversibly electroporated tumor cells with MR EIT electric impedance tomography by using a 2.35-T MR imager. In addition, T1-weighted images of tumors were acquired to determine entrapment of contrast agent within the reversibly electroporated area. A correlation between predicted reversible electroporated tumor areas as determined with MR EIT electric impedance tomography and areas of entrapped MR contrast agent was evaluated to verify the accuracy of the prediction. Group 2 consisted of seven tumors that were used for validation of radiologic imaging with histopathologic staining. Histologic analysis results were then compared with predicted reversible electroporated tumor areas from group 1. Results were analyzed with Pearson correlation analysis and one-way analysis of variance.

RESULTS

Mean coverage ± standard deviation of tumors with electric field that leads to reversible electroporation of tumor cells obtained with MR EIT electric impedance tomography (38% ± 9) and mean fraction of tumors with entrapped MR contrast agent (41% ± 13) were correlated (Pearson analysis, r = 0.956, P = .005) and were not statistically different (analysis of variance, P = .11) from mean fraction of tumors from group 2 with entrapped fluorescent dye (39% ± 12).

CONCLUSION

MR EIT electric impedance tomography can be used for determining electric field distribution in situ during electroporation of tissue. Implementation of MR EIT electric impedance tomography in electroporation-based applications, such as electrochemotherapy and irreversible electroporation tissue ablation, would enable corrective interventions before the end of the procedure and would additionally improve the treatment outcome.

In Vivo Evidences of Nanosecond Pulsed Electric Fields for Melanoma Malignancy Treatment on Tumor-Bearing BALB/c Nude Mice

In order to get in vivo evidences of nanosecond pulsed electric fields (nsPEF) for skin tumor treatment, tumor models in 10 female BALB/c nude mice were established by inoculating them with human melanoma cells A375. These mice were randomly divided into treated group (exposed to nsPEF with intensity of 20 kV/cm and duration of 300 ns) and control group equally. Five days post-nsPEF treatment, tumor growth in the treated group was effectively inhibited ( P < 0.01 compared with that in control group), typical apoptotic characteristics (DNA damage and fragmentation) were observed by terminal deoxynucleotidyl transferase dUTP nick end labeling (TUNEL), and significant increases in Bax and decreases in Bcl-2, micro-vessel density (MVD), vascular endothelial growth factor (VEGF) and proliferating cell nuclear antigen (PCNA) were observed by immunohistochemistry ( P < 0.01). These experimental results indicate that in vivo tumor growth can be effectively inhibited by nsPEF, which activate two targets, apoptosis initiation and angiogenesis inhibition.