Treatment planning of electroporation-based medical interventions: electrochemotherapy, gene electrotransfer and irreversible electroporation

A New Hope for the Treatment of Atrial Fibrillation: Application of Pulsed-Field Ablation Technology

In recent years, the prevalence of and mortality associated with cardiovascular diseases have been rising in most countries and regions. AF is the most common arrhythmic condition, and there are several treatment options for AF. Pulmonary vein isolation is an effective treatment for AF and is the cornerstone of current ablation techniques, which have one major limitation: even when diagnosed and treated at a facility that specializes in ablation, patients have a greater chance of recurrence. Therefore, there is a need to develop better ablation techniques for the treatment of AF. This article first compares the current cryoablation (CBA) and radiofrequency ablation (RFA) techniques for the treatment of AF and discusses the utility and advantages of the development of pulsed-field ablation (PFA) technology. The current research on PFA is summarized from three perspectives, namely, simulation experiments, animal experiments, and clinical studies. The results of different stages of experiments are summarized, especially during animal studies, where pulmonary vein isolation was carried out effectively without causing injury to the phrenic nerve, esophagus, and pulmonary veins, with higher safety and shorter incision times. This paper focuses on a review of various a priori and clinical studies of this new technique for the treatment of AF.

How Impedance Measurements and Imaging Can Be Used to Characterize the Conductivity of Tissues During the Workflow of an Electroporation-Based Therapy

In this article we investigate the possibility of using needles, which the interventional radiologist inserts near a deep-seated tumor during an electroporation-based therapy, to characterize the electrical conductivity of patient's tissues. Specifically, we propose to exploit voltage/current measurements and imaging that are performed prior to the application of electroporation pulses. The approach is partly based on the concepts of electrical impedance tomography; however, imaging is used to build a specific geometric model and compensate for the lack of information resulting from the small number of electrodes available. 3D canonical and clinical examples, where a few electrodes surround a tumor, demonstrate the feasibility of this method: solving the inverse problem to estimate tissues conductivity converges in a few iterations. For a given error on the measurement, it is also possible to calculate the error on the estimated conductivities. The uncertainty error with clinical data is at best 5% for one of the tissues identified, due to the limitations of the clinical device used. Various improvements to clinical devices are discussed to make the conductivity estimation more accurate but also to extract more information.

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.

Tissue Nanotransfection Silicon Chip and Related Electroporation-Based Technologies for In Vivo Tissue Reprogramming

Tissue nanotransfection (TNT), a cutting-edge technique of in vivo gene therapy, has gained substantial attention in various applications ranging from in vivo tissue reprogramming in regenerative medicine, and wound healing to cancer treatment. This technique harnesses the advancements in the semiconductor processes, facilitating the integration of conventional transdermal gene delivery methods-nanoelectroporation and microneedle technologies. TNT silicon chips have demonstrated considerable promise in reprogramming fibroblast cells of skin in vivo into vascular or neural cells in preclinical studies to assist in the recovery of injured limbs and damaged brain tissue. More recently, the application of TNT chips has been extended to the area of exosomes, which are vital for intracellular communication to track their functionality during the wound healing process. In this review, we provide an in-depth examination of the design, fabrication, and applications of TNT silicon chips, alongside a critical analysis of the electroporation-based gene transfer mechanisms. Additionally, the review discussed the existing limitations and challenges in the current technique, which may project future trajectories in the landscape of gene therapy. Through this exploration, the review aims to shed light on the prospects of TNT in the broader context of gene therapy and tissue regeneration.

Electroporation-Based Biopsy Treatment Planning with Numerical Models and Tissue Phantoms

Molecular sampling with vacuum-assisted tissue electroporation is a novel, minimally invasive method for molecular profiling of solid lesions. In this paper, we report on the design of the battery-powered pulsed electric field generator and electrode configuration for an electroporation-based molecular sampling device for skin cancer diagnostics. Using numerical models of skin electroporation corroborated by the potato tissue phantom model, we show that the electroporated tissue volume, which is the maximum volume for biomarker sampling, strongly depends on the electrode's geometry, needle electrode skin penetration depths, and the applied pulsed electric field protocol. In addition, using excised human basal cell carcinoma (BCC) tissues, we show that diffusion of proteins out of human BCC tissues into water strongly depends on the strength of the applied electric field and on the time after the field application. The developed numerical simulations, confirmed by experiments in potato tissue phantoms and excised human cancer lesions, provide essential tools for the development of electroporation-based molecular markers sampling devices for personalized skin cancer diagnostics.

Investigation of lethal thresholds of nanosecond pulsed electric field in rabbit VX2 hepatic tumors through finite element analysis and verification with a single-needle bipolar electrode: A prospective strategy employing three-dimensional comparisons

Pulsed electric field has emerged as a promising modality for the solid tumor ablation with the advantage in treatment planning, however, the accurate prediction of the lesion margin requires the determination of the lethal electric field (E) thresholds. Herein we employ the highly repetitive nanosecond pulsed electric field (RnsPEF) to ablate the normal and VX2 tumor-bearing livers of rabbits. The ultrasound-guided surgery is operated using the conventional double- and newly devised single-needle bipolar electrodes. Finite element analysis is also introduced to simulate the E distribution in the practical treatments. Two- and three-dimensional investigations are performed on the image measurements and reconstructed calcification models on micro-CT, respectively. Specially, an algorithm considering the model surface, volume and shape is employed to compare the similarities between the simulative and experimental models. Blood vessel injury, temperature and synergistic efficacy with doxorubicin (DOX) are also investigated. According to the three-dimensional calculation, the overall E threshold is 4536.4 ± 618.2 V/cm and the single-needle bipolar electrode is verified to be effective in tissue ablation. Vessels are well preserved and the increment of temperature is limited. Synergy of RnsPEF and DOX shows increased apoptosis and improved long-term tumor survival. Our study presents a prospective strategy for the evaluation of the lethal E threshold, which can be considered to guide the future clinical treatment planning for RnsPEF.

Musa acuminata as electroporation model

Electrochemotherapy (ECT) and Irreversible electroporation (IRE) are cancer treatments based on electric field distribution in tissues. Solanum tuberosum (potato tissue) phantom is known to mimic changes in the electrical conductivity that occur in animal tissues during electroporation (EP). Electric field distribution is assessed through enzymatic staining. However, the 24-h wait for this assessment could slow agile response scenarios. We developed and validated the Musa acuminata (cavendish banana) conductivity model, which quickly evaluates EP by tissue staining. We investigated the frequency response of the tissue using impedance spectroscopy analysis, conductivity changes, and enzymatic staining. We optimized three usual EP models: adapted Gompertz, smoothed Heaviside, and the sigmoid or logistic function. We found dielectric parameters in banana tissue similar to those in potato (electrical conductivity of 0.035 S/m and relative permittivity of 4.1×104). The coefficients of determination R2 were 99.94% (Gompertz), 99.85% (Heaviside), and 99.58% (sigmoid). The sigmoid and Heaviside functions described the calibration and validation electric currents with 95% confidence. We observed the electroporated areas in bananas 3h30m after EP. Staining was significant after 450 V/cm. The conductivity model of Musa acuminata suits treatment planning, hardware development, and training scenarios. Banana phantom supports the 3Rs practice and is a reliable alternative for potato in EP studies.

Electroacoustic tomography for real-time visualization of electrical field dynamics in deep tissue during electroporation

Despite the widespread applications of electroporation in biotechnology and medicine, monitoring the distribution of deep tissue electrical fields in real-time during treatment continues to pose a challenge. Current medical imaging modalities are unable to monitor electroporation during pulse delivery. Here we propose a method to use electroacoustic tomography (EAT) to prompt the emission of broadband ultrasound waves via electrical energy deposition. EAT boasts submillimeter resolution at depths reaching 7.5 centimeters and can deliver imaging speeds up to 100 frames per second when paired with an ultrasound array system. We’ve successfully detected EAT signals at electric field strengths ranging from 60 volts per centimeter to several tens of kilovolts per centimeter. This establishes EAT as a potential label-free, high-resolution approach for real-time evaluation of deep tissue electroporation during therapeutic procedures.

Electroporation stimulated by pulsed electrical fields can increase the permeability of cell membranes. However, real-time monitoring of electroporation during pulse delivery is challenging. Xu and colleagues use electroacoustic tomography to image electrical field deposition in deep tissue. This label-free method achieves submillimeter resolution at depths up to 7.5 centimetres.

Thermal damage map prediction during irreversible electroporation with U-Net

Recent developments in cancer treatment with irreversible electroporation (IRE) have led to a renewed interest in developing a treatment planning system based on Deep-Learning methods. This paper will give an account of U-Net, as a Deep-Learning architecture usage for predicting thermal damage area during IRE. In this study, an irregular shape of the liver tumor with MIMICS and 3-Matic software was created from Magnetic Resonance Imaging (MRI) images. To create electric field distribution and thermal damage maps in IRE, COMSOL Multiphysics 5.3 finite element analysis was performed. It was decided to use the pair needle, single bipolar, and multi-tine electrodes with different geometrical parameters as electrodes. The U-Net was designed as a Deep-Learning network to train and predict the thermal damage area from electric field distribution in the IRE. The average DICE coefficient and accuracy of trained U-Net for predicting thermal damage area on test data sets were 0.96 and 0.98, respectively, for the dataset consisting of all electrode type electric field intensity images. This is the first time that U-Net has been used to predict thermal damage area. The results of this research support the idea that the U-Net can be used for predicting thermal damage areas during IRE as a treatment planning system.

Expression of GFP and DsRed fluorescent proteins after gene electrotransfer of tumour cells in vitro

Fluorescent reporter genes are widely used to study the transfection of various types of primary cells and cell lines. The aim of our research was to investigate the expression dynamics of GFP and DsRed reporter genes individually and combined after gene electrotransfer of plasmids with two different electroporation protocols in B16F10 and CT26 cells in vitro. The cytotoxicity after gene electrotransfer of both plasmids was first determined. Second, the intensity of fluorescence and the percentage of cells transfected with both plasmids individually and in combination were monitored in real time. The results show that the percentage of viability after gene electrotransfer of plasmids using the EP2 pulses was significantly higher compared to the EP1 pulses. In contrast, the percentage of transfected cells and fluorescence intensity were higher after gene electrotransfer with the EP1 pulse protocol. Moreover, the percentage of transfected cells was higher and started earlier in the B16F10 cell line than in the CT26 cell line. However, fluorescence intensity was higher in CT26 cells. Co-expression of fluorescent proteins was achieved only in a small number of cells. In conclusion, this study elucidated some of the dynamics of reporter gene expression in cancer cell lines after gene electrotransfer.

PIRET-A Platform for Treatment Planning in Electroporation-Based Therapies

Tissue electroporation is the basis of several therapies. Electroporation is performed by briefly exposing tissues to high electric fields. It is generally accepted that electroporation is effective where an electric field magnitude threshold is overreached. However, it is difficult to preoperatively estimate the field distribution because it is highly dependent on anatomy and treatment parameters.

OBJECTIVE

We developed PIRET, a platform to predict the treatment volume in electroporation-based therapies.

METHODS

The platform seamlessly integrates tools to build patient-specific models where the electric field is simulated to predict the treatment volume. Patient anatomy is segmented from medical images and 3D reconstruction aids in placing the electrodes and setting up treatment parameters.

RESULTS

Four canine patients that had been treated with high-frequency irreversible electroporation were retrospectively planned with PIRET and with a workflow commonly used in previous studies, which uses different general-purpose segmentation (3D Slicer) and modeling software (3Matic and COMSOL Multiphysics). PIRET outperformed the other workflow by 65 minutes (× 1.7 faster), thanks to the improved user experience during treatment setup and model building. Both approaches computed similarly accurate electric field distributions, with average Dice scores higher than 0.93.

CONCLUSION

A platform which integrates all the required tools for electroporation treatment planning is presented. Treatment plan can be performed rapidly with minimal user interaction in a stand-alone platform.

SIGNIFICANCE

This platform is, to the best of our knowledge, the most complete software for treatment planning of irreversible electroporation. It can potentially be used for other electroporation applications.

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.

Human cardiomyocytes are more susceptible to irreversible electroporation by pulsed electric field than human esophageal cells

Pulse electric field-based (PEF) ablation is a technique whereby short high-intensity electric fields inducing irreversible electroporation (IRE) are applied to various tissues. Here, we implemented a standardized in vitro model to compare the effects of biphasic symmetrical pulses (100 pulses, 1-10 μs phase duration (d), 10-1000 Hz pulse repetition rate (f)) using two different human cellular models: human-induced pluripotent stem cell-derived cardiomyocytes (hiPSC-CMs) and human esophageal smooth muscle cells (hESMCs) cultured in monolayer format. We report the PEF-induced irreversibly electroporated cell monolayer areas and the corresponding electric field thresholds (EFTs) for both cardiac and esophageal cultures. Our results suggest marked cell type specificity with EFT estimated to be 2-2.5 times lower in hiPSC-CMs than in hESMCs when subjected to identical PEF treatments (e.g., 0.90 vs 1.85 kV/cm for the treatment of 100 pulses with d = 5 μs, f = 10 Hz, and 0.65 vs 1.67 kV/cm for the treatment of 100 pulses with d = 10 μs, f = 10 Hz). PEF treatment can result in increased temperature around the stimulating electrodes and lead to unanticipated thermal tissue damage that is proportional to the peak temperature rise and to the duration of the PEF-induced elevated temperatures. In our study, temperature increases ranged from less than 1°C to as high as 30°C, however, all temperature changes were transient and quickly returned to baseline and the highest observed ∆T returned to 50% of its maximum recorded temperature in tens of seconds.

Nondestructive protein sampling with electroporation facilitates profiling of spatial differential protein expression in breast tumors in vivo

Excision tissue biopsy, while central to cancer treatment and precision medicine, presents risks to the patient and does not provide a sufficiently broad and faithful representation of the heterogeneity of solid tumors. Here we introduce e-biopsy—a novel concept for molecular profiling of solid tumors using molecular sampling with electroporation. As e-biopsy provides access to the molecular composition of a solid tumor by permeabilization of the cell membrane, it facilitates tumor diagnostics without tissue resection. Furthermore, thanks to its non tissue destructive characteristics, e-biopsy enables probing the solid tumor multiple times in several distinct locations in the same procedure, thereby enabling the spatial profiling of tumor molecular heterogeneity.We demonstrate e-biopsy in vivo, using the 4T1 breast cancer model in mice to assess its performance, as well as the inferred spatial differential protein expression. In particular, we show that proteomic profiles obtained via e-biopsy in vivo distinguish the tumors from healthy breast tissue and reflect spatial tumor differential protein expression. E-biopsy provides a completely new molecular sampling modality for solid tumors molecular cartography, providing information that potentially enables more rapid and sensitive detection at lesser risk, as well as more precise personalized medicine.

The Effect of Discharge Mode on the Distribution of Myocardial Pulsed Electric Field—A Simulation Study for Pulsed Field Ablation of Atrial Fibrillation

Background: At present, the effects of discharge modes of multielectrode catheters on the distribution of pulsed electric fields have not been completely clarified. Therefore, the control of the distribution of the pulsed electric field by selecting the discharge mode remains one of the key technical problems to be solved. Methods: We constructed a model including myocardium, blood, and a flower catheter. Subsequently, by setting different positive and ground electrodes, we simulated the electric field distribution in the myocardium of four discharge modes (A, B, C, and D) before and after the catheter rotation and analyzed their mechanisms. Results: Modes B, C, and D formed a continuous circumferential ablation lesion without the rotation of the catheter, with depths of 1.6 mm, 2.7 mm, and 0.7 mm, respectively. After the catheter rotation, the four modes could form a continuous circumferential ablation lesion with widths of 10.8 mm, 10.6 mm, 11.8 mm, and 11.5 mm, respectively, and depths of 5.2 mm, 2.7 mm, 4.7 mm, and 4.0 mm, respectively. Conclusions: The discharge mode directly affects the electric field distribution in the myocardium. Our results can help improve PFA procedures and provide enlightenment for the design of the discharge mode with multielectrode catheters.

Electroporation-Based Therapy for Brain Tumors: A Review

Electroporation-based therapy (EBT), as a high-voltage-pulse technology has been prevalent with favorable clinical outcomes in the treatment of various solid tumors. This review paper aims to promote the clinical translation of EBT for brain tumors. First, we briefly introduced the mechanism of pore formation in a cell membrane activated by external electric fields using a single cell model. Then, we summarized and discussed the current in vitro and in vivo preclinical studies, in terms of (1) the safety and effectiveness of EBT for brain tumors in animal models, and (2) the blood-brain barrier (BBB) disruption induced by EBT. Two therapeutic effects could be achieved in EBT for brain tumors simultaneously, i.e., the tumor ablation induced by irreversible electroporation (IRE) and transient BBB disruption induced by reversible electroporation (RE). The BBB disruption could potentially improve the uptake of antitumor drugs thereby enhancing brain tumor treatment. The challenges that hinder the application of EBT in the treatment of human brain tumors are discussed in the review paper as well.

Modeling methods for treatment planning in overlapping electroporation treatments

OBJECTIVE

Irreversible electroporation (IRE) is a non thermal tissue ablation therapy which is induced by applying high voltage waveforms across electrode pairs. When multiple electrode pairs are sequentially used, the treatment volume (TV) is typically computed as the geometric union of the TVs of individual pairs. However, this method neglects that some regions are exposed to overlapping treatments. Recently, a model describing cell survival probability was introduced which effectively predicted TV with overlapping fields in vivo. However, treatment overlap has yet to be quantified. This study characterizes TV overlap in a controlled in vitro setup with the two existing methods which are compared to an adapted logistic model proposed here.

METHODS

CHO cells were immobilized in agarose gel. Initially, we characterized the electric field threshold and the cell survival probability for overlapping treatments. Subsequently, we created a 2D setup where we compared and validated the accuracy of the different methods in predicting the TV.

RESULTS

Overlap can reduce the electric field threshold required to induce cell death, particularly for treatments with low pulse number. However, it does not have a major impact on TV in the models assayed here, and all the studied methods predict TV with similar accuracy.

CONCLUSION

Treatment overlap has a minor influence in the TV for typical protocols found in IRE therapies.

SIGNIFICANCE

This study provides evidence that the modeling method used in most pre-clinical and clinical studies seems adequate.

Ablation Zone Involution of Liver Tumors Is Faster in Patients Treated with Irreversible Electroporation Than Microwave Ablation

Background and Objectives: To compare ablation zone involution following microwave ablation (MWA) or irreversible electroporation (IRE) of liver tumors. Materials and Methods: MWA or IRE performed for colorectal cancer liver metastasis (CRLM) or hepatocellular carcinoma (HCC) during January 2011 to December 2015 were analyzed. Patients with a tumoral response on 1-year follow-up computed tomography (CT) were included. Generalized estimating equations were used to evaluate the differences between the two modalities on ablation zone involution observed on CT at 6 (M6) and 12 months (M12), and on laboratory values (total bilirubin, alanine transaminase, aspartate transaminase, alkaline phosphatase, albumin, and platelets count). The likelihood ratio test was used to assess whether the association between ablation modalities and these outcomes differed over time. Results: Seventeen (17/44, 39%) women and 27 (27/44, 61%) men were included, with 25 HCC (25/44, 57%) and 19 CRLM (19/44, 43%) patients. IRE was used in 9 (9/19, 47%) CRLM and 5 (5/25, 20%) HCC patients, respectively. All other patients had MWA. Ablation zone size and involution between IRE and MWA differed significantly over time (interaction p < 0.01), with a mean of 241.04 vs. 771.08 mm2 (ratio 0.313; 95% CI, 0.165-0.592; p < 0.01) at M6 and 60.47 vs. 589.43 mm2 (ratio 0.103; 95% CI, 0.029-0.365; p < 0.01) at M12. Changes in liver enzymes did not differ significantly between IRE and MWA at both timepoints. Conclusions: Liver tumors treated with IRE underwent faster involution when compared to tumors treated with MWA, but liver enzymes levels were comparable.

Multi-Tissue Analysis on the Impact of Electroporation on Electrical and Thermal Properties

OBJECTIVE

Tissue electroporation is achieved by applying a series of electric pulses to destabilize cell membranes within the target tissue. The treatment volume is dictated by the electric field distribution, which depends on the pulse parameters and tissue type and can be readily predicted using numerical methods. These models require the relevant tissue properties to be known beforehand. This study aims to quantify electrical and thermal properties for three different tissue types relevant to current clinical electroporation.

METHODS

Pancreatic, brain, and liver tissue were harvested from pigs, then treated with IRE pulses in a parallel-plate configuration. Resulting current and temperature readings were used to calculate the conductivity and its temperature dependence for each tissue type. Finally, a computational model was constructed to examine the impact of differences between tissue types.

RESULTS

Baseline conductivity values (mean 0.11, 0.14, and 0.12 S/m) and temperature coefficients of conductivity (mean 2.0, 2.3, and 1.2 % per degree Celsius) were calculated for pancreas, brain, and liver, respectively. The accompanying computational models suggest field distribution and thermal damage volumes are dependent on tissue type.

CONCLUSION

The three tissue types show similar electrical and thermal responses to IRE, though brain tissue exhibits the greatest differences. The results also show that tissue type plays a role in the expected ablation and thermal damage volumes.

SIGNIFICANCE

The conductivity and its changes due to heating are expected to have a marked impact on the ablation volume. Incorporating these tissue properties aids in the prediction and optimization of electroporation-based therapies.

A Prospective Phase II Study Evaluating Intraoperative Electrochemotherapy of Hepatocellular Carcinoma

The aim of this clinical study was to investigate the effectiveness and long-term safety of electrochemotherapy as an emerging treatment for HCC in patients not suitable for other treatment options. A prospective phase II clinical study was conducted in patients with primary HCC who were not suitable for other treatment options according to the Barcelona Clinic Liver Cancer classification. A total of 24 patients with 32 tumors were treated by electrochemotherapy. The procedure was effective, feasible, and safe with some procedure-related side effects. The responses of the 32 treated nodules were: 84.4% complete response (CR), 12.5% partial response (PR), and 3.1% stable disease (SD). The treatment was equally effective for nodules located centrally and peripherally. Electrochemotherapy provided a durable response with local tumor control over 50 months of observation in 78.0% of nodules. The patient responses were: 79.2% CR and 16.6% PR. The median progression-free survival was 12 months (range 2.7-50), and the overall survival over 5 years of observation was 72.0%. This prospective phase II clinical study showed that electrochemotherapy was an effective, feasible, and safe option for treating HCC in patients not suitable for other treatment options.

EView: An electric field visualization web platform for electroporation-based therapies

BACKGROUND AND OBJECTIVES

Electroporation is the phenomenon by which cell membrane permeability to ions and macromolecules is increased when the cell is briefly exposed to high electric fields. In electroporation-based treatments, such exposure is typically performed by delivering high voltage pulses across needle electrodes in tissue. For a given tissue and pulsing protocol, an electric field magnitude threshold exists that must be overreached for treatment efficacy. However, it is hard to preoperatively infer the treatment volume because the electric field distribution intricately depends on the electrodes' positioning and length, the applied voltage, and the electric conductivity of the treated tissues. For illustrating such dependencies, we have created EView (https://eview.upf.edu), a web platform that estimates the electric field distribution for arbitrary needle electrode locations and orientations and overlays it on 3D medical images.

METHODS

A client-server approach has been implemented to let the user set the electrode configuration easily on the web browser, whereas the simulation is computed on a dedicated server. By means of the finite element method, the electric field is solved in a 3D volume. For the sake of simplicity, only a homogeneous tissue is modeled, assuming the same properties for healthy and pathologic tissues. The non-linear dependence of tissue conductivity on the electric field due to the electroporation effect is modeled. The implemented model has been validated against a state of the art finite element solver, and the server has undergone a heavy load test to ensure reliability and to report execution times.

RESULTS

The electric field is rapidly computed for any electrode and tissue configuration, and alternative setups can be easily compared. The platform provides the same results as the state of the art finite element solver (Dice = 98.3 ± 0.4%). During the high load test, the server remained responsive. Simulations are computed in less than 2 min for simple cases consisting of two electrodes and take up to 40 min for complex scenarios consisting of 6 electrodes.

CONCLUSIONS

With this free platform we provide expert and non-expert electroporation users a way to rapidly model the electric field distribution for arbitrary electrode configurations.

HyCHEED System for Maintaining Stable Temperature Control during Preclinical Irreversible Electroporation Experiments at Clinically Relevant Temperature and Pulse Settings

Electric permeabilization of cell membranes is the main mechanism of irreversible electroporation (IRE), an ablation technique for treatment of unresectable cancers, but the pulses also induce a significant temperature increase in the treated volume. To investigate the therapeutically thermal contribution, a preclinical setup is required to apply IRE at desired temperatures while maintaining stable temperatures. This study’s aim was to develop and test an electroporation device capable of maintaining a pre-specified stable and spatially homogeneous temperatures and electric field in a tumor cell suspension for several clinical-IRE-settings. A hydraulically controllable heat exchange electroporation device (HyCHEED) was developed and validated at 37 °C and 46 °C. Through plate electrodes, HyCHEED achieved both a homogeneous electric field and homogenous-stable temperatures; IRE heat was removed through hydraulic cooling. IRE was applied to 300 μL of pancreatic carcinoma cell suspension (Mia PaCa-2), after which cell viability and specific conductivity were determined. HyCHEED maintained stable temperatures within ±1.5 °C with respect to the target temperature for multiple IRE-settings at the selected temperature levels. An increase of cell death and specific conductivity, including post-treatment, was found to depend on electric-field strength and temperature. HyCHEED is capable of maintaining stable temperatures during IRE-experiments. This provides an excellent basis to assess the contribution of thermal effects to IRE and other bio-electromagnetic techniques.

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.

Intraoperative electrochemotherapy of colorectal liver metastases: A prospective phase II study

BACKGROUND AND OBJECTIVES

A previous pilot study proved the feasibility, safety and efficacy of electrochemotherapy in the treatment of colorectal liver metastases. The aim of this study was to evaluate long-term effectiveness and safety of electrochemotherapy in the treatment of unresectable colorectal liver metastases.

PATIENTS AND METHODS

In this prospective phase II study, patients with metachronous colorectal liver metastases were included. In all patients, at least one metastasis was unresectable due to its central location or a too-small future remnant liver volume. Patients were treated by electrochemotherapy using intravenously administered bleomycin during open surgery. Treated were 84 metastases in 39 patients. Local tumor control, progression-free survival and overall survival were evaluated.

RESULTS

The objective response was 75% (63% CR, 12% PR). The median duration of the response was 20.8 months for metastases in CR and 9.8 months for metastases in PR. The therapy was significantly more effective for metastases smaller than 3 cm in diameter than for larger ones. There was no difference in response according to the metastatic location, i.e., metastases in central vs. peripheral locations. Progression-free survival was better in patients who responded well to electrochemotherapy compared to those metastases that had a partial response or progressive disease. However, there was no difference in overall survival, with a median of 29.0 months.

CONCLUSIONS

Electrochemotherapy has proven to be safe and effective in the treatment of colorectal liver metastases, with a durable response. It provides local tumor control that enables patients with unresectable metastases to receive further treatments.

Molecular harvesting with electroporation for tissue profiling

Recent developments in personalized medicine are based on molecular measurement steps that guide personally adjusted medical decisions. A central approach to molecular profiling consists of measuring DNA, RNA, and/or proteins in tissue samples, most notably in and around tumors. This measurement yields molecular biomarkers that are potentially predictive of response and of tumor type. Current methods in cancer therapy mostly use tissue biopsy as the starting point of molecular profiling. Tissue biopsies involve a physical resection of a small tissue sample, leading to localized tissue injury, bleeding, inflammation and stress, as well as to an increased risk of metastasis. Here we developed a technology for harvesting biomolecules from tissues using electroporation. We show that tissue electroporation, achieved using a combination of high-voltage short pulses, 50 pulses 500 V cm-1, 30 µs, 1 Hz, with low-voltage long pulses 50 pulses 50 V cm-1, 10 ms, delivered at 1 Hz, allows for tissue-specific extraction of RNA and proteins. We specifically tested RNA and protein extraction from excised kidney and liver samples and from excised HepG2 tumors in mice. Further in vivo development of extraction methods based on electroporation can drive novel approaches to the molecular profiling of tumors and of tumor environment and to related diagnosis practices.

Computer simulation of commercial conductive gels and their application to increase the safety of electrochemotherapy treatment

Electrochemotherapy (ECT) exploits the phenomenon of electroporation, which is the increase of cell permeability through the application of an electrical field. This technique is applied in medical centers in Europe and in veterinary clinics in Europe, Brazil, and Argentina. ECT treatment requires a minimum electric field and anti-cancer drugs (e.g., bleomycin). Irregularly shaped tumors may induce ECT treatment failure because of irregular electric field distribution. Conductive gels have been suggested as a means to increase the homogeneity of the electrical field distribution. The aim of this work was to evaluate if commercial conductive gels could increase the safety of ECT. A veterinary case study of ECT in a dog provided the tumor dimensions for the numerical model. Electrode displacement and commercial conductive gels were simulated to determine if they improved ECT treatments. We conclude that a commercial gel having a conductivity of 0.2 S/m when used in combination with effective treatment planning may improve the outcome of electrochemotherapy procedures.

Percutaneous image-guided ablation: From techniques to treatments

Image-guided ablation is performed by percutaneously introducing ablation probes to deliver energy into a tumor to destroy it in a controlled and localized fashion. Ablation modalities can be broadly classified as thermal or non-thermal based on the mechanism of tumor destruction and are performed using different types of image guidance for planning, delivering and follow-up of the treatment. Ablation is performed in a minimally invasive fashion, providing greater residual organ preservation with minimal morbidity to the patient. Image-guided ablation is being used in the clinic for the treatment of primary and metastatic tumors, and this article reviews state of the art for the treatment of malignancies in the liver, lung, kidney and musculoskeletal tissue.

High-frequency irreversible electroporation is an effective tumor ablation strategy that induces immunologic cell death and promotes systemic anti-tumor immunity

Background

Despite promising treatments for breast cancer, mortality rates remain high and treatments for metastatic disease are limited. High-frequency irreversible electroporation (H-FIRE) is a novel tumor ablation technique that utilizes high-frequency bipolar electric pulses to destabilize cancer cell membranes and induce cell death. However, there is currently a paucity of data pertaining to immune system activation following H-FIRE and other electroporation based tumor ablation techniques.

Methods

Here, we utilized the mouse 4T1 mammary tumor model to evaluate H-FIRE treatment parameters on cancer progression and immune system activation in vitro and in vivo.

Findings

H-FIRE effectively ablates the primary tumor and induces a pro-inflammatory shift in the tumor microenvironment. We further show that local treatment with H-FIRE significantly reduces 4T1 metastases. H-FIRE kills 4T1 cells through non-thermal mechanisms associated with necrosis and pyroptosis resulting in damage associated molecular pattern signaling in vitro and in vivo. Our data indicate that the level of tumor ablation correlates with increased activation of cellular immunity. Likewise, we show that the decrease in metastatic lesions is dependent on the intact immune system and H-FIRE generates 4T1 neoantigens that engage the adaptive immune system to significantly attenuate tumor progression.

Interpretation

Cell death and tumor ablation following H-FIRE treatment activates the local innate immune system, which shifts the tumor microenvironment from an anti-inflammatory state to a pro-inflammatory state. The non-thermal damage to the cancer cells and increased innate immune system stimulation improves antigen presentation, resulting in the engagement of the adaptive immune system and improved systemic anti-tumor immunity.

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.

Numerical workflow of irreversible electroporation for deep-seated tumor

The paper provides a numerical workflow, based on the 'real-life' clinical workflow of irreversible electroporation (IRE) performed for the treatment of deep-seated liver tumors. Thanks to a combination of numerical modeling, image registration algorithm and clinical data, our numerical workflow enables to provide the distribution of the electric field as effectively delivered by the clinical IRE procedure. As a proof of concept, we show on a specific clinical case of IRE ablation of liver tumor that clinical data could be advantageously combined to numerical simulations in a near future, in order to give to the interventional radiologists information on the effective IRE ablation. We also corroborate the simulated treated region with the post-treatment MRI performed 3 d after the treatment.

Electroporation of the Liver: More Than 2 Concurrently Active, Curved Electrodes Allow New Concepts for Irreversible Electroporation and Electrochemotherapy

Irreversible electroporation and electrochemotherapy are 2 innovative electroporation-based minimally invasive therapies for the treatment of cancer. Combining nonthermal effects of irreversible electroporation with local application of chemotherapy, electrochemotherapy is an established treatment modality for skin malignancies. Since the application of electrochemotherapy in solid organs is a promising approach, this article describes a novel electrode configuration and field generating method. For the treatment of hepatic malignancies, the shape of the electric field should resemble a spherical 3-dimensional geometry around the target tissue inside the liver. To adapt the actual shape of the field, the probe is designed in computer-aided design with a live link to a computer simulation software: Changes in design can be revalued quickly, regarding different quality criteria for field strength inside and outside the tumor. To rate these criteria, a set of formulas with weighting coefficients has been included. As a result of this design process, a needle-shaped prototype applicator has been built, designed for an intracorporal electroporation-based treatment. It can be used as percutaneous, image-guided, minimally invasive treatment option for malignant liver tumors. The shaft of the probe is used as central electrode and fitted with additional 4 expandable electrodes. These satellite electrodes are hollow, thus serving as injectors for chemotherapeutic agents within the area of the electric field. This configuration can be used for electrochemotherapy as well as irreversible electroporation. By placing 5 electrodes with just one needle, the procedure duration as well as the radiation dose can be reduced tremendously. Additionally, the probe offers an option to adapt the field geometry to the tumor geometry by connecting the 5 electrodes to 5 individually chosen electric potentials: By fine-tuning the ablation zone via the potentials instead of adjusting the location of the electrode(s), the procedure duration as well as the radiation dose will decrease further.

Computational Feasibility Analysis of Electrochemotherapy With Novel Needle-Electrode Arrays for the Treatment of Invasive Breast Ductal Carcinoma

Breast cancer represents a rising problem concerning public health worldwide. Current efforts are aimed to the development of new minimally invasive and conservative treatment procedures for this disease. A treatment approach for invasive breast ductal carcinoma could be based on electroporation. Hence, in order to determine the effectiveness of electrochemotherapy in the treatment of this disease, 12 electrode models were investigated on realistic patient-specific computational breast models of 3 patients diagnosed by Digital Breast Tomosynthesis imaging. The electrode models exhibit 4, 5, and 6 needles arranged in 4 geometric configurations (delta, diamond, and star) and 3 different needle spacing resulting in a total of 12 needle-electrode arrays. Electric field distribution in the tumors and a surrounding safety margin of 1 cm around the tumor edge is computed using the finite element method. Efficiency of the electrode arrays was determined hierarchically based on (1) percentage of tumor volume reversibly electroporated, (2) percentage of tumor volume irreversibly electroporated, (3) percentage of treated safety margin volume, (4) minimal invasiveness, that is, minimal number of electrodes used, (5) minimal activated electrode pairs, and (6) minimal electric current. Results show that 3 electrode arrays (4 needle-delta, 5 needle-diamond, and 6 needle-star) with fixed-geometry configuration could be used in the treatment with electrochemotherapy of invasive breast ductal carcinomas ranging from 1 to 5 cm³ along with a surrounding safety margin of 1 cm.

Navigation Systems for Treatment Planning and Execution of Percutaneous Irreversible Electroporation

The application of navigational systems has the potential to improve percutaneous interventions. The accuracy of ablation probe placement can be increased and radiation doses reduced. Two different types of systems can be distinguished, tracking systems and robotic systems. This review gives an overview of navigation devices for clinical application and summarizes first findings in the implementation of navigation in percutaneous interventions using irreversible electroporation. Because of the high number of navigation systems, this review focuses on commercially available ones.

Time-Dependent Finite Element Analysis of In Vivo Electrochemotherapy Treatment

Electrochemotherapy and irreversible electroporation are gaining importance in clinical practice for the treatment of solid tumors. For successful treatment, it is extremely important that the coverage and exposure time of the treated tumor to the electric field are within the specified range. In order to ensure successful coverage of the entire target volume with sufficiently strong electric fields, numerical treatment planning has been proposed and its use has also been demonstrated in practice. Most of numerical models in treatment planning are based on charge conservation equation and are not able to provide time course of electric current, electrical conductivity, or electric field distribution changes established in the tissue during pulse delivery. Recently, a model based on inverse analysis of experimental data that delivers time course of tissue electroporation has been introduced. The aim of this study was to apply the previously reported time-dependent numerical model to a complex in vivo example of electroporation with different tissue types and with a long-term follow-up. The model, consisting of a tumor placed in the liver with 2 needle electrodes inserted in the center of the tumor and 4 around the tumor, was validated by comparison of measured and calculated time course of applied electric current. Results of simulations clearly indicated that proposed numerical model can successfully capture transient effects, such as evolution of electric current during each pulse, and effects of pulse frequency due to electroporation effects in the tissue. Additionally, the model can provide evolution of electric field amplitude and electrical conductivity in the tumor with consecutive pulse sequences.

Electrochemotherapy - Emerging applications technical advances, new indications, combined approaches, and multi-institutional collaboration

The treatment of tumors with electrochemotherapy (ECT) has surged over the past decade. Thanks to the transient cell membrane permeabilization induced by the short electric pulses used by ECT, cancer cells are exposed to otherwise poorly permeant chemotherapy agents, with consequent increased cytotoxicity. The codification of the procedure in 2006 led to a broad diffusion of the procedure, mainly in Europe, and since then, the progressive clinical experience, together with the emerging technologies, have extended the range of its application. Herein, we review the key advances in the ECT field since the European Standard Operating Procedures on ECT (ESOPE) 2006 guidelines and discuss the emerging clinical data on the new ECT indications. First, technical developments have improved ECT equipment, with custom electrode probes and dedicated tools supporting individual treatment planning in anatomically challenging tumors. Second, the feasibility and short-term efficacy of ECT has been established in deep-seated tumors, including bone metastases, liver malignancies, and pancreatic and prostate cancers (long-needle variable electrode geometry ECT), and gastrointestinal tumors (endoscopic ECT). Moreover, pioneering studies indicate lung and brain tumors as suitable future targets. A further advance relates to new combination strategies with immunotherapy, gene electro transfer (GET), calcium EP, and radiotherapy. Finally and fourth, cross-institutional collaborative groups have been established to refine procedural guidelines, promote clinical research, and explore new indications.

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.

Numerical study of gene electrotransfer efficiency based on electroporation volume and electrophoretic movement of plasmid DNA

Background

The efficiency of gene electrotransfer, an electroporation-based method for delivery of pDNA into target tissues, depends on several processes. The method relies on application of electric pulses with appropriate amplitude and pulse duration. A careful choice of electric pulse parameters is required to obtain the appropriate electric field distribution, which not only controls the electroporated volume, but also affects the movement of pDNA. We used numerical modeling to assess the influence of different types of electrodes and pulse parameters on reversibly electroporated volume and on the extent of pDNA–membrane interaction, which is necessary for successful gene electrotransfer.

Methods

A 3D geometry was built representing the mice skin tissue and intradermally injected plasmid volume. The geometry of three different types of electrodes (plate, finger, needle) was built according to the configuration and placement of electrodes used in previously reported in vivo experiments of gene electrotransfer. Electric field distribution, resulting from different pulse protocols was determined, which served for calculation of reversible electroporation volume and for simulation of electrophoretic movement of pDNA. The efficiency of gene electrotransfer was evaluated in terms of predicted amount of pDNA present inside the volume of reversible electroporation at the end of pulse delivery.

Results

According to results of our numerical study, finger and needle electrodes provide larger amount of pDNA inside the volume of reversible electroporation than plate electrodes. However, these results are not consistent with the experiments showing that plate electrodes achieve the best transfection efficiency. Some inconsistencies were observed also by comparing the efficiencies of different high and low voltage pulse combinations, delivered by plate electrodes. The reason for inconsistencies probably lies in insufficient knowledge regarding the electroporation of stratum corneum. Namely, the size of the regions with high electrical conductivity, created by electroporation, was found to strongly affect predicted transfection efficiency.

Conclusions

The presented numerical model simulates the two most important processes involved in gene electrotransfer: electroporation of cells, and electrophoretic movement of pDNA. The inconsistencies between the model and experiments indicate incomplete knowledge of skin electroporation, or the involvement of other mechanisms, whose importance has not been yet identified.

Reduction of Muscle Contractions during Irreversible Electroporation Therapy Using High-Frequency Bursts of Alternating Polarity Pulses: A Laboratory Investigation in an Ex Vivo Swine Model

PURPOSE

To compare the intensity of muscle contractions in irreversible electroporation (IRE) treatments when traditional IRE and high-frequency IRE (H-FIRE) waveforms are used in combination with a single applicator and distal grounding pad (A+GP) configuration.

MATERIALS AND METHODS

An ex vivo in situ porcine model was used to compare muscle contractions induced by traditional monopolar IRE waveforms vs high-frequency bipolar IRE waveforms. Pulses with voltages between 200 and 5,000 V were investigated, and muscle contractions were recorded by using accelerometers placed on or near the applicators.

RESULTS

H-FIRE waveforms reduced the intensity of muscle contractions in comparison with traditional monopolar IRE pulses. A high-energy burst of 2-μs alternating-polarity pulses energized for 200 μs at 4,500 V produced less intense muscle contractions than traditional IRE pulses, which were 25-100 μs in duration at 3,000 V.

CONCLUSIONS

H-FIRE appears to be an effective technique to mitigate the muscle contractions associated with traditional IRE pulses. This may enable the use of voltages greater than 3,000 V necessary for the creation of large ablations in vivo.

Electrochemotherapy as treatment option for hepatocellular carcinoma, a prospective pilot study

BACKGROUND AND OBJECTIVES

Electrochemotherapy provides non-thermal ablation of cutaneous as well as deep seated tumors. Based on positive results of the treatment of colorectal liver metastases, we conducted a prospective pilot study on hepatocellular carcinomas with the aim of testing the feasibility, safety and effectiveness of electrochemotherapy.

PATIENTS AND METHODS

Electrochemotherapy with bleomycin was performed on 17 hepatocellular carcinomas in 10 patients using a previously established protocol. The procedure was performed during open surgery and the patients were followed for median 20.5 months.

RESULTS

Electrochemotherapy was feasible for all 17 lesions, and no treatment-related adverse events or major post-operative complications were observed. The median size of the treated lesions was 24 mm (range 8-41 mm), located either centrally, i.e., near the major hepatic vessels, or peripherally. The complete response rate at 3-6 months was 80% per patient and 88% per treated lesion.

CONCLUSIONS

Electrochemotherapy of hepatocellular carcinoma proved to be a feasible and safe treatment in all 10 patients included in this study. To evaluate the effectiveness of this method, longer observation period is needed; however the results at medium observation time of 20.5 months after treatment are encouraging, in 15 out of 17 lesions complete response was obtained. Electrochemotherapy is predominantly applicable in patients with impaired liver function due to liver cirrhosis and/or with lesions where a high-risk operation is needed to achieve curative intent, given the intra/perioperative risk for high morbidity and mortality.

Avoiding neuromuscular stimulation in liver irreversible electroporation using radiofrequency electric fields

Electroporation-based treatments typically consist of the application of high-voltage dc pulses. As an undesired side effect, these dc pulses cause electrical stimulation of excitable tissues such as motor nerves. The present in vivo study explores the use of bursts of sinusoidal voltage in a frequency range from 50 kHz to 2 MHz, to induce irreversible electroporation (IRE) whilst avoiding neuromuscular stimulation. A series of 100 dc pulses or sinusoidal bursts, both with an individual duration of 100 µs, were delivered to rabbit liver through thin needles in a monopolar electrode configuration, and thoracic movements were recorded with an accelerometer. Tissue samples were harvested three hours after treatment and later post-processed to determine the dimensions of the IRE lesions. Thermal damage due to Joule heating was ruled out via computer simulations. Sinusoidal bursts with a frequency equal to or above 100 kHz did not cause thoracic movements and induced lesions equivalent to those obtained with conventional dc pulses when the applied voltage amplitude was sufficiently high. IRE efficacy dropped with increasing frequency. For 100 kHz bursts, it was estimated that the electric field threshold for IRE is about 1.4 kV cm^-1 whereas that of dc pulses is about 0.5 kV cm^-1.

Electrochemotherapy as a New Modality in Interventional Oncology: A Review

Electroporation is a well-known phenomenon that occurs at the cell membrane when cells are exposed to high-intensity electric pulses. Depending on electric pulse amplitude and number of pulses, applied electroporation can be reversible with membrane permeability recovery or irreversible. Reversible electroporation is used to introduce drugs or genetic material into the cell without affecting cell viability. Electrochemotherapy refers to a combined treatment: electroporation and drug injection to enhance its cytotoxic effect up to 1000-fold for bleomycin. Since several years, electrochemotherapy is gaining popularity as minimally invasive oncologic treatment. The adoption of electrochemotherapy procedure in interventional oncology poses several unsolved questions, since suitable tumor histology and size as well as therapeutic efficacy still needs to be deepen. Electrochemotherapy is usually applied in palliative settings for the treatment of patients with unresectable tumors to relieve pain and ameliorate quality of life. In most cases, it is used in the treatment of advanced stages of neoplasia when radical surgical treatment is not possible (eg, due to lesion location, size, and/or number). Further, electrochemotherapy allows treating tumor nodules in the proximity of important structures like vessels and nerves as the treatment does not involve tissue heating. Overall, the safety profile of electrochemotherapy is favorable. Most of the observed adverse events are local and transient, moderate local pain, erythema, edema, and muscle contractions during electroporation. The aim of this article is to review the recent published clinical experiences of electrochemotherapy use in deep-seated tumors with particular focus on liver cases. The principle of electrochemotherapy as well as the application to cutaneous metastases is briefly described. A short insight in the treatment of bone metastases, unresectable pancreas cancer, and soft tissue sarcoma will be given. Preclinical and clinical studies on treatment efficacy with electrochemotherapy of hepatic lesions and safety of the procedure adopted are discussed.

Avoiding nerve stimulation in irreversible electroporation: a numerical modeling study

Electroporation based treatments consist in applying one or multiple high voltage pulses to the tissues to be treated. As an undesired side effect, these pulses cause electrical stimulation of excitable tissues such as nerves and muscles. This increases the complexity of the treatments and may pose a risk to the patient. To minimize electrical stimulation during electroporation based treatments, it has been proposed to replace the commonly used monopolar pulses by bursts of short bipolar pulses. In the present study, we have numerically analyzed the rationale for such approach. We have compared different pulsing protocols in terms of their electroporation efficacy and their capability of triggering action potentials in nerves. For that, we have developed a modeling framework that combines numerical models of nerve fibers and experimental data on irreversible electroporation. Our results indicate that, by replacing the conventional relatively long monopolar pulses by bursts of short bipolar pulses, it is possible to ablate a large tissue region without triggering action potentials in a nearby nerve. Our models indicate that this is possible because, as the pulse length of these bipolar pulses is reduced, the stimulation thresholds raise faster than the irreversible electroporation thresholds. We propose that this different dependence on the pulse length is due to the fact that transmembrane charging for nerve fibers is much slower than that of cells treated by electroporation because of their geometrical differences.

Predicting irreversible electroporation-induced tissue damage by means of magnetic resonance electrical impedance tomography

Irreversible electroporation (IRE) is gaining importance in routine clinical practice for nonthermal ablation of solid tumors. For its success, it is extremely important that the coverage and exposure time of the treated tumor to the electric field is within the specified range. Measurement of electric field distribution during the electroporation treatment can be achieved using magnetic resonance electrical impedance tomography (MREIT). Here, we show improved MREIT-enabled electroporation monitoring of IRE-treated tumors by predicting IRE-ablated tumor areas during IRE of mouse tumors in vivo. The in situ prediction is enabled by coupling MREIT with a corresponding Peleg-Fermi mathematical model to obtain more informative monitoring of IRE tissue ablation by providing cell death probability in the IRE-treated tumors. This technique can potentially be used in electroporation-based clinical applications, such as IRE tissue ablation and electrochemotherapy, to improve and assure the desired treatment outcome.

Bipolar Microsecond Pulses and Insulated Needle Electrodes for Reducing Muscle Contractions During Irreversible Electroporation

OBJECTIVE

To minimize the effect of muscle contractions during irreversible electroporation (IRE), this paper attempts to research the ablation effect and muscle contractions by applying high-frequency IRE (H-FIRE) ablation to liver tissue in vivo.

METHODS

An insulated needle electrode was produced by painting an insulating coating on the outer surface of the needle electrode tip. A series of experiments were conducted using insulated needle electrodes and traditional needle electrodes to apply H-FIRE pulses and traditional monopolar IRE pulses to rabbit liver tissues. The finite element model of the rabbit liver tissue was established to determine the lethal thresholds of H-FIRE in liver tissues. Muscle contractions were measured by an accelerometer.

RESULTS

With increased constitutive pulse width and pulse voltage, the ablation area and muscle contraction strength are also increased, which can be used to optimize the ablation parameters of H-FIRE. Under the same pulse parameters, the ablation areas are similar for the two types of electrodes, and the ablation region has a clear boundary. H-FIRE and insulated needle electrodes can mitigate the extent of muscle contractions. The lethal thresholds of H-FIRE in rabbit liver tissues were determined.

CONCLUSION

This paper describes the relationships between the ablation area, muscle contractions, and pulse parameters; the designed insulated needle electrodes can be used in IRE for reducing muscle contraction.

SIGNIFICANCE

The study provides guidance for treatment planning and reducing muscle contractions in the clinical application of H-FIRE.