Electrosclerotherapy for capillary malformations: study protocol for a randomised within-patient controlled pilot trial

Current Operating Procedure (COP) for Bleomycin ElectroScleroTherapy (BEST) of low-flow vascular malformations

BACKGROUND

Bleomycin ElectroScleroTherapy (BEST) is a new approach in the treatment of vascular malformations. After bleomycin is administered to the malformation, electric pulses are applied to the target area to enhance the effectiveness of bleomycin. The mode of action is comparable to the effect of electrochemotherapy on tumour vasculature. For the wider and safer use of BEST in the clinical treatment of low-flow vascular malformations, this Current Operating Procedure (COP) is being prepared. It is a proposal for the clinical standardisation of BEST using the Cliniporator® as the electrical pulse generator with its associated electrodes. The electrical parameters considered in this protocol are those validated by the European Standard Operating Procedures for Electrochemotherapy (ESOPE) with the Cliniporator®.

CONCLUSIONS

General requirements are proposed, and, depending on the type of lesion, local skills and the availability of radiological equipment, two technical approaches of BEST are described based on ultrasound guided intervention or combined ultrasound and fluoroscopic guided intervention.

Bleomycin sclerotherapy for large diffuse microcystic lymphatic malformations

Background

Microcystic lymphatic malformations (LMs) are congenital lesions with the diameter of the majority of cysts <1 cm. Bleomycin sclerotherapy has been shown to yield beneficial results for macrocystic LMs. This study aims to evaluate the safety and efficacy of consecutive bleomycin sclerotherapy for large diffuse microcystic LMs.

Methods

The location and size of the lesions were detected by ultrasound for the 46 patients included in this study. Bleomycin lavage was performed in larger cysts and intradermal injection for the superficial lesion. The outcome and complications were assessed for its efficacy and safety.

Results

The large diffuse microcystic LMs mainly located in the neck, abdominal wall and axilla/lateral chest wall. The average lesion size was 10.6 cm × 7.2 cm. The mean number of treatment sessions was 4.5 with 7.3 mg bleomycin for per session averagely. Excellent (69.6%) and moderate (23.9%) responses were obtained. There was no recurrence for the 6 patients (13%) who received a long follow-up. Obvious local swelling, slight intralesional hemorrhage and low-grade fever were the most commonly occurred complications. No lung fibrosis was identified for the patients who received more than 6 sessions.

Conclusions

Local lavage combined with intradermal injection of bleomycin is effective and safe for large diffuse microcystic LMs with good therapeutic effect and low complication rates, and can be regarded as the mainstay of therapy for microcystic LMs.

New Treatment Option for Capillary Lymphangioma: Bleomycin-Based Electrochemotherapy of an Infant

The treatment of microcystic and combined lymphangiomas, especially in the head and neck region, is still a challenge because the lymphangiomas do not respond to conventional therapies and their recurrence rate is high, regardless of the treatment choice. Complete surgical resection is the main treatment of lymphangiomas, but because of localization perioperative complications, such as bleeding, neural damage and airway obstruction are common disadvantages of this method. Bleomycin-based sclerotherapy is another common therapeutic approach, in which the lymphocysts are aspirated, and 25% to 50% of their volumes are replaced with a sclerotisant drug. This is an effective treatment in cases in which the vessels are large enough for an intravascular or intracystic injection, but because of the small size of vessels and cysts, the microcystic and combined lymphangiomas are not suitable for sclerotherapy. Delivery of drugs for treating sclerosis to endothelial cells can be achieved by electroporation (electrochemotherapy), even for capillary malformations. A congenital, rapidly growing combined lymphangioma of the left cervicofacial region was treated with one session of bleomycin-based electrochemotherapy. Seven months after treatment, the growth-corrected target volume decrease was 63% and the dislocation of the trachea and blood vessels previously observed had ceased. We suggest that bleomycin-based electrochemotherapy is a feasible alternative treatment option for capillary malformations.

Bleomycin electrosclerotherapy in therapy-resistant venous malformations of the body

OBJECTIVE

Bleomycin is one of the most commonly used agents in sclerotherapy for slow-flow vascular malformations worldwide. However, its efficiency remains unknown. The objective of the present study was to assess whether reversible electroporation combined with bleomycin would increase the sclerotherapy effect in patients with previously unsuccessfully treated venous malformations (VMs).

METHODS

We performed, to the best of our knowledge, the first retrospective observational case series from January 2019 to January 2020 of 17 patients (20 lesions) with symptomatic VMs, who had previously undergone at least two unsuccessful invasive treatments. Reversible electroporation was performed with various electrodes and directly injected bleomycin. All patient records, magnetic resonance imaging data, documentation of previous treatments, and data regarding the intervention, complications, and clinical symptoms were analyzed.

RESULTS

The 17 VM patients (mean age, 20.8 ± 8.2 years; 9 females) had previously undergone an average of 4.2 invasive treatments. These patients had subsequently undergone 22 electrosclerotherapy sessions of 20 lesions. The median dose of bleomycin was 3 mg. The median magnetic resonance imaging-derived lesion volume before treatment was 24.9 cm³, which had decreased by 86% to 3.5 cm³ after treatment. After 3.7 months, eight patients were asymptomatic without residual symptoms and nine patients showed improvement.

CONCLUSIONS

Bleomycin electrosclerotherapy appears to be an effective therapy for patients with VMs resistive to previous invasive therapy. Because of the small sample size and short follow-up period, our results should be examined further using a larger patient population.

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.