Minimally invasive treatment of peristomal metastases from gastric cancer at an ileostomy site by electrochemotherapy

Management of Parastomal Recurrence Following Total Laryngectomy

Parastomal recurrence occurs in around 5% of patients undergoing total laryngectomy for laryngeal squamous cell carcinoma. It carries a poor prognosis which has changed little over the last 50 years, and poses a significant challenge to the head and neck surgeon. At present, surgical excision offers the only realistic chance of cure, although patients must be selected carefully following thorough work-up and in-depth multidisciplinary team discussion. This article provides a review of the literature on the management of parastomal recurrence following total laryngectomy.

A systematic review of primary ileostomy site malignancies

BACKGROUND

This paper aimed to elucidate the etiologies of all primary ileostomy site malignancies published in the literature.

METHODS

A review of the literature was conducted following PRISMA guidelines by querying PubMed, Global Health, and Web of Science for articles published before November 2020. Search criteria contained broad terminology for ileostomy site neoplasms without language, date, or publication limitations. A full-text review of the abstracts confirmed primary malignant pathologies and was evaluated for study inclusion.

RESULTS

Literature search discovered 858 publications, with 76 meeting eligibility criteria. The final sample contained 91 patients, with equal males and females. The mean age of patients with ileostomy site malignancy was 62.0 ± 12.2, with an average ileostomy age of 29.4 ± 12.4. The most common indications for ileostomy creation were inflammatory bowel disease (IBD) (73.6%) and familial adenomatous polyposis (FAP) (20.9%). There was a total of eight ileostomy malignant pathologies reported, with adenocarcinoma being the most common (76.9%), followed by squamous cell carcinoma (SCC) (11.0%). Adenocarcinoma was diagnosed at a younger age than SCC (59.7 vs. 72.3) and developed over a shorter time (28.8 vs. 37.0). Patients with FAP almost exclusively developed adenocarcinoma (94.4%) at a younger stoma age (25.8 vs. 31.4) than those with IBD who developed seven diverse pathologies. With a median follow-up of 0.75 years, four patients developed disease recurrence and received oncologic resection of their cancer less often than the 55 negative patients (p = 0.04).

CONCLUSION

Ileostomy site malignancies are late-appearing complications that require curative surgery. Their presentation is associated with ileostomy duration and creation indication, such as FAP or IBD. We recommend screening at a stoma age ≥ 20 or patient age ≥ 50 for patients with FAP, while stoma age ≥ 25 or patient age ≥ 60 for IBD patients.

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 - 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.

A prototype of a flexible grid electrode to treat widespread superficial tumors by means of Electrochemotherapy

Background

In recent years, superficial chest wall recurrence from breast cancer can be effectively treated by means of electrochemotherapy, with the majority of patients achieving response to treatment. Nevertheless, tumor spread along superficial lymphatic vessels makes this peculiar type of tumor recurrence prone to involve large skin areas and difficult to treat. In these cases, electroporation with standard, small size needle electrodes can be time-consuming and produce an inhomogeneous coverage of the target area, ultimately resulting in patient under treatment.

Materials and methods

Authors designed and developed a prototype of a flexible grid electrode aimed at the treatment of large skin surfaces and manufactured a connection box to link the pulse applicator to a voltage pulse generator. Laboratory tests on potato tissue were performed in order to evaluate the electroporation effect, which was evaluated by observing color change of treated tissue.

Results

A device has been designed in order to treat chest wall recurrences from breast cancer. According to preliminary tests, the new flexible support of the electrode allows the adaptability to the surface to be treated. Moreover, the designed devices can be useful to treat a larger surface in 2–5 minutes.

Conclusions

Authors developed the prototype of a new pulse applicator aimed at the treatment of widespread superficial tumors. This flexible grid needle electrode was successfully tested on potato tissue and produced an electroporation effect. From a clinical point of view, the development of this device may shorten electrochemotherapy procedure thus allowing clinicians to administer electric pulses at the time of maximum tumor exposure to drugs. Moreover, since the treatment time is 2–5 min long, it could also reduce the time of anesthesia, thus improving patient recovery.

Doxorubicin delivery enhanced by electroporation to gastrointestinal adenocarcinoma cells with P-gp overexpression

Electroporation (EP) can effectively support the penetration of macromolecules from the extracellular space into cells. Electropores induced by the influence of electromagnetic field generate additional paths of transport for macromolecules. The aim of this study was evaluation of the electroporation effect on doxorubicin transport efficiency to human colon (LoVo and LoVo/DX) and gastric (EPG85-257/P and EPG85-257/RDB) adenocarcinoma cells with overexpression of P-glycoprotein and murine macrophage cell line (P388/D1). In our EP experiments cells were placed into a cuvette with aluminum electrodes and pulsed with five square electric pulses of 1300 V/cm and duration of 50 μs each. Cells were also treated with low doxorubicin concentration ([DOX]=1.7 μM). The ultrastructure (TEM) and changes of P-glycoprotein expression of tumor cells subjected to electric field were monitored. The mitochondrial cell function and trypan blue staining were evaluated after 24h. Our results indicate the most pronounced effect of EP with DOX and disturbed ultrastructure in resistant gastric and colon cells with decrease of P-gp expression. Electroporation may be an attractive delivery method of cytostatic drugs in chemotherapy, enabling reduction of drug dose, exposure time and side effects.

The value of electrochemotherapy in the treatment of peristomal tumors

Electrochemotherapy (ECT) holds promise as a minimally invasive palliative tool for selected patients with peristomal tumors. We present the favorable short-term outcome of three patients (two with head and neck cancer, one with gastric cancer) successfully palliated by ECT. Treatment effectiveness and clinical benefit for patients with unresectable stoma recurrence need to be confirmed in future multicenter studies.