Electrochemotherapy in radiotherapy-resistant epidural spinal cord compression in metastatic cancer patients

Electrochemotherapy in metastatic epidural spinal cord compression: a review and technical update

This review aims to analyse the safety and clinical efficacy in terms of pain relief and local tumour control, in patients with metastatic epidural spinal cord compression undergoing electrochemotherapy (ECT). Moreover, a recommendation detailing optimal electrodes insertion is proposed with the intent of improving treatment planning. Clinical studies published between 2015 and 2023 were included since this time window is consistent with recent developments in the field of ECT of spinal metastases. In the whole, 3 articles were included. Results showed that percutaneous image-guided ECT provides effective pain relief with limited procedure-related morbidity, along with local tumour control (complete response 28.5%, 38% partial response, 24% stable disease) at 3-month follow-up in the largest published series so far. In conclusion, ECT should integrate the armamentarium of therapies that are currently being proposed to patients with painful metastatic epidural disease.

Desmoid fibromatosis: interventional radiology (sometimes) to the rescue for an atypical disease

Desmoid fibromatosis (DF) is a rare locally aggressive soft tissue tumour that is characterized as benign as it cannot metastasize. It was managed until recently like sarcomas, that is, with radical surgical resection combined or not with radiotherapy. However, this approach was associated with a high rate of recurrence and significant morbidity. The management of this disease has progressively changed to a more conservative approach given the fact that DF may spontaneously stop to grow or even shrink in more than half of the cases. Should treatment be required, recent guidelines recommend choosing between systemic therapies, which include principally chemotherapy and tyrosine kinase inhibitors, and local treatments. And this is where the interventional radiologist may have an important role in treating the disease. Various ablation modalities have been reported in the literature to treat DF, notably high-intensity focused ultrasound and cryoablation. Results are promising and cryoablation is now mentioned in recent guidelines. The interventional radiologist should nevertheless apprehend the disease in its globality to understand the place of percutaneous treatments among the other therapeutic options. The goal of this review is therefore to present and discuss the role of interventional radiology in the management of DF.

Prospective multicentre study of patients with cutaneous metastases from breast cancer treated with electrochemotherapy

Electrochemotherapy (ECT) is a local treatment combining chemotherapy with electroporation. This prospective multicentre study aimed to evaluate the efficacy of ECT in the treatment of patients with skin metastases from breast cancer and confirm whether "luminal A-like" tumors are more responsive to treatment. One-hundred and ninety-five patients were included in the analysis. 55% achieved complete response, 27% partial response (objective response OR 82%); 12% stable disease and 5% experienced progressive disease. The analysis by tumor phenotype showed a significant better response rate in Luminal A-like (p = 0.0060) and Luminal B-like (p = 0.0271) groups compared to Triple-Negative. Patients were divided into 4 groups based on the number and size of cutaneous metastases. Higher response rate was observed in patients with small (≤ 3 cm), single or multiple, metastases (OR rate 95% and 90%, respectively); larger tumors (> 3 cm) showed an OR rate of 85%. Tumor response was not affected by the presence of distant metastases, whereas patients with large cutaneous lesions and distant metastases showed a OR rate of 58%. One-year local progression-free survival (LPFS) was 86% (C.I. 82-89%). In the multivariate analysis, patient age and response to ECT were significantly associated with longer LPFS. This study confirms the efficacy of ECT in small-volume cutaneous metastases from breast cancer regardless the presence of systemic disease and suggests higher efficacy in patients with luminal A- and luminal B-like tumors. ECT can be utilized not only as a palliative measure but also as an alternative treatment for patients not eligible for standard treatments, or in combination with them. Trial registered on https://clinicaltrials.gov/study/NCT06683404 (date of registration 11/11/2024) retrospectively registered.

In Vivo Safety and Feasibility of a CT-Guided Robotic Device for Percutaneous Needle Placement in Bone

PURPOSE

To evaluate the feasibility and accuracy of a robotic device used clinically in soft tissues (abdomen and lung), modified in design and workflow, to perform needle insertions in percutaneous skeletal procedures.

MATERIALS AND METHODS

The primary objective was safety (severe adverse events) of robotic-assisted insertion in this new application. Secondary objectives were feasibility (placement technical success), performance (rate of acceptable insertions), accuracy (lateral deviation), number of intermediate computed tomography (CT) scans, and tolerability (mild/moderate adverse events). Robotic-assisted insertions were performed by 6 interventional radiologists on 3 male pigs under general anesthesia. Needle trajectory was planned on the device software, and then needles were inserted with robotic guidance to reach the cortical bone. Intermediate CT was then performed to verify needle direction; if needed, the trajectory was modified, and robotic-assisted modified insertion into the target was performed. As many intermediate CT scans and trajectory modifications as needed by the operator were allowed.

RESULTS

Twenty-eight needles were inserted (10 in the spine and 18 in the pelvis). No adverse event was reported. Technical success rate was 96.4% (27/28). One insertion was not feasible after several robotic attempts. The placement success rate was 100% (27/27). After the planned intermediate CT scan, 13 (48.1%) of 27 trajectories did not require any modification, and 11 (40.7%) of 27 trajectories required a single modification. One needle was removed and replaced to achieve correct placement. Placement accuracy was similar for spinal and pelvic insertions, with a mean lateral deviation of 2.1 mm (SD ± 1.3).

CONCLUSIONS

Preclinical robotic-assisted needle insertions in bone were safe and feasible, with satisfactory accuracy. A multicenter in-human study is ongoing to evaluate feasibility and safety for percutaneous bone ablation and consolidation procedures.

State-of-the-art of multidisciplinary approach of bone metastasis-directed therapy: review and challenging questions for preparation of a GEMO practice guidelines

Bone is a common secondary site of dissemination during the course of cancer. Bone metastases (BM) can be associated with skeletal-related events (SRE) such as disabling pain, hypercalcemia, and bone instability that leads to pathological fractures or spinal cord compression. SRE contribute to high morbidity as well as, mortality, and have a negative economic impact. Modern management of BM integrates focal treatments (such as radiotherapy, surgery, and interventional radiology), orthoses, and antiresorptive and systemic oncological treatment. The choice of a metastasis-directed therapy depends on the objective of the treatment, the patient characteristics, and the complete assessment of the bone lesion (pain, neurological risk, and instability). In the narrative review present herein, we aim to provide an updated summary of the literature, with description of the advantages and disadvantages of current and emerging strategies in the multimodal treatment of BM and, based on these data, an updated algorithm for the management of BM.

Comparison of selective intra-arterial to standard intravenous administration in percutaneous electrochemotherapy (pECT) for liver tumors

BACKGROUND

Electrochemotherapy (ECT) is a local nonsurgical effective tumor treatment in the hand of the clinician for the treatment of patients with liver tumors or metastases. The study aimed to test the technical feasibility and safety of intra-arterial (i.a.) bleomycin administration compared to the established intravenous (i.v.) administration in percutaneous electrochemotherapy (pECT). Furthermore, the equivalence hypothesis was tested between the 2 modalities in terms of local short-term response and progression-free survival.

PATIENTS AND METHODS

Forty-four patients have been recruited and treated by pECT for hepatocellular carcinoma, cholangiocarcinoma and liver metastatic lesions from cancers of different origin: 18 were treated with standard i.v., 26 with bleomycin i.a. administration.

RESULTS

The 2 groups were similar for anagraphic and anamnestic data, as well as for most relevant disease specific characteristics. Technical success of the treatment was obtained in 95% and 100% of patients in i.v. and i.a. groups respectively. Short-term local response was similar in the 2 groups with a slightly higher complete remission (CR) rate in the i.a. group. There were 61.9% CR, 23.8% partial remission (PR), 4.8% stable disease (SD) in the i.v. group, and 80.6%, CR 12.9% PR, 3.2% PD (p = 0.3454). One-year progression free survival was 60% (C.I. 33%-88%) in the i.v. group and 67% (C.I. 42%-91%) in the i.a. group (p = 0.5849).

CONCLUSIONS

The results of this study confirmed the safety and feasibility of super-selective i.a. bleomycin administration. Analysis of local response and progression free survival confirmed the equivalence hypothesis of the new modality compared to standard i.v. administration in the treatment of primary and secondary liver malignancies by pECT.

Electrochemotherapy in Spine Metastases: A Case Series Focused on Technical Aspects, Surgical Strategies and Results

Metastases are complications of primary tumors due to prolonged cancer survival and have become an important issue for oncological patients and the most frequent cause of death and disability. Bone metastases occur at a later stage of cancer disease, and the spine is the most frequent site. To date, the aim of the treatment of metastases remains to be the control of disease and provide a satisfactory quality of life. The decision making of treatment is influenced by several factors such as the status of the primary disease, the number of metastases, site involvement, and the performance status of the patients. For this reason, the treatment of metastases is challenging and undergoes constant development. Therefore, alternative techniques with respect to surgery, which is the first option but not always practicable, and radiochemotherapy are attractive. Lately, electrochemotherapy has emerged as an innovative method for treating various primary and metastatic solid tumors, showing promising outcomes in terms of inducing tumor tissue necrosis and alleviating symptoms. This technique uses electric pulses to increase the uptake of chemotherapy by tumor cells. Despite the initial enthusiasm and good results in the treatment of bone tumors, relatively few papers have described its use in spine metastases. Therefore, we conducted a systemic review of this intriguing topic while also reporting our experience in the use of electrochemotherapy for the treatment of spine metastases.

Summary and update on the management of differentiated thyroid cancer in 2023

The 6-fold increase in the incidence of differentiated thyroid cancer over the past 30 years in industrialized countries can be mainly attributed to improved detection. At the same time, in addition to the excellent prognosis for low-risk cancers, improved survival in metastatic forms has been also reported, likely due to the progress made recently in the treatment of aggressive forms, for which there is now an extensive therapeutic arsenal. Today, clinical management of differentiated thyroid cancer represents a paradigm of precision oncology, with personalized, risk-adapted therapeutic strategies. This has led to therapeutic de-escalation in those forms with a good prognosis, while targeted treatments play an increasingly important role in the management of radioiodine-refractory or advanced cancers. While endocrinologists will not always have the opportunity to prescribe these treatments, they will be called on to support and monitor patients during treatment. The aim of this article is to provide an overview of treatment options for differentiated thyroid cancer in 2023.

Electrochemotherapy in Aggressive Hemangioma of the Spine: A Case Series and Narrative Literature Review

(1) Background: this case series and literature review aims to evaluate the efficacy and safety of electrochemotherapy in the management of aggressive spinal hemangiomas, presenting two distinct cases. (2) Methods: we present two cases of spinal aggressive hemangioma which were refractory to conventional treatments and underwent electrochemotherapy. Case 1 involves a 50-year-old female who presented with an aggressive spinal hemangioma of L1, who previously underwent various treatments including surgery, radio-chemotherapy, and arterial embolization. Case 2 describes a 16-year-old female with a T12 vertebral hemangioma, previously treated with surgery and stabilization, who faced limitations in treatment options due to her young age and the location of the hemangioma. (3) Results: in Case 1, electrochemotherapy with bleomycin was administered following the failure of previous treatments and resulted in the reduction of the lesion size and improvement in clinical symptoms. In Case 2, electrochemotherapy was chosen due to the risks associated with other treatments and was completed without any adverse events. Both cases demonstrated the potential of electrochemotherapy as a viable treatment option for spinal hemangiomas, especially in complex or recurrent cases. (4) Conclusions: electrochemotherapy with bleomycin is a promising treatment for aggressive spinal hemangiomas when conventional therapies are not feasible or have failed. Further research is needed to establish definitive protocols and long-term outcomes of electrochemotherapy in spinal hemangioma management.

Interventional management of malignant bone tumours

In the last few decades, interventional radiology (IR) has significantly increased its role in the management of bone tumours including bone metastases (BM) that represent the most common type of tumour involving the bone. The current IR management of BM is based on the 'palliative-curative' paradigm and relies on the use of consolidative (i.e. osteplasty, osteosynthesis) and/or ablation (i.e. cryoablation, radiofrequency ablation, electrochemotherapy) techniques. The present narrative review will overview the current role of IR for the management of BM.

Electrochemotherapy in the Treatment of Bone Metastases: A Systematic Review

BACKGROUND AND AIM

Cancers are one of the most frequent causes of death and disability in humans. Skeletal involvement has a major impact on the quality of life and prognosis of cancer patients. Electrochemotherapy is a palliative and minimally invasive oncologic treatment that was first used to treat subcutaneous nodules for malignant tumors. The aim of our review is to evaluate the results of electrochemotherapy in the treatment of bone metastases.

METHODS

A systematic review of the literature indexed in the PubMed MEDLINE and Cochrane Library databases using the search key words "electrochemotherapy" AND ("metastasis" OR "metastases") was performed. The Preferred Reporting Items for Systematic Reviews and MetaAnalyses was followed. Inclusion criteria were proven involvement of the appendicular skeleton in metastatic carcinoma or melanoma, through at least one percutaneous electrochemotherapy session on the metastatic bone lesion. The exclusion criterion was no skeletal metastatic involvement.

RESULTS

Eight articles were finally included. We reached a population of 246 patients. The mean age and follow up were 60.1 years old and 11.4 months, respectively. The most represented primary tumor was breast cancer (18.9%). A total of 250 bone lesions were treated with electrochemotherapy. According to RECIST criteria, in our population we observed 55.5% stable diseases. The mean pre-electrochemotherapy VAS value was 6.9, which lowered to 2.7 after treatment. Adverse events occurred in 3.4% of patients.

CONCLUSIONS

Electrochemotherapy as a minimally invasive and tissue-sparing treatment should be considered for patients with no other alternative to obtain tumor control and improvement in quality of life.