Efficacy of Electrochemotherapy in Breast Cancer Patients of Different Receptor Status: The INSPECT Experience

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.

Systemic anti-cancer therapy and anaesthesia: a narrative review

INTRODUCTION

Cancer research has revolutionised the treatment, quality of life and life expectancy of people living with cancer. Systemic anti-cancer treatments have expanded to involve not only cytotoxic drugs, but targeted drugs and immunotherapy. Although highly effective in many patients, these drugs can cause serious and sometimes life-threatening adverse reactions. As part of their treatment, many patients living with cancer will be offered both systemic anti-cancer therapy and surgery, and many patients will undergo recurrent episodes of both with the aims of cure, palliation or prolongation of life expectancy. It is important for anaesthetists to understand the effects of systemic anti-cancer therapy on their patients.

METHODS

An electronic literature search using was conducted in May 2024 for peer-reviewed articles in English. An initial search of the terms 'anaesthesia' and 'chemotherapy' revealed that existing review literature was tailored towards the neoadjuvant setting and prompted this review to include the complications of targeted therapies, emergency care and intra-operative administration of systemic anti-cancer therapy to reflect this evolving field. A narrative approach was taken to discuss common regimens and their complications.

RESULTS

The review encompasses a wide range of sub-topics including pharmacology; physiology; peri-operative medicine; specialist surgery; adverse events; and safety. Data from multicentre trials that form the basis of current treatment regimens and practice were prioritised during the selection process. Smaller studies, case series and case reports were included to illustrate the rarer but clinically significant adverse effects of specific therapies.

CONCLUSIONS

It is important for anaesthetists to have a comprehensive understanding of the effects of systemic anti-cancer therapies, including cytotoxic and immunotherapies. There are many potential toxicities and complications associated with these treatments, particularly in the context of emergency surgery and the administration of cytotoxic drugs within the operating theatre environment.

Advances in Pharmaceutical Science in Electrochemotherapy: A Tribute to Prof. Jolanta Saczko

This Special Issue is dedicated to the memory of Professor Jolanta Saczko (1964-2023), a remarkable leader whose guidance and dedication were instrumental in advancing electroporation-based research in Poland [...].

Arterial Infusion and Isolated Perfusion in Combination with Reversible Electroporation for Locally Relapsed Unresectable Breast Cancer

BACKGROUND

Relapsed unresectable triple-negative breast cancer is a demanding disease with only a few treatment options. Especially for patients with unresectable tumor masses, a treatment that offers rapid tumor shrinkage is needed. If patients are exhausted from several treatment lines, systemic side effects have to be avoided. Reversible electroporation has shown to be effective for breast cancer if combined with systemic bleomycin and/or cisplatin. To enhance the local effect and reduce the systemic side effects, we combined reversible electroporation with regional chemotherapy.

MATERIALS AND METHODS

Patients with advanced metastasized and relapsed breast cancer received regional chemotherapy via intra-arterial infusion and isolated thoracic perfusion combined with percutanous reversible electroporation. Circulating tumor cells (CETCs/CTCs) were counted before and 24 h after the treatment. Tumor response was evaluated by CT (computer tomography) control.

RESULTS

A total of 21 treatments were conducted for 14 patients who had a mean tumor size of 7.6 cm (standard deviation 3.3 cm). Higher local drug levels are present with arterial infusion compared to venous infusion and result in enhanced response rates. Circulating tumor cells decreased or stayed stable for 24 h after the treatment for 11 and 8 cases, respectively. An increase was observed in two cases. A total of 13 patients showed a clinical response with tumor shrinkage that led to resectability. One patient did not respond to the treatment regimen.

CONCLUSIONS

The combination of reversible electroporation with intra-arterial chemotherapy is feasible and results in a good clinical response with neglectable side effects. The treatment is repeatable and can lead to resectability.

Threshold Interphase Delay for Bipolar Pulses to Prevent Cancellation Phenomenon during Electrochemotherapy

Electroporation-based procedures employing nanosecond bipolar pulses are commonly linked to an undesirable phenomenon known as the cancelation effect. The cancellation effect arises when the second pulse partially or completely neutralizes the effects of the first pulse, simultaneously diminishing cells' plasma membrane permeabilization and the overall efficiency of the procedure. Introducing a temporal gap between the positive and negative phases of the bipolar pulses during electroporation procedures may help to overcome the cancellation phenomenon; however, the exact thresholds are not yet known. Therefore, in this work, we have tested the influence of different interphase delay values (from 0 ms to 95 ms) using symmetric bipolar nanoseconds (300 and 500 ns) on cell permeabilization using 10 Hz, 100 Hz, and 1 kHz protocols. As a model mouse hepatoma, the MH-22a cell line was employed. Additionally, we conducted in vitro electrochemotherapy with cisplatin, employing reduced interphase delay values (0 ms and 0.1 ms) at 10 Hz. Cell plasma membrane permeabilization and viability dependence on a variety of bipolar pulsed electric field protocols were characterized. It was shown that it is possible to minimize bipolar cancellation, enabling treatment efficiency comparable to monophasic pulses with identical parameters. At the same time, it was highlighted that bipolar cancellation has a significant influence on permeabilization, while the effects on the outcome of electrochemotherapy are minimal.

Electrochemotherapy combined with immunotherapy - a promising potential in the treatment of cancer

Electrochemotherapy is a novel, locoregional therapy that is used to treat cutaneous and deep-seated tumors. The electric pulses used in electrochemotherapy increase the permeability of the cell membranes of the target lesion and thus enhance the delivery of low-permeant cytotoxic drugs to the cells, leading to their death. It has also been postulated that electrochemotherapy acts as an in situ vaccination by inducing immunogenic cell death. This in turn leads to an enhanced systemic antitumor response, which could be further exploited by immunotherapy. However, only a few clinical studies have investigated the role of combined treatment in patients with melanoma, breast cancer, hepatocellular carcinoma, and cutaneous squamous cell carcinoma. In this review, we therefore aim to review the published preclinical evidence on combined treatment and to review clinical studies that have investigated the combined role of electrochemotherapy and immunotherapy.