Clinical Phase I/II Study: Local Disease Control and Survival in Locally Advanced Pancreatic Cancer Treated with Electrochemotherapy

A Systematic Review of Indications and Clinical Outcomes of Electrochemotherapy in Pancreatic Ductal Adenocarcinoma

BACKGROUND

Pancreatic ductal adenocarcinoma (PDAC) is one of the most difficult cancers to treat, with a dismal 5-year survival rate of only 8-10%. This challenging prognosis highlights the urgent need for innovative therapeutic approaches to improve outcomes for patients with PDAC. Electrochemotherapy (ECT), which enhances intracellular chemotherapeutic uptake via electric pulses, has been explored for resectable, borderline resectable (BR), locally advanced (LA), recurrent, and metastatic PDAC, either as a complement to conventional treatments or as an alternative when these are not feasible or effective, offering possible benefits in symptomatic palliation and local tumor control.

METHODS

A systematic review was performed in accordance with PRISMA guidelines for studies assessing the efficacy of ECT in PDAC. After searching Embase, PubMed/MEDLINE, Scopus, and Web of Science, five studies with a combined total of 43 patients in various disease stages were identified.

RESULTS

ECT showed promise in improving tumor control, alleviating cancer-related pain, and improving quality of life. One study noted a trend towards tumor size reduction of 8.3% at one-month and 16.1% at six-months follow-up (p = 0.211 and p = 0.315), although these findings were derived from studies conducted without specific comparative control groups. Severity of complication was mainly mild (Clavien-Dindo I-II), while severe complications occurred in only 2.3% of patients. Median overall survival was reported in two studies as 8 months (range 2-19) and 11.5 months (range 1-74). ECT showed efficacy for symptom management, with 60% of patients reporting reduced pain/discomfort and 40% showing enhanced quality of life in one study, while another reported pain scores as decreasing from 6 to 3 at one month and to 2 at six months.

CONCLUSIONS

ECT appears to be a new promising and safe adjunct treatment modality in PDAC management across different disease stages, with potential benefits in tumor control, cancer-related pain reduction, and quality of life. Further studies are warranted to validate these findings and identify patients who could benefit most.

Clinical Insights and Future Prospects: A Comprehensive Narrative Review on Immunomodulation Induced by Electrochemotherapy

Electrochemotherapy (ECT) is an emerging therapeutic approach gaining growing interest for its potential immunomodulatory effects in cancer treatment. This narrative review systematically examines the current state of knowledge regarding the interplay between ECT and the immune system. Through an analysis of preclinical and clinical studies, the review highlights ECT capacity to induce immunogenic cell death, activate dendritic cells, release tumor antigens, trigger inflammatory responses, and occasionally manifest systemic effects-the abscopal phenomenon. These mechanisms collectively suggest the ECT potential to influence both local tumor control and immune responses. While implications for clinical practice appear promising, warranting the consideration of ECT as a complementary treatment to immunotherapy, the evidence remains preliminary. Consequently, further research is needed to elucidate the underlying mechanisms, optimize treatment protocols, explore potential synergies, and decipher the parameters influencing the abscopal effect. As the field advances, the integration of ECT's potential immunomodulatory aspects into clinical practice will need careful evaluation and collaboration among clinical practitioners, researchers, and policymakers.

Electro-antibacterial therapy (EAT) to enhance intracellular bacteria clearance in pancreatic cancer cells

Intratumoral bacteria have been implicated in driving tumor progression, yet effective treatments to modulate the tumor microbiome remain limited. In this study, we investigate the use of electroporation in combination with metronidazole to enhance the clearance of intracellular Fusobacterium nucleatum within pancreatic cancer cells. We explore various parameters, including electric field strength, pulse width, and pulse number to assess the permeability of pancreatic cancer cells infected with F. nucleatum, compared to non-infected cells of the same type. We subsequently quantify the clearance of intracellular bacteria when these pulsing schemes are applied to a suspension of infected pancreatic cancer cells in the presence of metronidazole. Our results reveal distinct differences in cell permeability between infected and non-infected cells, identifying a unique biophysical marker for host cells infected with F. nucleatum. We demonstrate that the combinatorial use of electroporation and metronidazole significantly enhances the delivery of metronidazole into host cells, leading to more effective clearance of intracellular F. nucleatum compared to independent treatments; we term this novel approach Electro-Antibacterial Therapy (EAT). EAT holds promise as an innovative strategy for addressing intratumoral bacteria in pancreatic cancer, other malignancies, and potentially treatment-resistant infections, offering new avenues for therapeutic intervention.

The Efficacy of Electrochemotherapy with Dacarbazine on Melanoma Cells

Electrochemotherapy (ECT) involves locally applying electrical pulses to permeabilize cell membranes, using electroporation (EP). This process enhances the uptake of low-permeant chemotherapeutic agents, consequently amplifying their cytotoxic effects. In melanoma treatment, dacarbazine (DTIC) is a cornerstone, but it faces limitations because of poor cell membrane penetration, necessitating the use of high doses, which, in turn, leads to increased side effects. In our study, we investigated the effects of DTIC and EP, both individually and in combination, on the melanoma cell line (SK-MEL-30) as well as human dermal fibroblasts (HDF) using in vitro assays. First, the effects of different DTIC concentrations on the viability of SK-MEL-30 and HDF cells were determined, revealing that DTIC was more effective against melanoma cells at lower concentrations, whereas its cytotoxicity at 1000 μM was similar in both cell types. Next, an ideal electric field strength of 1500 V/cm achieved a balance between permeability (84%) and melanoma cell viability (79%), paving the way for effective ECT. The combined DTIC-EP (ECT) application reduced IC50 values by 2.2-fold in SK-MEL-30 cells and 2.7-fold in HDF cells compared with DTIC alone. In conclusion, ECT not only increased DTIC's cytotoxicity against melanoma cells but also affected healthy fibroblasts. These findings emphasize the need for cautious, targeted ECT management in melanoma therapy.

Histologic changes of porcine portal vein anastomosis after electrochemotherapy with bleomycin

Electrochemotherapy (ECT1) is used for treatment of unresectable abdominal malignancies. This study aims to show that ECT of porcine portal vein anastomosis is safe and feasible in order to extend the indications for margin attenuation after resection of locally advanced pancreatic carcinoma. No marked differences were found between the control group and ECT treated groups. Electroporation thus caused irreversible damage to the vascular smooth muscle cells in tunica media that could bedue to the narrow irreversible electroporation zone that may occur near the electrodes, or due to vasa vasorum thrombosis in the tunica externa. Based on the absence of vascular complications, and similar histological changes in lienal veinanastomosis, we can conclude that ECT of portal vein anastomosis is safe and feasible.

Radiomics and machine learning analysis by computed tomography and magnetic resonance imaging in colorectal liver metastases prognostic assessment

OBJECTIVE

The aim of this study was the evaluation radiomics analysis efficacy performed using computed tomography (CT) and magnetic resonance imaging in the prediction of colorectal liver metastases patterns linked to patient prognosis: tumor growth front; grade; tumor budding; mucinous type. Moreover, the prediction of liver recurrence was also evaluated.

METHODS

The retrospective study included an internal and validation dataset; the first was composed by 119 liver metastases from 49 patients while the second consisted to 28 patients with single lesion. Radiomic features were extracted using PyRadiomics. Univariate and multivariate approaches including machine learning algorithms were employed.

RESULTS

The best predictor to identify tumor growth was the Wavelet_HLH_glcm_MaximumProbability with an accuracy of 84% and to detect recurrence the best predictor was wavelet_HLH_ngtdm_Complexity with an accuracy of 90%, both extracted by T1-weigthed arterial phase sequence. The best predictor to detect tumor budding was the wavelet_LLH_glcm_Imc1 with an accuracy of 88% and to identify mucinous type was wavelet_LLH_glcm_JointEntropy with an accuracy of 92%, both calculated on T2-weigthed sequence. An increase statistically significant of accuracy (90%) was obtained using a linear weighted combination of 15 predictors extracted by T2-weigthed images to detect tumor front growth. An increase statistically significant of accuracy at 93% was obtained using a linear weighted combination of 11 predictors by the T1-weigthed arterial phase sequence to classify tumor budding. An increase statistically significant of accuracy at 97% was obtained using a linear weighted combination of 16 predictors extracted on CT to detect recurrence. An increase statistically significant of accuracy was obtained in the tumor budding identification considering a K-nearest neighbors and the 11 significant features extracted T1-weigthed arterial phase sequence.

CONCLUSIONS

The results confirmed the Radiomics capacity to recognize clinical and histopathological prognostic features that should influence the choice of treatments in colorectal liver metastases patients to obtain a more personalized therapy.

Research frontiers of electroporation-based applications in cancer treatment: a bibliometric analysis

OBJECTIVES

Electroporation, the breakdown of the biomembrane induced by external electric fields, has increasingly become a research hotspot for its promising related methods in various kinds of cancers.

CONTENT

In this article, we utilized CiteSpace 6.1.R2 to perform a bibliometric analysis on the research foundation and frontier of electroporation-based applications in cancer therapy. A total of 3,966 bibliographic records were retrieved from the Web of Science Core Collection for the bibliometric analysis. Sersa G. and Mir L. M. are the most indispensable researchers in this field, and the University of Ljubljana of Slovenia is a prominent institution. By analyzing references and keywords, we found that, with a lower recurrence rate, fewer severe adverse events, and a higher success rate, irreversible electroporation, gene electrotransfer, and electrochemotherapy are the three main research directions that may influence the future treatment protocol of cancers.

SUMMARY

This article visualized relevant data to synthesize scientific research on electroporation-based cancer therapy, providing helpful suggestions for further investigations on electroporation.

OUTLOOK

Although electroporation-based technologies have been proven as promising tools for cancer treatment, its radical mechanism is still opaque and their commercialization and universalization need further efforts from peers.

Optimal Dosing and Patient Selection for Electrochemotherapy in Solid Abdominal Organ and Bone Tumors

The primary aim of this study was to analyze studies that use electrochemotherapy (ECT) in "deep-seated" tumors in solid organs (liver, kidney, bone metastasis, pancreas, and abdomen) and understand the similarities between patient selection, oncologic selection, and use of new procedures and technology across the organ systems to assess response rates. A literature search was conducted using the term "Electrochemotherapy" in the title field using publications from 2017 to 2023. After factoring in inclusion and exclusion criteria, 29 studies were analyzed and graded based on quality in full. The authors determined key patient and oncologic selection characteristics and ECT technology employed across organ systems that yielded overall responses, complete responses, and partial responses of the treated tumor. It was determined that key selection factors included: the ability to be administered bleomycin, life expectancy greater than three months, unrespectability of the lesion being treated, and a later stage, more advanced cancer. Regarding oncologic selection, all patient cohorts had received chemotherapy or surgery previously but had disease recurrence, making ECT the only option for further treatment. Lastly, in terms of the use of technology, the authors found that studies with better response rates used the ClinporatorTM and updated procedural guidelines by SOP. Thus, by considering patient, oncologic, and technology selection, ECT can be further improved in treating lesions in solid organs.

Pulsed Electric Fields in Oncology: A Snapshot of Current Clinical Practices and Research Directions from the 4th World Congress of Electroporation

The 4th World Congress of Electroporation (Copenhagen, 9-13 October 2022) provided a unique opportunity to convene leading experts in pulsed electric fields (PEF). PEF-based therapies harness electric fields to produce therapeutically useful effects on cancers and represent a valuable option for a variety of patients. As such, irreversible electroporation (IRE), gene electrotransfer (GET), electrochemotherapy (ECT), calcium electroporation (Ca-EP), and tumour-treating fields (TTF) are on the rise. Still, their full therapeutic potential remains underappreciated, and the field faces fragmentation, as shown by parallel maturation and differences in the stages of development and regulatory approval worldwide. This narrative review provides a glimpse of PEF-based techniques, including key mechanisms, clinical indications, and advances in therapy; finally, it offers insights into current research directions. By highlighting a common ground, the authors aim to break silos, strengthen cross-functional collaboration, and pave the way to novel possibilities for intervention. Intriguingly, beyond their peculiar mechanism of action, PEF-based therapies share technical interconnections and multifaceted biological effects (e.g., vascular, immunological) worth exploiting in combinatorial strategies.

Recent Advancements in Electroporation Technologies: From Bench to Clinic

Over the past decade, the increased adoption of electroporation-based technologies has led to an expansion of clinical research initiatives. Electroporation has been utilized in molecular biology for mammalian and bacterial transfection; for food sanitation; and in therapeutic settings to increase drug uptake, for gene therapy, and to eliminate cancerous tissues. We begin this article by discussing the biophysics required for understanding the concepts behind the cell permeation phenomenon that is electroporation. We then review nano- and microscale single-cell electroporation technologies before scaling up to emerging in vivo applications.

Colorectal liver metastases patients prognostic assessment: prospects and limits of radiomics and radiogenomics

In this narrative review, we reported un up-to-date on the role of radiomics to assess prognostic features, which can impact on the liver metastases patient treatment choice. In the liver metastases patients, the possibility to assess mutational status (RAS or MSI), the tumor growth pattern and the histological subtype (NOS or mucinous) allows a better treatment selection to avoid unnecessary therapies. However, today, the detection of these features require an invasive approach. Recently, radiomics analysis application has improved rapidly, with a consequent growing interest in the oncological field. Radiomics analysis allows the textural characteristics assessment, which are correlated to biological data. This approach is captivating since it should allow to extract biological data from the radiological images, without invasive approach, so that to reduce costs and time, avoiding any risk for the patients. Several studies showed the ability of Radiomics to identify mutational status, tumor growth pattern and histological type in colorectal liver metastases. Although, radiomics analysis in a non-invasive and repeatable way, however features as the poor standardization and generalization of clinical studies results limit the translation of this analysis into clinical practice. Clear limits are data-quality control, reproducibility, repeatability, generalizability of results, and issues related to model overfitting.

Risk Assessment and Cholangiocarcinoma: Diagnostic Management and Artificial Intelligence

Intrahepatic cholangiocarcinoma (iCCA) is the second most common primary liver tumor, with a median survival of only 13 months. Surgical resection remains the only curative therapy; however, at first detection, only one-third of patients are at an early enough stage for this approach to be effective, thus rendering early diagnosis as an efficient approach to improving survival. Therefore, the identification of higher-risk patients, whose risk is correlated with genetic and pre-cancerous conditions, and the employment of non-invasive-screening modalities would be appropriate. For several at-risk patients, such as those suffering from primary sclerosing cholangitis or fibropolycystic liver disease, the use of periodic (6-12 months) imaging of the liver by ultrasound (US), magnetic Resonance Imaging (MRI)/cholangiopancreatography (MRCP), or computed tomography (CT) in association with serum CA19-9 measurement has been proposed. For liver cirrhosis patients, it has been proposed that at-risk iCCA patients are monitored in a similar fashion to at-risk HCC patients. The possibility of using Artificial Intelligence models to evaluate higher-risk patients could favor the diagnosis of these entities, although more data are needed to support the practical utility of these applications in the field of screening. For these reasons, it would be appropriate to develop screening programs in the research protocols setting. In fact, the success of these programs reauires patient compliance and multidisciplinary cooperation.

Immunotherapy Assessment: A New Paradigm for Radiologists

Immunotherapy denotes an exemplar change in an oncological setting. Despite the effective application of these treatments across a broad range of tumors, only a minority of patients have beneficial effects. The efficacy of immunotherapy is affected by several factors, including human immunity, which is strongly correlated to genetic features, such as intra-tumor heterogeneity. Classic imaging assessment, based on computed tomography (CT) or magnetic resonance imaging (MRI), which is useful for conventional treatments, has a limited role in immunotherapy. The reason is due to different patterns of response and/or progression during this kind of treatment which differs from those seen during other treatments, such as the possibility to assess the wide spectrum of immunotherapy-correlated toxic effects (ir-AEs) as soon as possible. In addition, considering the unusual response patterns, the limits of conventional response criteria and the necessity of using related immune-response criteria are clear. Radiomics analysis is a recent field of great interest in a radiological setting and recently it has grown the idea that we could identify patients who will be fit for this treatment or who will develop ir-AEs.

Risk Assessment and Pancreatic Cancer: Diagnostic Management and Artificial Intelligence

Pancreatic cancer (PC) is one of the deadliest cancers, and it is responsible for a number of deaths almost equal to its incidence. The high mortality rate is correlated with several explanations; the main one is the late disease stage at which the majority of patients are diagnosed. Since surgical resection has been recognised as the only curative treatment, a PC diagnosis at the initial stage is believed the main tool to improve survival. Therefore, patient stratification according to familial and genetic risk and the creation of screening protocol by using minimally invasive diagnostic tools would be appropriate. Pancreatic cystic neoplasms (PCNs) are subsets of lesions which deserve special management to avoid overtreatment. The current PC screening programs are based on the annual employment of magnetic resonance imaging with cholangiopancreatography sequences (MR/MRCP) and/or endoscopic ultrasonography (EUS). For patients unfit for MRI, computed tomography (CT) could be proposed, although CT results in lower detection rates, compared to MRI, for small lesions. The actual major limit is the incapacity to detect and characterize the pancreatic intraepithelial neoplasia (PanIN) by EUS and MR/MRCP. The possibility of utilizing artificial intelligence models to evaluate higher-risk patients could favour the diagnosis of these entities, although more data are needed to support the real utility of these applications in the field of screening. For these motives, it would be appropriate to realize screening programs in research settings.

Safety and Efficacy of Irreversible Electroporation in Locally Advanced Pancreatic Cancer: An Evaluation from a Surgeon's Perspective

Irreversible electroporation (IRE) has emerged as a promising treatment for patients with locally advanced pancreatic cancer (LAPC). Therefore, in this study, we evaluate the safety and efficacy of IRE against LAPC, as well as exploring its impact on anti-tumor immunity. A retrospective analysis was conducted in consecutive patients at a single institution. Eligible patients were assigned to IRE, palliative surgery (PS), or vascular resection (VR) groups, according to their respective treatments. The IRE group consisted of LAPC patients. One-to-one propensity score matching was performed, in order to compare the incidence of complications and median overall survival (mOS). Serum and intratumoral cytokines, as well as intratumoral immune cells, were analyzed in order to identify changes in immunity after IRE. A total of 210 patients were included. After matching, the rate of major complications (Clavien−Dindo III−V), intra-abdominal hemorrhage, and re-intervention in the IRE group were similar to those in the VR group (p > 0.05). The mOS of the IRE group (13.0 months) was shorter than that of the VR group (15.0 months), but longer than that of the PS group (8.0 months) (p < 0.05). Patients in the IRE group had elevated serum levels of immunogenic cytokines, including IL-2, IL-6, and TNF-α, which were related to anti-tumor immunity. The survival advantage in IRE-treated patients was attributed to tumor ablation and immune modulation effects. Overall, IRE can be considered a feasible treatment for patients with LAPC.

Electrochemically Enhanced Delivery of Pemetrexed from Electroactive Hydrogels

Electroactive hydrogels based on derivatives of polyethyleneglycol (PEG), chitosan and polypyrrole were prepared via a combination of photopolymerization and oxidative chemical polymerization, and optionally doped with anions (e.g., lignin, drugs, etc.). The products were analyzed with a variety of techniques, including: FT-IR, UV-Vis, ¹H NMR (solution state), ¹³C NMR (solid state), XRD, TGA, SEM, swelling ratios and rheology. The conductive gels swell ca. 8 times less than the non-conductive gels due to the presence of the interpenetrating network (IPN) of polypyrrole and lignin. A rheological study showed that the non-conductive gels are soft (G' 0.35 kPa, G″ 0.02 kPa) with properties analogous to brain tissue, whereas the conductive gels are significantly stronger (G' 30 kPa, G″ 19 kPa) analogous to breast tissue due to the presence of the IPN of polypyrrole and lignin. The potential of these biomaterials to be used for biomedical applications was validated in vitro by cell culture studies (assessing adhesion and proliferation of fibroblasts) and drug delivery studies (electrochemically loading the FDA-approved chemotherapeutic pemetrexed and measuring passive and stimulated release); indeed, the application of electrical stimulus enhanced the release of PEM from gels by ca. 10-15% relative to the passive release control experiment for each application of electrical stimulation over a short period analogous to the duration of stimulation applied for electrochemotherapy. It is foreseeable that such materials could be integrated in electrochemotherapeutic medical devices, e.g., electrode arrays or plates currently used in the clinic.

Preliminary Experience of Liquid Biopsy in Lung Cancer Compared to Conventional Assessment: Light and Shadows

Purpose: To assess the qualitative relationship between liquid biopsy and conventional tissue biopsy. As a secondary target, we evaluated the relationship between the liquid biopsy results and the T stage, N stage, M stage, and compared to grading. Methods: The Local Ethics Committee of the “Università degli Studi della Campania Luigi Vanvitelli”, with the internal resolution number 24997/2020 of 12.11.2020, approved this spontaneous prospective study. According to the approved protocol, patients with lung cancer who underwent Fine-Needle Aspiration Cytology (FNAC), CT-guided biopsy, and liquid biopsy were enrolled. A Yates chi-square test was employed to analyze differences in percentage values of categorical variables. A p-value < 0.05 was considered statistically significant. Data analysis was performed using the Matlab Statistic Toolbox (The MathWorks, Inc., Natick, MA, USA). Results: When a genetic mutation is present on the pathological examination, this was also detected on the liquid biopsy. ROS1 and PDL1 mutations were found in 2/29 patients, while EGFR Exon 21 was identified in a single patient. At liquid biopsy, 26 mutations were identified in the analyzed samples. The mutations with the highest prevalence rate in the study populations were: ALK (Ile1461Val), found in 28/29 patients (96.6%), EML4 (Lys398Arg), identified in 16/29 (55.2%) patients, ALK (Asp1529Glu), found in 14/29 (48.3%) patients, EGFR (Arg521Lys), found in 12/29 (41.4%) patients, ROS (Lys2228Gln), identified in 11/29 (37.9%) patients, ROS (Arg167Gln) and ROS (Ser2229Cys), identified in 10/29 (34.5%) patients, ALK (Lys1491Arg) and PIK3CA (Ile391Met), identified in 8/29 (27.6%) patients, ROS (Thr145Pro), identified in 6/29 (20.7%) patients, and ROS (Ser1109Leu), identified in 4/29 (13.8%) patients. No statistically significant differences can be observed in the mutation rate between the adenocarcinoma population and the squamous carcinoma population (p > 0.05, Yates chi-square test). Conclusions: We showed that, when a genetic mutation was detected in pathological examination, this was always detected by liquid biopsy, demonstrating a very high concordance rate of genomic testing between tissues and their corresponding mutations obtained by liquid biopsy, without cases of false-negative results. In addition, in our study, liquid biopsy highlighted 26 mutations, with the prevalence of ALK mutation in 96.6% of patients, supporting the idea that this approach could be an effective tool in cases with insufficient tumor tissue specimens or in cases where tissue specimens are not obtainable.

The role of catechin in electroporation of pancreatic cancer cells - Effects on pore formation and multidrug resistance proteins

Catechin is a bioflavonoid known for its anti-cancer properties. In the present study, we combined theoretical and experimental approaches to reveal the potential of catechin application in the electroporation (EP) or electrochemotherapy (ECT) of pancreatic cancer cells. The molecular dynamics simulations were implemented to examine the interactions of catechin with a model of a membrane, its influence on the membrane's thickness, and the impact of the catechin-membrane interaction on the pore formation. The data were confronted with experimental measurement of the threshold electric field required for permeabilization of pancreatic cancer cells to a fluorescent dye YO-PRO-1. Further, we examined the influence of catechin on cell viability following electroporation with cisplatin or calcium ions. Finally, we investigated the catechin impact on four proteins associated with multidrug resistance: P-glycoprotein, MRP1, BCRP, and LRP. We demonstrated that catechin may boost the effects of electroporation through various mechanisms: i) increasing the cell permeability prior to electroporation ii) increasing the electroporation threshold iii) sensitization of cells to chemotherapeutic compounds. We showed that catechin incubation influences mRNA levels and mitigates the immunoreactivity of Pgp, MRP1, BCRP, and LRP but these changes did not translate to the efficacy of electrochemotherapy.

The Synergistic Role of Irreversible Electroporation and Chemotherapy for Locally Advanced Pancreatic Cancer

Irreversible electroporation (IRE) is a local ablative technique used in conjunction with chemotherapy to treat locally advanced pancreatic cancer (LAPC). The combination of IRE and chemotherapy has showed increased overall survival when compared to chemotherapy alone, pointing towards a possible facilitating effect of IRE on chemotherapeutic drug action and delivery. This review aims to present current chemotherapeutic regimens for LAPC and their co-implementation with IRE, with an emphasis on possible molecular augmentative mechanisms of drug delivery and action. Moreover, the potentiating mechanism of IRE on immunotherapy, M1 oncolytic virus and dendritic cell (DC)-based treatments is briefly explored. Investigating the synergistic effect of IRE on currently established treatment regimens as well as newer ones, may present exciting new possibilities for future studies seeking to improve current LAPC treatment algorithms.

Electroporation and Immunotherapy-Unleashing the Abscopal Effect

Simple Summary

Electrochemotherapy and irreversible electroporation are primarily used for treating patients with cutaneous and subcutaneous tumors and pancreatic cancer, respectively. Increasing numbers of studies have shown that the treatments may elicit an immune response in addition to eliminating the tumor cells. The purpose of this review is to give an in-depth introduction to the electroporation-induced immune response and the local and peripheral immune systems, and to describe the various studies investigating the combination of electroporation and immunotherapy. The review may help guide and inspire the design of future clinical trials investigating the potential synergy of electroporation and immunotherapy in cancer treatment.

Abstract

The discovery of electroporation in 1968 has led to the development of electrochemotherapy (ECT) and irreversible electroporation (IRE). ECT and IRE have been established as treatments of cutaneous and subcutaneous tumors and locally advanced pancreatic cancer, respectively. Interestingly, the treatment modalities have been shown to elicit immunogenic cell death, which in turn can induce an immune response towards the tumor cells. With the dawn of the immunotherapy era, the potential of combining ECT and IRE with immunotherapy has led to the launch of numerous studies. Data from the first clinical trials are promising, and new combination regimes might change the way we treat tumors characterized by low immunogenicity and high levels of immunosuppression, such as melanoma and pancreatic cancer. In this review we will give an introduction to ECT and IRE and discuss the impact on the immune system. Additionally, we will present the results of clinical and preclinical trials, investigating the combination of electroporation modalities and immunotherapy.

Diffusion weighted imaging and diffusion kurtosis imaging in abdominal oncological setting: why and when

This article provides an overview of diffusion kurtosis (DKI) imaging in abdominal oncology. DKI allows for more data on tissue structures than the conventional diffusion model (DWI). However, DKI requires high quality images at b-values greater than 1000 s/mm² and high signal-to-noise ratio (SNR) that traditionally MRI systems are not able to acquire and therefore there are generally amplified anatomical distortions on the images due to less homogeneity of the field. Advances in both hardware and software on modern MRI scanners have currently enabled ultra-high b-value imaging and offered the ability to apply DKI to multiple extracranial sites. Previous studies have evaluated the ability of DKI to characterize and discriminate tumor grade compared to conventional DWI. Additionally, in several studies the DKI sequences used were based on planar echo (EPI) acquisition, which is susceptible to motion, metal and air artefacts and prone to low SNRs and distortions, leading to low quality images for some small lesions, which may affect the accuracy of the results. Another problem is the optimal b-value of DKI, which remains to be explored and not yet standardized, as well as the manual selection of the ROI, which could affect the accuracy of some parameters.

Structured Reporting of Computed Tomography and Magnetic Resonance in the Staging of Pancreatic Adenocarcinoma: A Delphi Consensus Proposal

Background: Structured reporting (SR) in radiology has been recognized recently by major scientific societies. This study aims to build structured computed tomography (CT) and magnetic resonance (MR)-based reports in pancreatic adenocarcinoma during the staging phase in order to improve communication between the radiologist and members of multidisciplinary teams. Materials and Methods: A panel of expert radiologists, members of the Italian Society of Medical and Interventional Radiology, was established. A modified Delphi process was used to develop the CT-SR and MRI-SR, assessing a level of agreement for all report sections. Cronbach’s alpha (Cα) correlation coefficient was used to assess internal consistency for each section and to measure quality analysis according to the average inter-item correlation. Results: The final CT-SR version was built by including n = 16 items in the “Patient Clinical Data” section, n = 11 items in the “Clinical Evaluation” section, n = 7 items in the “Imaging Protocol” section, and n = 18 items in the “Report” section. Overall, 52 items were included in the final version of the CT-SR. The final MRI-SR version was built by including n = 16 items in the “Patient Clinical Data” section, n = 11 items in the “Clinical Evaluation” section, n = 8 items in the “Imaging Protocol” section, and n = 14 items in the “Report” section. Overall, 49 items were included in the final version of the MRI-SR. In the first round for CT-SR, all sections received more than a good rating. The overall mean score of the experts was 4.85. The Cα correlation coefficient was 0.85. In the second round, the overall mean score of the experts was 4.87, and the Cα correlation coefficient was 0.94. In the first round, for MRI-SR, all sections received more than a good rating. The overall mean score of the experts was 4.73. The Cα correlation coefficient was 0.82. In the second round, the overall mean score of the experts was 4.91, and the Cα correlation coefficient was 0.93. Conclusions: The CT-SR and MRI-SR are based on a multi-round consensus-building Delphi exercise derived from the multidisciplinary agreement of expert radiologists in order to obtain more appropriate communication tools for referring physicians.

A Multicenter Randomized Controlled Prospective Study to Assess Efficacy of Laparoscopic Electrochemotherapy in the Treatment of Locally Advanced Pancreatic Cancer

Background: Eighty percent of patients with pancreatic adenocarcinoma present a locally advanced or metastatic disease at diagnosis and are not eligible for surgery if not with palliative intent. In cases of locally advanced disease (LAPC), the combination of chemo and radiotherapy is the only therapeutic option and correlates with a median survival of 15 months (10 months without treatment), with partial remission of disease in 50% of cases. The feasibility and safety of Electrochemotherapy (ECT) have been demonstrated in the treatment of deep tumors. Aim: The aim of the study is to evaluate the efficacy of electrochemotherapy (ECT) followed by conventional systemic treatment compared to the only conventional systemic treatment in LAPC in terms of objective response and overall survival. Patients and Methods: This study is a phase IIb prospective multicenter randomized controlled trial with two arms. The study will include 90 patients: 45 in the control group and 45 in the experimental group. Patients with LAPC in the control arm will receive conventional chemotherapy (FOLFOXIRI). Patients with LAPC in the experimental arm will be subjected to Electrochemotherapy and subsequently to FOLFOXIRI. The objective response at 30, 90, and 180 days from treatment will be based on the computed tomography (CT), magnetic resonance (MR), and positron emission tomography/CT response (PET/CT). The objective long-term treatment response will be evaluated with the modified response evaluation criteria in solid tumors (m-RECIST) criteria, which will take into account the difference in vascularization, determined by the images obtained by CT and MR of the tumor treated before and after ECT. Conclusions: Not resectable liver metastasis, pancreatic tumors, and locally advanced renal carcinomas can be treated with laparoscopic electrodes. ECT could represent an effective therapeutic option for patients not eligible for surgery susceptible to be managed only with palliative therapies.

Margin Accentuation Irreversible Electroporation in Stage III Pancreatic Cancer: A Systematic Review

Simple Summary

This literature review shows preliminary evidence to suggest that electroporation, the use of electricity to cause the death of cells around the tumour, may be associated with an improved survival and complete resection rates following pancreatic surgery for higher stage pancreatic cancer. However, one in five patients have a complication from the procedure that alters their normal course in hospital. Moreover, the number of patients who underwent this technique is small and further data is needed to support the preliminary evidence. The results therefore should be interpreted with caution.

Abstract

The present systematic review aimed to summarise the available evidence on indications and oncological outcomes after MA IRE for stage III pancreatic cancer (PC). A literature search was performed in the Pubmed, MEDLINE, EMBASE, SCOPUS databases using the PRISMA framework to identify all MA IRE studies. Nine studies with 235 locally advanced (LA) (82%, 192/235) or Borderline resectable (BR) PC (18%, 43/235) patients undergoing MA IRE pancreatic resection were included. Patients were mostly male (56%) with a weighted-mean age of 61 years (95% CI: 58–64). Pancreatoduodenectomy was performed in 51% (120/235) and distal pancreatectomy in 49% (115/235). R0 resection rate was 73% (77/105). Clavien Dindo grade 3–5 postoperative complications occurred in 19% (36/187). Follow-up intervals ranged from 3 to 29 months. Local and systematic recurrences were noted in 8 and 43 patients, respectively. The weighted-mean progression free survival was 11 months (95% CI: 7–15). The weighted-mean overall survival was 22 months (95% CI 20–23 months) and 8 months (95% CI 1–32 months) for MA IRE and IRE alone, respectively. Early non-randomised data suggest MA IRE during pancreatic surgery for stage III pancreatic cancer may result in increased R0 resection rates and improved OS with acceptable postoperative morbidity. Further, larger studies are warranted to corroborate this evidence.

A Systematic Review about Imaging and Histopathological Findings for Detecting and Evaluating Electroporation Based Treatments Response

BACKGROUND

Imaging methods and the most appropriate criteria to be used for detecting and evaluating response to oncological treatments depend on the pathology and anatomical site to be treated and on the treatment to be performed. This document provides a general overview of the main imaging and histopathological findings of electroporation-based treatments (Electrochemotherapy-ECT and Irreversible electroporation-IRE) compared to thermal approach, such as radiofrequency ablation (RFA), in deep-seated cancers with a particular attention to pancreatic and liver cancer.

METHODS

Numerous electronic datasets were examined: PubMed, Scopus, Web of Science and Google Scholar. The research covered the years from January 1990 to April 2021. All titles and abstracts were analyzed. The inclusion criteria were the following: studies that report imaging or histopathological findings after ablative thermal and not thermal loco-regional treatments (ECT, IRE, RFA) in deep-seated cancers including pancreatic and liver cancer and articles published in the English language. Exclusion criteria were unavailability of full text and congress abstracts or posters and different topic respect to inclusion criteria.

RESULTS

558 potentially relevant references through electronic searches were identified. A total of 38 articles met the inclusion criteria: 20 studies report imaging findings after RFA or ECT or IRE in pancreatic and liver cancer; 17 studies report histopathological findings after RFA or ECT or IRE; 1 study reports both imaging and histopathological findings after RFA or ECT or IRE.

CONCLUSIONS

Imaging features are related to the type of therapy administrated, to the timing of re-assessment post therapy and to the imaging technique being used to observe the effects. Histological findings after both ECT and IRE show that the treated area becomes necrotic and encapsulated in fibrous tissue, suggesting that the size of the treated lesion cannot be measured as an endpoint to detect response. Moreover, histology frequently reported signs of apoptosis and reduced vital tissue, implying that imaging criteria, which take into account the viability and not the size of the lesion, are more appropriate to evaluate response to treatment.