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Articles by Gregor Sersa in JoVE

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Electrochemotherapy of Tumours

1Department of Experimental Oncology, Institute of Oncology Ljubljana, 2Faculty of Electrical Engineering, University of Ljubljana


JoVE 1038

Electrochemotherapy is a combined use of certain chemotherapeutic drugs such as cisplatin and bleomycin and electric pulses applied to the treated tumour nodule. We present the clinical protocol of electrochemotherapy for treatmen of subcutaneous and cutaneous metastases of melanoma.

Other articles by Gregor Sersa on PubMed

Effective Gene Transfer to Solid Tumors Using Different Nonviral Gene Delivery Techniques: Electroporation, Liposomes, and Integrin-targeted Vector

In this study, we measured transfection efficiency in vitro and in vivo using the following nonviral approaches of gene delivery: injection of plasmid DNA, electroporation-assisted, liposome-enhanced, and integrin-targeted gene delivery, as well as the combination of these methods. Four histologically different tumor models were transfected with a plasmid encoding the green fluorescent protein (GFP) (B16 mouse melanoma, P22 rat carcinosarcoma, SaF mouse sarcoma, and T24 human bladder carcinoma) using adherent cells, dense cell suspensions, and solid tumors. Emphasis was placed on different electroporation conditions to optimise the duration and amplitude of the electric pulses, as well as on different DNA concentrations for effective gene delivery. In addition, transfection efficiency was correlated with cell density of the tumors. The major in vivo findings were: (a) electroporation-assisted gene delivery with plasmid DNA, employing long electric pulses with low amplitude, yielded significantly better GFP expression than short electric pulses with high amplitude; (b) electroporation combined with liposome-DNA complexes yielded the highest percentage of transfected tumor area in B16F1 tumor (6%); (c) transfection efficiency of electroporation-assisted plasmid DNA delivery was dependent on tumor type; (d) integrin-targeted vector, alone or combined with electroporation, was largely ineffective. In conclusion, our results demonstrate that some nonviral methods of gene delivery are feasible and efficient in transfecting solid tumors. Therefore, this makes nonviral methods attractive for further development.

Schedule-dependent Interaction Between Vinblastine and Cisplatin in Ehrlich Ascites Tumors in Mice

Information on the in vivo antitumor efficiency of the combination of Vinca alkaloids in animal tumor models, especially vinblastine (VLB) with cisplatin [cis-diamminedichloroplatinum(II); CDDP] is very limited. Therefore, the aim of our study was to explore whether antitumor schedule dependence exists for the combination of CDDP and VLB on i.p. Ehrlich ascites tumors in mice. Animals were treated 3 days after tumor transplantation with VLB (0.006 mg/kg) or CDDP (0.05 mg/kg) alone, VLB followed by CDDP, and CDDP followed by VLB. The time interval between i.p. injections of the drugs was 24 h. Cell number was measured by counting viable cells using the trypan blue exclusion assay, cell platinum content by electrothermal atomic absorption spectrometry, DNA distribution pattern using flow cytometry, apoptosis by flow-cytometric terminal deoxynucleotidyl transferase dUTP nick-end labeling assay, and cell morphology. Combination of CDDP and VLB resulted in additive interaction when VLB preceded CDDP as determined from cell survival data 24 h after completion of the therapy and in increased platinum content (two times) compared with the same combination in a reverse schedule (CDDP given before VLB), which resulted in antagonism. None of the treatment combinations induced apoptosis. We propose that the observed increase in antitumor effectiveness is mainly due to higher platinum accumulation in tumor cells, which we unambiguously demonstrated by measurement of platinum content in the tumor cells, leading to increased cytotoxicity as well as to cell cycle-dependent effects of VLB and CDDP.

Optimisation of Pulse Parameters in Vitro for in Vivo Electrochemotherapy

The aim of our study was to optimise electric pulse parameters for electrochemotherapy by sampling the space of pulse parameter variables using systematic in vitro experiments. For this purpose we defined parameters that describe the effectiveness of different sets of electric pulse parameters in vitro and combined them into an objective function that characterises requirements for successful electrochemotherapy. The objective function values were calculated for all the sets of electric pulse parameters included in in vitro experiments. Similar values were grouped together by hierarchical clustering. The 'electrochemotherapeutic' effectiveness of two sets of pulse parameters (8 pulses, 100 micros, 1 Hz and 1 pulse, 1000 micros, 1 Hz), which belong to the most efficient cluster, and one set of pulse parameters (16 pulses, 20 ms, 1 Hz), which belongs to the least efficient cluster, was tested in vivo on a murine tumor model. The sets of pulse parameters from the most efficient cluster had comparable effects in vivo, while the electrochemotherapy with the set of pulse parameters from the least efficient cluster was less effective. Our results demonstrated that electric pulse parameters for effective in vivo application can be determined from in vitro experiments considering application specifications.

Oxygenation and Blood Flow in Tumors Treated with Hydralazine: Evaluation with a Novel Luminescence-based Fiber-optic Sensor

Two optical methods were used simultaneously to evaluate the effect of a vasoactive drug hydralazine on oxygenation and blood flow in SA-1 tumors in A/J mice. A novel luminescence-based optical sensor (OxyLite instrument, Oxford Optronix, UK) was used to monitor partial pressure of oxygen (pO2) in tumors. Laser Doppler flowmetry was used to assess relative blood perfusion in tumors. Measurements were performed continuously on anesthetized mice before and after i.v. injection of hydralazine at a dose of 2.5 mg/kg. Hydralazine reduced pO2 on average by 80% minutes after injection. Our results indicate that hydralazine could be used to improve the antitumor effectiveness of hypoxic cell-specific therapies. We demonstrated that both optical methods can be used successfully to detect changes in blood perfusion and oxygenation in tumors after blood flow-modifying treatments. Some aspects of pO2 measurement with the new luminescence-based method require further investigation.

Effect of Hydralazine on Blood Flow, Oxygenation, and Interstitial Fluid Pressure in Subcutaneous Tumors

Perturbation of Blood Flow As a Mechanism of Anti-tumour Action of Direct Current Electrotherapy

Anti-tumour effects of direct current electrotherapy are attributed to different mechanisms depending on the electrode configuration and on the parameters of electric current. The effects mostly arise from the electrochemical products of electrolysis. Direct toxicity of these products to tumour tissue is, however, not a plausible explanation for the observed tumour growth retardation in the case when the electrodes are placed into healthy tissue surrounding the tumour and not into the tumour itself. The hypothesis that the anti-tumour effectiveness of electrotherapy could result from disturbed blood flow in tumours was tested by the measurement of changes in blood perfusion and oxygenation in tumours with three different methods (in vivo tissue staining with Patent Blue Violet dye, polarographic oximetry, near-infrared spectroscopy). The effects induced by electrotherapy were evaluated in two experimental tumour models: Sa-1 fibrosarcoma in A/J mice and LPB fibrosarcoma in C57B1/6 mice. We found that perfusion and oxygenation were significantly decreased after electrotherapy. Good agreement between the results of different methods was observed. The effect of electrotherapy on local perfusion of tumours is probably the prevalent mechanism of anti-tumour action for the particular type of electrotherapy used in the study. The importance of this effect should be considered for the optimization of electrotherapy protocols in experimental and clinical trials. The non-invasive technique of near-infrared spectroscopy proved to be a reliable method for detecting perfusion and oxygenation changes in small solid tumours.

Electroporation of LPB Sarcoma Cells in Vitro and Tumors in Vivo Increases the Radiosensitizing Effect of Cisplatin

Cisplatin is a cytotoxic drug with radiosensitizing effect. In this study a physical drug delivery system, electroporation, was used to facilitate cisplatin delivery into the cells and tumors with the aim of increasing radiation response.

Effects of Electrogenetherapy with P53wt Combined with Cisplatin on Curvival of Human Tumor Cell Lines with Different P53 Status

The aim of our study was to evaluate electrogenetherapy with p53wt alone or combined with cisplatin on two colorectal (HT-29 and LoVo) and two prostatic (PC-3 and Du145) carcinoma cell lines with different p53 status. In addition, the feasibility of electrogenetherapy with p53wt was tested also in vivo on PC-3 prostatic cancer xenografts. Electrogenetherapy with p53wt was dependent on the p53 status of the cell lines used. Electrogenetherapy was the most effective on the PC-3 (p53 null) and Du145 (p53mt) cells, and to the much lesser extent in LoVo cells (p53wt). The exception was the HT-29 cell line with overexpressed mutated p53, where electrogenetherapy with p53wt was the least effective. Sensitivity of the cell lines to cisplatin was independent of the p53 status. Furthermore, the presence of exogenous p53 due to electrogenetherapy did not enhance cisplatin cytotoxicity, since the combination of these therapies resulted in additive cytotoxic effect. The effectiveness of electrogenetherapy with p53wt was also demonstrated in vivo by successful treatment of subcutaneous PC-3 tumors in mice. In conclusion, our study shows that electrogenetherapy with p53wt is feasible, and resulted in comparable cytotoxic and antitumor effectiveness to viral-mediated p53wt gene therapy. This therapy was effective and dependent on the p53 status of the tumor cell lines. Combination of electrogenetherapy and cisplatin resulted in additional cell kill by cisplatin, and was not dependent on the p53 status.

EPR Oximetry of Tumors in Vivo in Cancer Therapy

The partial oxygen pressure (pO2) in tumors is considered to be one of important factors that affect the response of tumors to different treatment. Therefore, we anticipate that the information about the variation of oxygen concentration in tumors can be used as a guide for individualizing radiotherapy, chemotherapy, and especially the combined therapies. There is thus a need to obtain quantitative data on the effects of different therapies on tumor oxygenation under in vivo conditions. One of the methods, which enable these measurements is EPR oximetry. In this work basic principles of the method will be described as well as some examples of tumor oxygenation changes after application of chemotherapeutic drugs (vinblastine, cisplatin, bleomycin) or electric pulses in combination with cisplatin or bleomycin to fibrosarcoma SA-1 tumors in mice. A paramagnetic probe, a char of Bubinga tree, was implanted into the tumor (center and periphery) and in the muscle or subcutis. EPR spectra line-width, which is proportional to oxygen concentration, was measured with time after the treatments. Tumor oxygenation was reduced for 58% of pretreatment value 1 h after intraperitoneal injection of 2.5 mg kg(-1) VLB and returned to pretreatment level within 24 h. Reduction in oxygenation of muscle and subcutis was much smaller and returned to pretreatment value faster as in tumors. With cisplatin (4 mg kg(-1)) and bleomicyn (1 mg kg(-1)) the reduction was less than 15%, but increases in combined therapy to 70%. Similar reduction was observed also with electric pulses alone (eight pulses, 1300 V cm(-1), 100 micros, 1 Hz) with fast recovery of 8h. After electrochemotherapy the recovery was slower and occurs only after 48 h. This study demonstrates that EPR oximetry is a sensitive method for monitoring changes in tissue oxygenation after different treatments, which may have implications in controlling side effects of therapy and in the planning of combined treatments.

Electrochemotherapy with Cisplatin of Cutaneous Tumor Lesions in Breast Cancer

We have evaluated the efficiency of electrochemotherapy with cisplatin on cutaneous tumor lesions of breast cancer and have compared its efficiency with the efficiency of intratumoral (i.t.) administration of cisplatin alone. The study was performed on six breast cancer patients with 26 cutaneous lesions in whom all standard treatment modalities were exhausted. Of 26 lesions, 12 were treated by electrochemotherapy, six by i.t. cisplatin application, while eight were controls. In all 12 lesions treated by electrochemotherapy and followed-up for up to 26 weeks at the most, the objective response was obtained [complete response in 33% with mean duration of 10 weeks and partial response (PR) in 67% with a mean duration of 5 weeks]. In six lesions treated with i.t. application of cisplatin and followed-up for up to 12 weeks at the most, objective response was obtained in 83% of lesions; none of these responses were complete, the mean duration of PR was 5 weeks. During electrochemotherapy, only minimal local side-effects were observed, whereas no systemic side-effects of the treatment were noticed. We conclude that electrochemotherapy with i.t. cisplatin application is effective in local treatment of cutaneous tumor lesions of breast cancer.

Antitumour Effectiveness of Hyperthermia is Potentiated by Local Application of Electric Pulses to LPB Tumours in Mice

The aim of our study was to determine whether local application of electric pulses to tumours, which induce transient reduction of tumour perfusion, could potentiate the antitumour effectiveness of hyperthermia.

Direct Visualization of Electroporation-assisted in Vivo Gene Delivery to Tumors Using Intravital Microscopy - Spatial and Time Dependent Distribution

Electroporation is currently receiving much attention as a way to increase drug and DNA delivery. Recent studies demonstrated the feasibility of electrogene therapy using a range of therapeutic genes for the treatment of experimental tumors. However, the transfection efficiency of electroporation-assisted DNA delivery is still low compared to viral methods and there is a clear need to optimize this approach. In order to optimize treatment, knowledge about spatial and time dependency of gene expression following delivery is of utmost importance in order to improve gene delivery. Intravital microscopy of tumors growing in dorsal skin fold window chambers is a useful method for monitoring gene transfection, since it allows non-invasive dynamic monitoring of gene expression in tumors in a live animal.

Successful Sphincter-saving Treatment of Anorectal Malignant Melanoma with Electrochemotherapy, Local Excision and Adjuvant Brachytherapy

Anorectal malignant melanoma is a rare tumor and there is no consensus on whether aggressive or local management is more appropriate. Local sphincter-saving excision has been shown to have a higher recurrence rate than abdominoperineal resection, although there is no long-term survival difference between the two approaches. Therefore, new adjuvant treatment strategies to permit local sphincter-saving excisions are warranted. In our case, a large anorectal malignant melanoma was successfully treated preoperatively by electrochemotherapy with cisplatin that, by reducing the tumor size, enabled sphincter-saving local excision. Brachytherapy was postoperatively delivered to the excision site. Fourteen months after the beginning of treatment, the patient is without signs of local recurrence and is continent.

The Effect of High Frequency Electric Pulses on Muscle Contractions and Antitumor Efficiency in Vivo for a Potential Use in Clinical Electrochemotherapy

Muscle contractions present the main source of unpleasant sensations for patients undergoing electrochemotherapy. The contractions are a consequence of high voltage pulse delivery. Relatively low repetition frequency of these pulses (1 Hz) results in separate muscle contractions associated with each single pulse that is delivered. It would be possible to reduce the number of unpleasant sensations by increasing the frequency of electric pulses above the frequency of tetanic contraction, provided that the antitumor efficiency of electrochemotherapy remains the same. These assumptions were investigated in the present paper by measuring the muscle torque at different pulse repetition frequencies and at two different pulse amplitudes in rats and studying the antitumor efficiency of electrochemotherapy at different pulse repetition frequencies on tumors in mice. Measurements of muscle torque confirmed that pulse frequencies above the frequency of tetanic contraction (>100 Hz) reduce the number of individual contractions to a single muscle contraction. Regardless of the pulse amplitude, with increasing pulse frequency muscle torque increases up to the frequency of 100 or 200 Hz and then decreases to a value similar to that after application of a 1 Hz pulse train. Electrochemotherapy in vivo with higher repetition frequencies inhibits tumor growth and is efficient at all pulse frequencies examined (1 Hz-5 kHz). These results suggest that there is a considerable potential for clinical use of high frequency pulses in electrochemotherapy.

Effective Treatment of Perianal Tumors in Dogs with Electrochemotherapy

Electrochemotherapy is an antitumor therapy that utilizes locally-delivered, short intense direct current electric pulse to the tumor nodule plus chemotherapy. The aim of the present study was to evaluate the electrochemotherapy treatment of perianal tumors of different sizes in dogs.

Radiosensitising Effect of Electrochemotherapy with Bleomycin in LPB Sarcoma Cells and Tumors in Mice

Bleomycin is poorly permeant but potent cytotoxic and radiosensitizing drug. The aim of the study was to evaluate whether a physical drug delivery system - electroporation can increase radiosensitising effect of bleomycin in vitro and in vivo.

Sequence and Time Dependence of Transfection Efficiency of Electrically-assisted Gene Delivery to Tumors in Mice

Electrically-assisted gene delivery is a non-viral gene delivery technique, using application of square wave electric pulses to facilitate uptake of plasmid DNA into the cells. Feasibility and effectiveness of this method in vivo was already demonstrated, elaborating on pulse parameters and plasmid construction. However, there were no studies performed on sequencing and timing of plasmid DNA injection into the tumors and application of electric pulses. For this purpose we measured luciferase expression in two tumor models (LPB fibrosarcoma, B16F1 melanoma) after electrically-assisted gene delivery at varying time intervals between the pCMV-Luc plasmid injection and electroporation. Expression of luciferase was determined by measurement of its activity using luminometer. The results demonstrated that pCMV-Luc plasmid has to be injected before the application of electric pulses, since no measurable expression was detected in the tumors when pCMV-Luc plasmid was injected after electroporation of tumors. In both tumor models the highest transfection efficiency was obtained when pCMV-Luc plasmid was injected not less than 5 minutes but also not more than 30 minutes before the application of electric pulses. The results also demonstrated variability in the transfection efficiency depending on the tumor model. High expression was obtained in B16F1 tumor model (approximately 5500 pg luc/mg tumor) and lower in LPB fibrosarcoma (approximately 200 pg luc/mg tumor). In conclusion, our results demonstrate that regardless of the susceptibility of the tumors to electrically-assisted gene delivery, the best timing for pCMV-Luc plasmid is between 30 to 5 minutes prior to the application of electric pulses to the tumors.

Cytotoxicity of Different Platinum (II) Analogues to Human Tumour Cell Lines in Vitro and Murine Tumour in Vivo Alone or Combined with Electroporation

The in vitro cytotoxic activity of two new platinum(II) complexes (3P-SK and PtAMP) in comparison with cisplatin (CDDP), oxaliplatin (OXA) and carboplatin (CARBO) was determined in four different human tumour cell lines. The in vivo efficiencies of CDDP and 3P-SK in MCA mammary carcinoma tumours induced in CBA mice were compared.

In Vivo Imaging of Tumor Growth After Electrochemotherapy with Cisplatin

Imaging methods can give both temporal and spatial dimensions to characterize the processes in progression of and/or treatment of specific disease Subcutaneous tumors can be cured after electrochemotherapy (ECT). Growth and reduction of tumors as a result of cytotoxic therapy can be followed by fluorescence video imaging directly on the same animal after treatment. Imaging of tumors should bring more information on the cellular effects of ECT. Green fluorescent protein (eGFP) expressing B16F10 and LPB tumors implanted in C57Bl/6 mice were treated with ECT with cisplatin. The growth or regression of the tumors was monitored either classically by using a caliper or by a manual definition of the region of interest where critical fluorescence levels were detected on the animals. A very good correlation between the two methods was observed. The eGFP mean fluorescence emission was only slightly affected by ECT with intravenously injected cisplatin. Ex vivo observations under a fluorescence microscope showed that eGFP was only detected on the outer layer of the tumor. No fluorescence was detected in the central part of the tumors, which were necrotic.

The Endothelial Cytoskeleton As a Target of Electroporation-based Therapies

Electroporation-based therapies, such as electrochemotherapy and electrogene therapy, result in the disruption of blood vessel networks in vivo and cause changes in blood flow and vascular permeability. The effects of electroporation on the cytoskeleton of cultured primary endothelial cells and on endothelial monolayer permeability were investigated to elucidate possible mechanisms involved. Human umbilical vein endothelial cells (HUVECs) were electroporated in situ and then immunofluorescence staining for filamentous actin, beta-tubulin, vimentin, and VE-cadherin as well as Western blotting analysis of levels of phosphorylated myosin light chain and cytoskeletal proteins were performed. Endothelial permeability was determined by monitoring the passage of FITC-coupled dextran through endothelial monolayers. Exposure of endothelial cells to electric pulses resulted in a profound disruption of microfilament and microtubule cytoskeletal networks, loss of contractility, and loss of vascular endothelial cadherin from cell-to-cell junctions immediately after electroporation. These effects were voltage dependent and reversible because cytoskeletal structures recovered within 60 min of electroporation with up to 40 V, without any significant loss of cell viability. The cytoskeletal effects of electroporation were paralleled by a rapid increase in endothelial monolayer permeability. These results suggest that the remodeling of the endothelial cytoskeleton and changes in endothelial barrier function could contribute to the vascular disrupting actions of electroporation-based therapies and provide an insight into putative mechanisms responsible for the observed increase in permeability and cessation of blood flow in vivo.

Electrogene Therapy with P53 of Murine Sarcomas Alone or Combined with Electrochemotherapy Using Cisplatin

The aim of our study was to evaluate feasibility and therapeutic potential of electrogene therapy with p53 alone or combined with electrochemotherapy using cisplatin on two murine sarcomas with different p53 status. Antitumor effectiveness of three consecutive electrogene treatments with p53 was more effective in wild-type LPB tumors than mutated SA-1 tumors, resulting in 21.4% of tumor cures in LPB tumors and 12.5% in SA-1 tumors. Pretreatment of tumors with electrogene therapy with p53 enhanced chemosensitivity of both tumor models treated by electrochemotherapy with cisplatin. After only one application of this treatment combination in the LPB tumor model, specific tumor growth delay was prolonged in the combined treatment group compared to electrogene therapy with p53 or electrochemotherapy with cisplatin alone, whereas in SA-1 tumors this treatment combination resulted in 31.6% of cured animals. Results of our study show that electrogene therapy with p53 alone or combined with electrochemotherapy is feasible and effective treatment of tumors. The combination of electrogene therapy and electrochemotherapy after only one application resulted in complete regression of tumors.

Effective Treatment of Multiple Unresectable Skin Melanoma Metastases by Electrochemotherapy

Multiple unresectable melanoma skin metastases pose a treatment problem, especially in centers where isolated limb perfusion is not available. We report the case of a 59-year-old woman who developed multiple small unresectable cutaneous melanoma metastases on the thigh after her lower limb was amputated. Electrochemotherapy with bleomycin resulted in good local control of the disease, with a complete response of the treated melanoma nodules (224 tumor nodules) after 4 treatment sessions. Comparison between electrochemotherapy using repetition frequency of the applied electric pulses of 1 Hz and 5 kHz demonstrated equal antitumor effectiveness. Electrochemotherapy with intravenous bleomycin can also be used as a treatment of choice for local control of multiple unresectable cutaneous melanoma skin metastases.

Electrotransfer of Therapeutic Molecules into Tissues

Electroporation is a physical method for the delivery of various molecules into cells by application of controlled external electrical fields that transiently increase permeability of the cell membrane. This technique is now widely used as an alternative to viral gene delivery for transfection of therapeutic genes into different tissues. Gene electrotransfer holds great potential for clinical application due to the ease of preparation of large quantities of endotoxin-free plasmid DNA, the control and reproducibility of this method, and the development of electric pulse generators approved for clinical use. Electroporation has been utilized mainly for DNA vaccination against infectious diseases and cancer. It has also been used for the delivery of other therapeutic genes, mainly cytokines, used in the treatment of various diseases, including cancer, arthritis, multiple sclerosis and inflammation, following organ transplantation. Electroporation as a delivery system for chemotherapeutic drugs, termed antitumor electrochemotherapy, is already at the clinical stage and is being used routinely in several oncology centers in Europe. In addition, the first clinical trials for electrogene therapy of cancer are ongoing. Therefore, it can be presumed that electrotransfer of therapeutic genes into tissues will soon form a validated alternative to viral delivery systems in a clinical setting.

Dynamic Contrast Enhanced MRI of Mouse Fibrosarcoma Using Small-molecular and Novel Macromolecular Contrast Agents

The aim of the study was a comparison of 2 novel macromolecular contrast agents, Gadomer-17 and Polylysine-Gd-DTPA, with commercially available Gd-DTPA in determining the quality of tumor microvasculature by dynamic contrast enhanced MRI. Three groups of 5 mice with SA-1 tumors were studied. To each group of animals one contrast agent was administered; i.e. the first group got Gd-DTPA, the second group Gadomer-17 and the third group Polylysine-Gd-DTPA. To perform dynamic contrast enhanced MRI a standard keyhole approach was used by which consecutive signal intensity change due to contrast agent accumulation in the tumor was measured. From the obtained data, tissue permeability surface area product PS and fractional blood volume BV were calculated on a pixel-by-pixel basis. PS and BV values were calculated for each contrast agent. Based on the values, contrast agents were classified according to their performance in characterizing tumor microvasculature. Results of our study suggest that Gadomer-17 and Polylysine-Gd-DTPA are significantly superior to Gd-DTPA in characterizing tumor microvasculature.

Gene Electrotransfer into Murine Skeletal Muscle: a Systematic Analysis of Parameters for Long-term Gene Expression

Skeletal muscle is an attractive target tissue for delivery of therapeutic genes, since it is well vascularized, easily accessible, and has a high capacity for protein synthesis. For efficient transfection in skeletal muscle, several protocols have been described, including delivery of low voltage electric pulses and a combination of high and low voltage electric pulses. The aim of this study was to determine the influence of different parameters of electrotransfection on short-term and long-term transfection efficiency in murine skeletal muscle, and to evaluate histological changes in the treated tissue. Different parameters of electric pulses, different time lags between plasmid DNA injection and application of electric pulses, and different doses of plasmid DNA were tested for electrotransfection of tibialis cranialis muscle of C57Bl/6 mice using DNA plasmid encoding green fluorescent protein (GFP). Transfection efficiency was assessed on frozen tissue sections one week after electrotransfection using a fluorescence microscope and also noninvasively, followed by an in vivo imaging system using a fluorescence stereo microscope over a period of several months. Histological changes in muscle were evaluated immediately or several months after electrotransfection by determining infiltration of inflammatory mononuclear cells and presence of necrotic muscle fibers. The most efficient electrotransfection into skeletal muscle of C57Bl/6 mice in our experiments was achieved when one high voltage (HV) and four low voltage (LV) electric pulses were applied 5 seconds after the injection of 30 microg of plasmid DNA. This protocol resulted in the highest short-term as well as long-term transfection. The fluorescence intensity of the transfected area declined after 2-3 weeks, but GFP fluorescence was still detectable 18 months after electrotransfection. Extensive inflammatory mononuclear cell infiltration was observed immediately after the electrotransfection procedure using the described parameters, but no necrosis or late tissue damage was observed. This study showed that electric pulse parameters, time lag between the injection of DNA and application of electric pulses, and dose of plasmid DNA affected the duration of transgene expression in murine skeletal muscle. Therefore, transgene expression in muscle can be controlled by appropriate selection of electrotransfection protocol.

The Effect of Electroporation Pulses on Functioning of the Heart

Electrochemotherapy is an effective antitumor treatment currently applied to cutaneous and subcutaneous tumors. Electrochemotherapy of tumors located close to the heart could lead to adverse effects, especially if electroporation pulses were delivered within the vulnerable period of the heart or if they coincided with arrhythmias of some types. We examined the influence of electroporation pulses on functioning of the heart of human patients by analyzing the electrocardiogram. We found no pathological morphological changes in the electrocardiogram; however, we demonstrated a transient RR interval decrease after application of electroporation pulses. Although no adverse effects due to electroporation have been reported so far, the probability for complications could increase in treatment of internal tumors, in tumor ablation by irreversible electroporation, and when using pulses of longer durations. We evaluated the performance of our algorithm for synchronization of electroporation pulse delivery with electrocardiogram. The application of this algorithm in clinical electroporation would increase the level of safety for the patient and suitability of electroporation for use in anatomical locations presently not accessible to existing electroporation devices and electrodes.

Electrode Commutation Sequence for Honeycomb Arrangement of Electrodes in Electrochemotherapy and Corresponding Electric Field Distribution

Electrochemotherapy is a treatment based on combination of chemotherapeutic drug and electroporation. It is used in clinics for treatment of solid tumours. For electrochemotherapy of larger tumours multiple needle electrodes were already suggested. We developed and tested electrode commutation circuit, which controls up to 19 electrodes independently. Each electrode can be in one of three possible states: on positive or negative potential or in the state of high impedance. In addition, we tested a pulse sequence using seven electrodes for which we also calculated electric field distribution in tumour tissue by means of finite-elements method. Electrochemotherapy, performed by multiple needle electrodes and tested pulse sequence on large subcutaneous murine tumour model resulted in tumour growth delay and 57% complete responses, thus demonstrating that the tested electrode commutation sequence is efficient.

Electrochemotherapy Compared to Surgery for Treatment of Canine Mast Cell Tumours

The aim of this study was to evaluate the effectiveness of local treatment electrochemotherapy (ECT) with cisplatin and to compare it with effectiveness of surgery for treatment of mast cell tumours (MCT) in dogs.

Limb Sparing Treatment of Bleeding Melanoma Recurrence by Electrochemotherapy

Electrochemotherapy is an effective local treatment for tumors that combines administration of a chemotherapeutic drug with the subsequent application of electric pulses to the tumor. In addition, it was also found to have a vascular-disrupting effect. We report a case of limb-sparing treatment of bleeding melanoma recurrence by electrochemotherapy

Electric Pulses Used in Electrochemotherapy and Electrogene Therapy Do Not Significantly Change the Expression Profile of Genes Involved in the Development of Cancer in Malignant Melanoma Cells

Electroporation is a versatile method for in vitro or in vivo delivery of different molecules into cells. However, no study so far has analysed the effects of electric pulses used in electrochemotherapy (ECT pulses) or electric pulses used in electrogene therapy (EGT pulses) on malignant cells. We studied the effect of ECT and EGT pulses on human malignant melanoma cells in vitro in order to understand and predict the possible effect of electric pulses on gene expression and their possible effect on cell behaviour.

Local and Systemic Antitumor Effect of Intratumoral and Peritumoral IL-12 Electrogene Therapy on Murine Sarcoma

Soft tissue sarcomas pose a challenge for successful treatment with conventional therapeutic methods, therefore newer therapeutic approaches are considered. In this study, we evaluated the antitumor effect of IL-12 electrogene therapy (EGT) on murine SA-1 fibrosarcoma. The therapeutic plasmid was injected either intratumorally into subcutaneous SA-1 nodules or intradermally into the peritumoral region. We achieved a remarkable local and systemic antitumor effect with both approaches after single plasmid DNA application, with significant intratumoral and systemic production of IL-12 and IFNgamma. Intratumoral IL-12 EGT resulted in over 90% complete response rate of the treated tumors with 60% of cured mice being resistant to challenge with SA-1 tumor cells. Peritumoral EGT resulted in a lower complete response rate (16%), with significant growth delay of remaining tumors. Both therapies also resulted in significant inhibition of growth of untreated tumors, growing simultaneously at a distant site. These data suggest that IL-12 EGT may be useful in the treatment of soft tissue sarcomas, exerting a local and systemic antitumor effect.

Controlled Systemic Release of Interleukin-12 After Gene Electrotransfer to Muscle for Cancer Gene Therapy Alone or in Combination with Ionizing Radiation in Murine Sarcomas

The present study aimed to evaluate the antitumor effectiveness of systemic interleukin (IL)-12 gene therapy in murine sarcoma models, and to evaluate its interaction with the irradiation of tumors and metastases. To avoid toxic side-effects of IL-12 gene therapy, the objective was to achieve the controlled release of IL-12 after intramuscular gene electrotransfer.

Radiosensitizing Effect of Electrochemotherapy in a Fractionated Radiation Regimen in Radiosensitive Murine Sarcoma and Radioresistant Adenocarcinoma Tumor Model

Electrochemotherapy can potentiate the radiosensitizing effect of bleomycin, as shown in our previous studies. To bring this treatment closer to use in clinical practice, we evaluated the interaction between electrochemotherapy with bleomycin and single-dose or fractionated radiation in two murine tumor models with different histology and radiosensitivity. Radiosensitive sarcoma SA-1 and radioresistant adenocarcinoma CaNT subcutaneous tumors grown in A/J and CBA mice, respectively, were used. The anti-tumor effect and skin damage around the treated tumors were evaluated after electrochemotherapy with bleomycin alone or combined with single-dose radiation or a fractionated radiation regimen. The anti-tumor effectiveness of electrochemotherapy was more pronounced in SA-1 than CaNT tumors. In both tumor models, the tumor response to radiation was not significantly influenced by bleomycin alone or by electroporation alone. However, electrochemotherapy before the first tumor irradiation potentiated the response to a single-dose or fractionated radiation regimen in both tumors. For the fractionated radiation regimen, normal skin around the treated tumors was damaged fourfold less than for the single-dose regimen. Electrochemotherapy prior to single-dose irradiation induced more damage to the skin around the treated tumors and greater loss of body weight compared to other irradiated groups, whereas electrochemotherapy combined with the fractionated radiation regimen did not. Electrochemotherapy with low doses of bleomycin can also be used safely for radiosensitization of different types of tumors in a fractionated radiation regimen, resulting in a good anti-tumor effect and no major potentiating effect on radiation-induced skin damage.

Towards Treatment Planning and Treatment of Deep-seated Solid Tumors by Electrochemotherapy

Electrochemotherapy treats tumors by combining specific chemotherapeutic drugs with an intracellular target and electric pulses, which increases drug uptake into the tumor cells. Electrochemotherapy has been successfully used for treatment of easily accessible superficial tumor nodules. In this paper, we present the first case of deep-seated tumor electrochemotherapy based on numerical treatment planning.

Antivascular Effects of Electrochemotherapy: Implications in Treatment of Bleeding Metastases

Solid tumors of various etiologies can be treated efficiently by electrochemotherapy (ECT), a combined use of electroporation (EP) and chemotherapeutic drugs, such as bleomycin and cisplatin. EP alone and ECT in particular, induce a profound reduction in tumor blood flow, which contributes to the antitumor effect. After EP and ECT, the time course of blood flow changes and follows the same two-phase pattern. The first rapid and short-lived vasoconstriction phase is followed by the second much longer-lived phase resulting from disrupted cytoskeletal structures and a compromised barrier function of the microvascular endothelium. In the case of ECT, however, tumor vascular endothelial cells are also affected by the chemotherapeutic drug, which leads to irrecoverable damage to tumor vessels and to a further decrease in tumor blood flow within hours after application of ECT. Tumor cells surviving the direct effects of ECT are consequently exposed to lack of oxygen and nutrients and are pushed into the secondary cascade of induced cell death. Clinically, the antitumor effectiveness of ECT has been proven extensively in the treatment of melanoma metastases, with 70-80% complete responses. The antivascular effects of ECT were also exploited for palliative treatment of bleeding melanoma metastases, with immediate cessation of bleeding and very good antitumor effectiveness. The antivascular effect of ECT is of utmost importance for translation of ECT into the treatment of deep-seated tumors, especially in well vascularized organs, such as the liver, where it prevents bleeding of the treated area.

Cancer Electrogene Therapy with Interleukin-12

Electrogene therapy combines administration of plasmid DNA into tissue followed by local application of electric pulses. In electrogene therapy with interleukin-12 (IL-12), different routes of administration, different doses of plasmid DNA and different protocols for delivery of electric pulses were evaluated in numerous preclinical studies. Antitumor effectiveness was tested in different types of primary tumors, distantly growing tumors and induced metastases. Intratumoral IL-12 electrogene therapy has been proved to be very effective in local tumor control, having also a systemic effect. Intramuscular and peritumoral IL-12 electrogene therapy had also a pronounced systemic effect and when combined with other treatment strategies resulted in tumor cures. Antitumor effectiveness of IL-12 electrogene therapy is due to the induction of adaptive immunity and innate resistance and anti-angiogenic action. Translation of preclinical studies into clinical trials in human and veterinary oncology has started with encouraging results that would hopefully lead to further investigation of this therapy, also in combination with other cancer treatment modalities.

Robustness of Treatment Planning for Electrochemotherapy of Deep-seated Tumors

Treatment of cutaneous and subcutaneous tumors with electrochemotherapy has become a regular clinical method, while treatment of deep-seated tumors is still at an early stage of development. We present a method for preparing a dedicated patient-specific, computer-optimized treatment plan for electrochemotherapy of deep-seated tumors based on medical images. The treatment plan takes into account the patient's anatomy, tissue conductivity changes during electroporation and the constraints of the pulse generator. Analysis of the robustness of a treatment plan made with this method shows that the effectiveness of the treatment is not affected significantly by small single errors in electrode positioning. However, when many errors occur simultaneously, the resulting drop in effectiveness is larger, which means that it is necessary to be as accurate as possible in electrode positioning. The largest effect on treatment effectiveness stems from uncertainties in dielectric properties and electroporation thresholds of treated tumors and surrounding tissues, which emphasizes the need for more accurate measurements and more research. The presented methods for treatment planning and robustness analysis allow quantification of the treatment reproducibility and enable the setting of suitable safety margins to improve the likelihood of successful treatment of deep-seated tumors by electrochemotherapy.

Increased Cellular Uptake of Biocompatible Superparamagnetic Iron Oxide Nanoparticles into Malignant Cells by an External Magnetic Field

Superparamagnetic iron oxide nanoparticles (SPIONs) are used as delivery systems for different therapeutics including nucleic acids for magnetofection-mediated gene therapy. The aim of our study was to evaluate physicochemical properties, biocompatibility, cellular uptake and trafficking pathways of the custom-synthesized SPIONs for their potential use in magnetofection. Custom-synthesized SPIONs were tested for size, shape, crystalline composition and magnetic behavior using a transmission electron microscope, X-ray diffractometer and magnetometer. SPIONs were dispersed in different aqueous media to obtain ferrofluids, which were tested for pH and stability using a pH meter and zetameter. Cytotoxicity was determined using the MTS and clonogenic assays. Cellular uptake and trafficking pathways were qualitatively evaluated by transmission electron microscopy and quantitatively by inductively coupled plasma atomic emission spectrometry. SPIONs were composed of an iron oxide core with a diameter of 8-9 nm, coated with a 2-nm-thick layer of silica. SPIONs, dispersed in 0.9% NaCl solution, resulted in a stable ferrofluid at physiological pH for several months. SPIONs were not cytotoxic in a broad range of concentrations and were readily internalized into different cells by endocytosis. Exposure to neodymium-iron-boron magnets significantly increased the cellular uptake of SPIONs, predominantly into malignant cells. The prepared SPIONs displayed adequate physicochemical and biomedical properties for potential use in magnetofection. Their cellular uptake was dependent on the cell type, and their accumulation within the cells was dependent on the duration of exposure to an external magnetic field.

The Influence of Electroporation on Cytotoxicity of Anticancer Ruthenium(III) Complex KP1339 in Vitro and in Vivo

In our study, the ruthenium-based anticancer agent KP1339 was tested in combination with electroporation for its cytotoxic effect on CHO and SA-1 cell lines in vitro and on SA-1 murine tumour model in vivo. Cells were treated with different doses of KP1339 for 15 or 60 min with or without electroporation in vitro. Cell viability was measured with the MTS assay. In vivo, mice bearing SA-1 tumours were treated with different doses of KP1339 with or without electroporation. Tumour growth was measured at various time points after treatment. Intratumoural ruthenium content was analysed as a measure of KP1339 accumulation to correlate it with antitumour effectiveness. Our results show that electroporation does not potentiate the cytotoxicity of KP1339 in vitro, but significantly potentiates antitumour effectiveness in vivo. Electroporation enhanced ruthenium uptake immediately after treatment, consequently causing persistently higher intratumoural ruthenium content throughout the whole observation period (48 h). In addition, ruthenium content rose continuously in electroporated and intact tumours throughout the whole observation period. The observed antitumour effectiveness is the result of both the direct cytotoxicity of KP1339 and an antivascular effect of electroporation.

Metastatic Potential of Melanoma Cells is Not Affected by Electrochemotherapy

Electrochemotherapy is a local treatment combining chemotherapy and application of electric pulses to the tumour. Electrochemotherapy with bleomycin and cisplatin has shown its effectiveness in controlling local tumour growth in the treatment of malignant melanoma. However, the effect of electrochemotherapy on the metastatic potential of tumour cells is not known. Prevention of metastasis is an important aspect of successful treatment; however, it is known that metastasis can be induced by different treatment modalities. Therefore, the aim of this study was to evaluate the effect of electrochemotherapy with cisplatin on the metastatic potential of human malignant melanoma cells. Cells treated by electrochemotherapy with cisplatin were tested for their ability to migrate and invade through Matrigel-coated porous membrane. In addition, RNA was isolated from cells after treatment and differentially expressed genes were investigated by microarray analysis to evaluate the effect of electrochemotherapy with cisplatin on gene expression. There were no significant changes observed in cell migration and invasion of melanoma cells after electrochemotherapy. In addition, there were no changes observed in cell adhesion on Matrigel. Gene expression analysis showed that a very low number of genes were differentially expressed after electrochemotherapy with cisplatin. Two genes, LAMB3 and CD63 involved in cell migration, were both downregulated after electrochemotherapy with cisplatin and the expression of metastasis promoting genes was not increased after electrochemotherapy. Our data suggest that electrochemotherapy does not increase the metastatic behaviour of human melanoma cells.

Irradiation, Cisplatin, and 5-azacytidine Upregulate Cytomegalovirus Promoter in Tumors and Muscles: Implementation of Non-invasive Fluorescence Imaging

The cytomegalovirus (CMV) promoter is one of the most commonly used promoters for expression of transgenes in mammalian cells. The aim of our study was to evaluate the role of methylation and upregulation of the CMV promoter by irradiation and the chemotherapeutic agent cisplatin in vivo using non-invasive fluorescence in vivo imaging.

Electrochemotherapy of Chest Wall Breast Cancer Recurrence

Chest wall breast cancer recurrence after mastectomy is a disease difficult to treat. Its incidence varies between 5% and 30% in different subset of patients. When possible, radical surgical therapy represents the main treatment approach, however when the disease progresses and/or treatments are not successful, ulceration, bleeding, lymphedema and psychological distress of progressive disease significantly decrease the quality of the remaining life of a patient. When surgical excision of chest wall recurrence is not possible, other local treatments such as radiotherapy, radiotherapy with hyperthermia, topical chemotherapy and electrochemotherapy might be taken into account. Electrochemotherapy provides safe, efficient and non-invasive locoregional treatment approach for chest wall breast cancer recurrence. Several clinical studies have demonstrated high efficacy and a good safety profile of electrochemotherapy applied in single or multiple consecutive sessions, till clinical response was reached. Electrochemotherapy can be performed either with cisplatin injected intratumorally or with bleomycin given intratumorally or intravenously. Furthermore, it can be effectively used in heavily pre-treated areas, after surgery, radiotherapy or systemic chemotherapy. These are the advantages that might demand its use especially in patients with pre-treated extensive disease and in frail elderly patients. With development of the technology electrochemotherapy could even be suggested as a primary local therapy in patients not suitable for surgical removal of the primary tumor.

Hyaluronidase and Collagenase Increase the Transfection Efficiency of Gene Electrotransfer in Various Murine Tumors

Abstract One of the applications of electroporation/electropulsation in biomedicine is gene electrotransfer, the wider use of which is hindered by low transfection efficiency in vivo compared with viral vectors. The aim of our study was to determine whether modulation of the extracellular matrix in solid tumors, using collagenase and hyaluronidase, could increase the transfection efficiency of gene electrotransfer in histologically different solid subcutaneous tumors in mice. Tumors were treated with enzymes before electrotransfer of plasmid DNA encoding either green fluorescent protein or luciferase. Transfection efficiency was determined 3, 9, and 15 days posttransfection. We demonstrated that pretreatment of tumors with a combination of enzymes significantly increased the transfection efficiency of electrotransfer in tumors with a high extracellular matrix area (LPB fibrosarcoma). In tumors with a smaller extracellular matrix area and less organized collagen lattice, the increase was not so pronounced (SA-1 fibrosarcoma and EAT carcinoma), whereas in B16 melanoma, in which only traces of collagen are present, pretreatment of tumors with hyaluronidase alone was more efficient than pretreatment with both enzymes. In conclusion, our results suggest that modification of the extracellular matrix could improve distribution of plasmid DNA in solid subcutaneous tumors, demonstrated by an increase in transfection efficiency, and thus have important clinical implications for electrogene therapy.

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