Damijan Miklavčič

Effective treatment of cutaneous and subcutaneous malignant tumours by electrochemotherapy.

Electrochemotherapy (ECT) enhances the effectiveness of chemotherapeutic agents by administering the drug in combination with short intense electric pulses. ECT is effective because electric pulses permeabilize tumour cell membranes and allow non-permeant drugs, such as bleomycin, to enter the cells. The aim of this study was to demonstrate the anti-tumour effectiveness of ECT with bleomycin on cutaneous and subcutaneous tumours. This article summarizes results obtained in independent clinical trials performed by five cancer centres. A total of 291 cutaneous or subcutaneous tumours of basal cell carcinoma (32), malignant melanoma (142), adenocarcinoma (30) and head and neck squamous cell carcinoma (87) were treated in 50 patients. Short and intense electric pulses were applied to tumours percutaneously after intravenous or intratumour administration of bleomycin. The tumours were measured and the response to the treatment evaluated 30 days after the treatment. Objective responses were obtained in 233 (85.3%) of the 273 evaluable tumours that were treated with ECT. Clinical complete responses were achieved in 154 (56.4%) tumours, and partial responses were observed in 79 (28.9%) tumours. The application of electric pulses to the patients was safe and well tolerated. An instantaneous contraction of the underlying muscles was noticed. Minimal adverse side-effects were observed. ECT was shown to be an effective local treatment. ECT was effective regardless of the histological type of the tumour. Therefore, ECT offers an approach to the treatment of cutaneous and subcutaneous tumours in patients with minimal adverse side-effects and with a high response rate.

A validated model of in vivo electric field distribution in tissues for electrochemotherapy and for DNA electrotransfer for gene therapy.

Permeabilising electric pulses can be advantageously used for DNA electrotransfer in vivo for gene therapy, as well as for drug delivery. In both cases, it is essential to know the electric field distribution in the tissues: the targeted tissue must be submitted to electric field intensities above the reversible permeabilisation threshold (to actually permeabilise it) and below the irreversible permeabilisation threshold (to avoid toxic effects of the electric pulses). A three-dimensional finite element model was built. Needle electrodes of different diameters were modelled by applying appropriate boundary conditions in corresponding grid points of the model. The observations resulting from the numerical calculations, like the electric field distribution dependence on the diameter of the electrodes, were confirmed in appropriate experiments in rabbit liver tissue. The agreement between numerical predictions and experimental observations validated our model. Then it was possible to make the first precise determination of the magnitude of the electric field intensity for reversible (362+/-21 V/cm, mean +/- S.D.) and for irreversible (637+/-43 V/cm) permeabilisation thresholds of rabbit liver tissue in vivo. Therefore the maximum of induced transmembrane potential difference in a single cell of the rabbit liver tissue can be estimated to be 394+/-75 and 694+/-136 mV, respectively, for reversible and irreversible electroporation threshold. These results carry important practical implications.

The importance of electric field distribution for effective in vivo electroporation of tissues.

Cells exposed to short and intense electric pulses become permeable to a number of various ionic molecules. This phenomenon was termed electroporation or electropermeabilization and is widely used for in vitro drug delivery into the cells and gene transfection. Tissues can also be permeabilized. These new approaches based on electroporation are used for cancer treatment, i.e., electrochemotherapy, and in vivo gene transfection. In vivo electroporation is thus gaining even wider interest. However, electrode geometry and distribution were not yet adequately addressed. Most of the electrodes used so far were determined empirically. In our study we 1) designed two electrode sets that produce notably different distribution of electric field in tumor, 2) qualitatively evaluated current density distribution for both electrode sets by means of magnetic resonance current density imaging, 3) used three-dimensional finite element model to calculate values of electric field for both electrode sets, and 4) demonstrated the difference in electrochemotherapy effectiveness in mouse tumor model between the two electrode sets. The results of our study clearly demonstrate that numerical model is reliable and can be very useful in the additional search for electrodes that would make electrochemotherapy and in vivo electroporation in general more efficient. Our study also shows that better coverage of tumors with sufficiently high electric field is necessary for improved effectiveness of electrochemotherapy.

Electroporation-Based Technologies for Medicine: Principles, Applications, and Challenges

When high-amplitude, short-duration pulsed electric fields are applied to cells and tissues, the permeability of the cell membranes and tissue is increased. This increase in permeability is currently explained by the temporary appearance of aqueous pores within the cell membrane, a phenomenon termed electroporation. During the past four decades, advances in fundamental and experimental electroporation research have allowed for the translation of electroporation-based technologies to the clinic. In this review, we describe the theory and current applications of electroporation in medicine and then discuss current challenges in electroporation research and barriers to a more extensive spread of these clinical applications.

Antitumor effectiveness of electrochemotherapy: A systematic review and meta-analysis

BACKGROUND This systematic review has two purposes: to consolidate the current knowledge about clinical effectiveness of electrochemotherapy, a highly effective local therapy for cutaneous and subcutaneous tumors; and to investigate the differences in effectiveness of electrochemotherapy with respect to tumor type, chemotherapeutic drug, and route of drug administration. METHODS All necessary steps for a systematic review were applied: formulation of research question, systematic search of literature, study selection and data extraction using independent screening process, assessment of risk of bias, and statistical data analysis using two-sided common statistical methods and meta-analysis. Studies were eligible for the review if they provided data about effectiveness of single-session electrochemotherapy of cutaneous or subcutaneous tumors in various treatment conditions. RESULTS In total, 44 studies involving 1894 tumors were included in the review. Data analysis confirmed that electrochemotherapy had significantly (p < .001) higher effectiveness (by more than 50%) than bleomycin or cisplatin alone. The effectiveness was significantly higher for intratumoral than for intravenous administration of bleomycin (p < .001 for CR%, p = .028 for OR%). Bleomycin and cisplatin administered intratumorally resulted in equal effectiveness of electrochemotherapy. Electrochemotherapy was more effective in sarcoma than in melanoma or carcinoma tumors. CONCLUSIONS The results of this review shed new light on effectiveness of electrochemotherapy and can be used for prediction of tumor response to electrochemotherapy with respect to various treatment conditions and should be taken into account for further refinement of electrochemotherapy protocols.

Sequential finite element model of tissue electropermeabilization

Permeabilization, when observed on a tissue level, is a dynamic process resulting from changes in membrane permeability when exposing biological cells to external electric field (E). In this paper we present a sequential finite element model of E distribution in tissue which considers local changes in tissue conductivity due to permeabilization. These changes affect the pattern of the field distribution during the high voltage pulse application. The presented model consists of a sequence of static models (steps), which describe E distribution at discrete time intervals during tissue permeabilization and in this way present the dynamics of electropermeabilization. The tissue conductivity for each static model in a sequence is determined based on E distribution from the previous step by considering a sigmoid dependency between specific conductivity and E intensity. Such a dependency was determined by parameter estimation on a set of current measurements, obtained by in vivo experiments. Another set of measurements was used for model validation. All experiments were performed on rabbit liver tissue with inserted needle electrodes. Model validation was carried out in four different ways: 1) by comparing reversibly permeabilized tissue computed by the model and the reversibly permeabilized area of tissue as obtained in the experiments; 2) by comparing the area of irreversibly permeabilized tissue computed by the model and the area where tissue necrosis was observed in experiments; 3) through the comparison of total current at the end of pulse and computed current in the last step of sequential electropermeabilization model; 4) by comparing total current during the first pulse and current computed in consecutive steps of a modeling sequence. The presented permeabilization model presents the first approach of describing the course of permeabilization on tissue level. Despite some approximations (ohmic tissue behavior) the model can predict the permeabilized volume of tissue, when exposed to electrical treatment. Therefore, the most important contribution and novelty of the model is its potentiality to be used as a tool for determining parameters for effective tissue permeabilization.

Cell membrane electroporation- Part 1: The phenomenon

Each biological cell, trillions of which build our bodies, is enveloped by its plasma membrane. Composed largely of a bilayer (double layer) of lipids just two molecules thick (about 5 nm), and behaving partly as a liquid and partly as a gel, the cell plasma membrane nonetheless separates and protects the cell from its surrounding environment very reliably and stably. Embedded within the lipid bilayer, also quite stably, are a number of different proteins, some of which act as channels and pumps, providing a pathway for transporting specific molecules across the membrane. Without these proteins, the membrane would be a largely impenetrable barrier. Electrically, the cell plasma membrane can be viewed as a thin insulating sheet surrounded on both sides by aqueous electrolyte solutions. When exposed to a sufficiently strong electric field, the membrane will undergo electrical breakdown, which renders it permeable to molecules that are otherwise unable to cross it. The process of rendering the membrane permeable is called membrane electroporation. Unlike solid insulators, in which an electrical breakdown generally causes permanent structural change, the membrane, with its lipids behaving as a two-dimensional liquid, can spontaneously return to its prebreakdown state. If the exposure is sufficiently short and the membrane recovery sufficiently rapid for the cell to remain viable, electroporation is termed reversible; otherwise, it is termed irreversible. Since its discovery [1]���[3], electroporation has steadily gained ground as a useful tool in various areas of medicine and biotechnology. Today, reversible electroporation is an established method for introducing chemotherapeutic drugs into tumor cells (electrochemotherapy) [4]. It also offers great promise as a technique for gene therapy without the risks caused by viral vectors (DNA electrotransfer) [5]. In clinical medicine, irreversible electroporation is being investigated as a method for tissue ablation (nonthermal electroablation) [6], whereas in biotechnology, it is useful for extraction of biomolecules [7] and for microbial deactivation, particularly in food preservation [8]. This article, the first in a series of three focusing on electroporation, describes the phenomenon at the molecular level of the lipid bilayer, and then proceeds to the cellular level, explaining how exposure of a cell as a whole to an external electric field results in an inducement of voltage on its plasma membrane, its electroporation, and transport thorough the electroporated membrane. The second article will review the most important and promising applications of electroporation, and the third article will focus on the hardware for electroporation (pulse generators and electrodes) and on the need for standards, safety, and certification.

Effect of electric field induced transmembrane potential on spheroidal cells: theory and experiment

The transmembrane potential on a cell exposed to an electric field is a critical parameter for successful cell permeabilization. In this study, the effect of cell shape and orientation on the induced transmembrane potential was analyzed. The transmembrane potential was calculated on prolate and oblate spheroidal cells for various orientations with respect to the electric field direction, both numerically and analytically. Changing the orientation of the cells decreases the induced transmembrane potential from its maximum value when the longest axis of the cell is parallel to the electric field, to its minimum value when the longest axis of the cell is perpendicular to the electric field. The dependency on orientation is more pronounced for elongated cells while it is negligible for spherical cells. The part of the cell membrane where a threshold transmembrane potential is exceeded represents the area of electropermeabilization, i.e. the membrane area through which the transport of molecules is established. Therefore the surface exposed to the transmembrane potential above the threshold value was calculated. The biological relevance of these theoretical results was confirmed with experimental results of the electropermeabilization of plated Chinese hamster ovary cells, which are elongated. Theoretical and experimental results show that permeabilization is not only a function of electric field intensity and cell size but also of cell shape and orientation.

TIME COURSE OF TRANSMEMBRANE VOLTAGE INDUCED BY TIME-VARYING ELECTRIC FIELDS : A METHOD FOR THEORETICAL ANALYSIS AND ITS APPLICATION

Abstract The paper describes a general method for analysis of time courses of transmembrane voltage induced by time-varying electric fields. Using this method, a response to a wide variety of time-varying fields can be studied. We apply it to different field shapes used for electroporation and electrofusion: rectangular pulses, trapezoidal pulses (approximating rectangular pulses with finite rise time), exponential pulses, and sine(RF)-modulated pulses. Using the described method, the course of induced transmembrane voltage is investigated for each selected pulse shape. All the studies are performed at different pulse durations, each for both the normal physiological and the low-conductivity medium. For all the pulse shapes investigated, it is shown that as the conductivity of extracellular medium is reduced, this slows down the process of transmembrane voltage inducement. Thus, longer pulses have to be used to attain the desired voltage amplitude, as the influence of the fast, short-lived phenomena on the induced voltage is diminished. Due to this reason, RF-modulation in such a medium is ineffective. The appendix gives a complete set of derived expressions and a discussion about possible simplifications.

Analytical Description of Transmembrane Voltage Induced by Electric Fields on Spheroidal Cells

An analytical description of transmembrane voltage induced on spherical cells was determined in the 1950s, and the tools for numerical assessment of transmembrane voltage induced on spheroidal cells were developed in the 1970s. However, it has often been claimed that an analytical description is unattainable for spheroidal cells, while others have asserted that even if attainable, it does not befit the reality due to the nonuniform membrane thickness, which is unrealistic but inevitable in spheroidal geometry. In this paper we show that for all spheroidal cells, membrane thickness is irrelevant to the induced transmembrane voltage under the assumption of a nonconductive membrane, which was also applied in the derivation of Schwans equation. We then derive the analytical description of transmembrane voltage induced on prolate and oblate spheroidal cells. The final result, which we cast from spheroidal into more familiar spherical coordinates, represents a generalization of Schwans equation to all spheroidal cells (of which spherical cells are a special case). The obtained expression is easy to apply, and we give a simple example of such application. We conclude the study by analyzing the variation of induced transmembrane voltage as a spheroidal cell is stretched by the field, performing one study at a constant membrane surface area, and another at a constant cell volume.