Name: electrochemotherapy of tumours
Uploaded: 2008-12-15T00:00:00
Duration: 3 min 57 s
Description: Watch this Scientific Journal Video about Electrochemotherapy of Tumours at JoVE.com

The authors gratefully acknowledge financial support from the state budget of the Slovenian Research Agency and the European Commission's ESOPE project (QLK-2002-02003), funded under the 5th Framework Programme. The authors acknowledge the contribution of prof. Marko Snoj, prof. Maja Cemazar, Matej Merkac and Rado Likon in preparation of this Video-article.

The treatment procedure for electrochemotherapy consists of local or systemic drug injection followed by delivery of electric pulses applied to the tumour 1. Detailed information about the treatment is published in Standard Operating Procedures (SOP) 2.
Treatment indications:
<ol>
<li>Tumour type: basal cell carcinoma, and cutaneous metastases of malignant melanoma, breast carcinoma, hypernephroma, Kaposi's sarcoma and others.</li>
<li>Tumour location: accessible cutaneous and subcutaneous tumour nodules on all parts of the body.</li>
<li>Tumour size can be from 3 mm to 3-5 cm in diameter.</li>
<li>Number of nodules; from 1 to up to 100.</li>
</ol>
Treatment procedure:
<ol>
<li>Local or general anaesthesia, depending on the number of the treated nodules and the location.</li>
<li>Drug choice: cisplatin or bleomycin. Cisplatin and bleomycin can be injected intratumorally, bleomycin also intravenously in a dose of 15000 IU/m2. Injected dose for intratumoural application of bleomycin is 250-1000 IU/cm3 of tumour tissue and for cisplatin 0.5 -1 mg/cm3 of tumour tissue </li>
<li>Time interval between the drug administration and application of electric pulses; after intratumoral injection of the drug immediately, after intravenous administration after 8 min. up to 28 min.</li>
<li>Electric pulse generator for electrochemotherapy should provide square wave electric pulses of amplitude 1000 V or more, repetition frequency from 1 Hz to 5 kHz.</li>
<li>Electric pulse parameters: 8 pulses of e.g. 1000 V at 8 mm distance between two plate electrodes, frequency 1 Hz or 5 kHz, duration of the pulse 100 &micro;s.</li>
<li>If the whole tumour can not be encompassed between the electrodes, application of electric pulses should be repeated that many times so as to cover the whole tumour area, including safety margins.</li>
<li>Electrode type: plate electrodes are used for small, superficial tumour nodules, needle electrodes are for treatment of deeper seeded nodules under the skin.</li>
</ol>
Other features of the treatment:
<ol>
<li>Usually single treatment is effective for tumour nodule eradication; however electrochemotherapy can be repeated in 4 weeks intervals on the remaining tumour tissue or other tumour nodules.</li>
</ol>
Due to lack of systemic toxicity - because very low doses of bleomycin or cisplatin are needed - patients can be treated on an out-patient basis, and can leave the hospital soon after the treatment.

<ol>
	<li>Mir, L. M. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Bases+and+rationale+of+the+electrochemotherapy.">Bases and rationale of the electrochemotherapy.</a> EJC Suppl. 4, 38-44 (2006).</li><li>Mir, L. M., Gehl, J., Sersa, G., Collins, C. G., Garbay, J. R., Billard, V., Geertsen, P., Rudolf, Z., O'Sullivan, G. C., Marty, M. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Standard+operating+procedures+of+the+electrochemotherapy:+instructions+for+the+use+of+bleomycin+or+cisplatin+administered+either+systemically+or+locally+and+electric+pulses+delivered+by+the+CliniporatorTM+by+means+of+invasive+or+non-invasive+electrodes.">Standard operating procedures of the electrochemotherapy: instructions for the use of bleomycin or cisplatin administered either systemically or locally and electric pulses delivered by the CliniporatorTM by means of invasive or non-invasive electrodes.</a> EJC Suppl. 4, 14-25 (2006).</li><li>Okino, M., Mohri, H. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Effects+of+high-voltage+electrical+impulse+and+an+anticancer+drug+on+in+vivo+growing+tumors.">Effects of high-voltage electrical impulse and an anticancer drug on in vivo growing tumors.</a> Jpn. J. Cancer Res. 78, 1319-1321 (1987).</li><li>Mir, L. M., Banoun, H., Paoletti, C. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Introduction+of+definite+amounts+of+nonpermeant+molecules+into+living+cells+after+electropermeabilization:+direct+access+to+the+cytosol.">Introduction of definite amounts of nonpermeant molecules into living cells after electropermeabilization: direct access to the cytosol.</a> Exp. Cell Res. 175, 15-25 (1988).</li><li>Sersa, G., Cemazar, M., Miklavcic, D. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Antitumor+effectiveness+of+electrochemotherapy+with+cis-diamminedichloroplatinum(II)+in+mice.">Antitumor effectiveness of electrochemotherapy with cis-diamminedichloroplatinum(II) in mice.</a> Cancer Res. 55, 3450-3455 (1995).</li><li>Sersa, G., Cemazar, M., Miklavcic, D., Rudolf, Z. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Electrochemotherapy+of+tumours.">Electrochemotherapy of tumours.</a> Radiol. Oncol. 40, 163-174 (2006).</li><li>Miklavcic, D., Beravs, K., Semrov, D., Cemazar, M., Demsar, F., Sersa, G. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=The+importance+of+electric+field+distribution+for+effective+in+vivo+electroporation+of+tissues.">The importance of electric field distribution for effective in vivo electroporation of tissues.</a> Biophys. J. 74, 2152-2158 (1998).</li><li>Miklavcic, D., Corovic, S., Pucihar, G., Pavselj, N. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Importance+of+tumour+coverage+by+sufficiently+high+local+electric+field+for+effective+electrochemotherapy.">Importance of tumour coverage by sufficiently high local electric field for effective electrochemotherapy.</a> EJC Suppl. 4, 45-51 (2006).</li><li>Sersa, G., Jarm, T., Kotnik, T., Coer, A., Podkrajsek, M., Sentjurc, M., Miklavcic, D., Kadivec, M., Kranjc, S., Secerov, A., Cemazar, M. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Vascular+disrupting+action+of+electroporation+and+electrochemotherapy+with+bleomycin+in+murine+sarcoma.">Vascular disrupting action of electroporation and electrochemotherapy with bleomycin in murine sarcoma.</a> Brit. J. Cancer. 98, 388-398 (2008).</li><li>Mir, L. M., Belehradek, M., Domenge, C., Orlowski, S., Poddevin, B., Belehradek, J., Schwaab, G., Luboinski, B., Paoletti, C. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Electrochemotherapy,+a+new+antitumor+treatment:+first+clinical+trial.">Electrochemotherapy, a new antitumor treatment: first clinical trial.</a> C. R. Acad. Sci. III. 313, (1991).</li><li>Mir, L. M., Glass, L. F., Sersa, G., Teissie, J., Domenge, C., Miklavcic, D., Jaroszeski, M. J., Orlowski, S., Reintgen, D. S., Rudolf, Z., Belehradek, M., Gilbert, R., Rols, M. P., Belehradek, J., Bachaud, J. M., DeConti, R., Stabuc, B., Cemazar, M., Coninx, P., Heller, R. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Effective+treatment+of+cutaneous+and+subcutaneous+malignant+tumours+by+electrochemotherapy.">Effective treatment of cutaneous and subcutaneous malignant tumours by electrochemotherapy.</a> Brit. J. Cancer. 77, 2336-2342 (1998).</li><li>Gothelf, A., Mir, L. M., Gehl, J. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Electrochemotherapy:+results+of+cancer+treatment+using+enhanced+delivery+of+bleomycin+by+electroporation.">Electrochemotherapy: results of cancer treatment using enhanced delivery of bleomycin by electroporation.</a> Cancer Treat. Rev. 29, 371-387 (2003).</li><li>Byrne, C. M., Thompson, J. F., Johnston, H., Hersey, P., Quinn, M. J., Hughes, M., McCarthy, W. H. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Treatment+of+metastatic+melanoma+using+electroporation+therapy+with+bleomycin+(electrochemotherapy).">Treatment of metastatic melanoma using electroporation therapy with bleomycin (electrochemotherapy).</a> Melanoma Res. 15, 45-51 (2005).</li><li>Sersa, G. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=The+state-of-the-art+of+electrochemotherapy+before+the+ESOPE+study:+advantages+and+clinical+uses.">The state-of-the-art of electrochemotherapy before the ESOPE study: advantages and clinical uses.</a> EJC Suppl. 4, 52-59 (2006).</li><li>Sersa, G., Miklavcic, D., Cemazar, M., Rudolf, Z., Pucihar, G., Snoj, M. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Electrochemotherapy+in+treatment+of+tumours.">Electrochemotherapy in treatment of tumours.</a> EJSO. 34, 232-240 (2008).</li><li>Marty, M., Sersa, G., Garbay, J. R., Gehl, J., Collins, C. G., Snoj, M., Billard, V., Geertsen, P. F., Larkin, J. O., Miklavcic, D., Pavlovic, I., Paulin-Kosir, S. M., Cemazar, M., Morsli, N., Soden, D. M., Rudolf, Z., Robert, C., O'Sullivan, G. C., Mir, L. M. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Electrochemotherapy+-+an+easy,+highly+effective+and+safe+treatment+of+cutaneous+and+subcutaneous+metastases:+results+of+ESOPE+(European+Standard+Operating+Procedures+of+Electrochemotherapy)+study.">Electrochemotherapy - an easy, highly effective and safe treatment of cutaneous and subcutaneous metastases: results of ESOPE (European Standard Operating Procedures of Electrochemotherapy) study.</a> EJC Suppl. 4, 3-13 (2006).</li><li>Quaglino, P., Mortera, C., Osella-Abate, S., Barberis, M., Illengo, M., Rissone, M., Savoia, P., Bernengo, M. G. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Electrochemotherapy+with+intravenous+bleomycin+in+the+local+treatment+of+skin+melanoma+metastases.">Electrochemotherapy with intravenous bleomycin in the local treatment of skin melanoma metastases.</a> Ann. Surg. Oncol. 15, 2215-2222 (2008).</li></ol>

Increase in cytotoxicity of bleomycin by exposure of cells to electroporative electric pulses was first described by Okino M and Mir LM 3,4. Thereafter electrochemotherapy was demonstrated to be effective also for cisplatin 5. Extensive preclinical data were collected on in vitro and in vivo tumour models in the following years. Treatment effectiveness was determined in relation to drug dosage, route of its administration, timing of drug injection and application of electric pulses, intensity of the electric field, coverage with sufficiently high electric field (E), and appropriate selection of electrodes and positioning with respect to the tumour 1,6,7,8. Furthermore, mechanisms underlying the effectiveness of electrochemotherapy were elaborated, demonstrating that, besides direct effect of electrochemotherapy to tumour cells, vascular disrupting effect and immune response are involved 1,6,9. All of these collected data enabled translation of electrochemotherapy into the clinics.
The first clinical trials demonstrated effectiveness of electrochemotherapy on head and neck and melanoma tumour nodules 10. Later on, its effectiveness was demonstrated on other tumour types, such as basal cell carcinoma of the skin, cutaneous metastases of melanoma, mammary tumours, hypernephroma and Kaposi's sarcoma. There are several reports evaluating collectively all clinical data published on electrochemotherapy with bleomycin and cisplatin 11-15. Overall, the response rate of the treated tumours was approximately 80% objective responses and approximately 70% complete responses 15,16. The effectiveness can be even higher by repetitive treatment 17.
All of these clinical data have enabled electrochemotherapy to be adopted in some European countries as standard treatment, with palliative intent, on various tumours. The future of this treatment is to introduce electrochemotherapy in treatment of internal tumours and metastases, and in combined treatment, either with gene therapy or radiation therapy. These attempts are already under way.

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		<div>
		<table border="1">
		<thead>
		<tr>
		<th>Material Name</th>
		<th>Type</th>
		<th>Company</th>
		<th>Catalogue Number</th>
		<th>Comment</th>
		</tr>
		</thead>
		<tbody>
		
<tr>
<td>Bleomycin (Blenamax)</td>
<td>Reagent</td>
<td>Pharmachemie B.V.</td>
<td>&nbsp;</td>
<td>chemotherapeutic drug used in electrochemotherapy </td>
</tr>
<tr>
<td>Cliniporator</td>
<td>Other</td>
<td>IGEA srl</td>
<td>&nbsp;</td>
<td>Generator of electric pulses</td>
</tr>		</tbody>
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electrochemotherapy of tumours

Electrochemotherapy is a combined use of certain chemotherapeutic drugs and electric pulses applied to the treated tumour nodule. Local application of electric pulses to the tumour increases drug delivery into cells, specifically at the site of electric pulse application. Drug uptake by delivery of electric pulses is increased for only those chemotherapeutic drugs whose transport through the plasma membrane is impeded. Among many drugs that have been tested so far, bleomycin and cisplatin found their way from preclinical testing to clinical use. Clinical data collected within a number of clinical studies indicate that approximately 80% of the treated cutaneous and subcutaneous tumour nodules of different malignancies are in an objective response, from these, approximately 70% in complete response after a single application of electrochemotherapy. Usually only one treatment is needed, however, electrochemotherapy can be repeated several times every few weeks with equal effectiveness each time. The treatment results in an effective eradication of the treated nodules, with a good cosmetic effect without tissue scarring.

Watch this Scientific Journal Video about Electrochemotherapy of Tumours at JoVE.com

Electrochemotherapy of Tumours

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.

Electrochemotherapy is a combined use of certain chemotherapeutic drugs and electric pulses applied to the treated tumour nodule. Local application of ...

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Isolation of Protoplasts from Tissues of 14-day-old Seedlings of Arabidopsis thaliana

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Protoplasts are plant cells that have had their cell walls enzymatically removed. Isolation of protoplasts  from different plant tissues was first ...

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Gross Dissection of the Stomach of the Lobster, Homarus Americanus

We describe the gross dissection of the stomach of the American lobster (Homarus americanus).

The stomach of the American lobster (Homarus americanus) is located in the cephalothorax, between the rostrum and the cervical groove. The anterior end of ...

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Gene deletion and protein overexpression are common methods for studying functions of proteins. In this article, we describe a protocol for analysis of phenotype development as a function of protein concentration at population and single-cell levels in Saccharomyces cerevisiae.

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Determination of DNA Methylation of Imprinted Genes in Arabidopsis Endosperm

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Cell transplantation is an essential technique for studying tissue regeneration and for developing cell-based therapies of disease. We demonstrate here a microsurgical technique that permits the transplantation of genetically labeled cells directly into the kidney of adult zebrafish fish.

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Preimplantation embryos may be cryopreserved after placement into a hypertonic cryoprotective solution to cause cellular dehydration. After equilibration, ice crystal formation is induced in the solution surrounding the embryo. Further dehydration occurs as the embryo is slowly cooled to subzero temperatures before plunging into liquid nitrogen for storage.

Preimplantation embryos from cattle, sheep, and goats may be cryopreserved for short- or long-term storage.  Preimplantation embryos consist predominantly ...

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The pathway of apoptosis is regulated at points upstream and downstream of cytochrome c release from mitochondria5. In order to study the post-mitochondrial regulation of caspase activation, many investigators have turned to direct cytoplasmic microinjection of holocytochrome c (heme-attached) protein into cells6-9. Cytochrome c is normally localized to the mitochondria where attachment of a heme group is necessary to enable it to activate apoptosis10-11. Therefore, to directly activate caspases, it is necessary to inject the holocytochrome c protein instead of its cDNA, because while the expression of cytochrome c from cDNA constructs will result in mitochondrial targeting and heme attachment, it will be sequestered from cytosolic caspases. Thus, the direct cytosolic microinjection of purified heme-attached cytochrome c protein is a useful tool to mimic mitochondrial cytochrome c release and apoptosis without the use of toxic insults which cause cellular and mitochondrial damage.
In this article, we describe a method for the microinjection of cytochrome c protein into cells, using mouse embryonic fibroblasts (MEFs) and primary sympathetic neurons as examples. While this protocol focuses on the injection of cytochrome c for investigations of apoptosis, the techniques shown here can also be easily adapted for microinjection of other proteins of interest.

Activation of Apoptosis by Cytoplasmic Microinjection of Cytochrome c

In this protocol, we describe the direct cytoplasmic microinjection of cytochrome c protein into fibroblasts and primary sympathetic neurons. This technique allows for the introduction of cytochrome c protein into the cytoplasm of cells and mimics the release of cytochrome c from mitochondria, which occurs during apoptosis.

Apoptosis, or programmed cell death, is a conserved and highly regulated pathway by which cells die1.  Apoptosis can be triggered when cells encounter a ...

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Here we describe a protein purification method for nucleotide-binding leucine-rich repeat (NB-LRR)-interacting proteins and the subsequent identification of their post-translational modifications (PTMs). With small modifications, the protocol can be applied for the purification of other plant protein complexes. The method is based on the expression of an epitope-tagged version of the protein of interest, which is subsequently partially purified by immunoprecipitation and subjected to mass spectrometry for identification of interacting proteins and PTMs.
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We describe here a protocol for the purification and characterization of plant protein complexes. We demonstrate that by immunoprecipitating a single protein within a complex, so we can identify its post-translational modifications and its interacting partners.

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A Method of Permeabilization of Drosophila Embryos for Assays of Small Molecule Activity

Introduction of small molecules to the developing Drosophila embryo offers great potential for characterizing biological activity of novel compounds, drugs, and toxins as well as for probing fundamental developmental pathways. Methods described herein outline steps that overcome natural barriers to this approach, expanding the utility of the Drosophila embryo model.

The Drosophila embryo has long been a powerful laboratory model for elucidating molecular and genetic mechanisms that control development. The ease of ...

Method for the Assessment of Effects of a Range of Wavelengths and Intensities of Red/near-infrared Light Therapy on Oxidative Stress In Vitro

Red/near-infrared light therapy (R/NIR-LT), delivered by laser or light emitting diode (LED), improves functional and morphological outcomes in a range of central nervous system injuries in vivo, possibly by reducing oxidative stress. However, effects of R/NIR-LT on oxidative stress have been shown to vary depending on wavelength or intensity of irradiation. Studies comparing treatment parameters are lacking, due to absence of commercially available devices that deliver multiple wavelengths or intensities, suitable for high through-put in vitro optimization studies. This protocol describes a technique for delivery of light at a range of wavelengths and intensities to optimize therapeutic doses required for a given injury model. We hypothesized that a method of delivering light, in which wavelength and intensity parameters could easily be altered, could facilitate determination of an optimal dose of R/NIR-LT for reducing reactive oxygen species (ROS) in vitro.
Non-coherent Xenon light was filtered through narrow-band interference filters to deliver varying wavelengths (center wavelengths of 440, 550, 670 and 810nm) and fluences (8.5 x 10-3 to 3.8 x 10-1 J/cm2) of light to cultured cells. Light output from the apparatus was calibrated to emit therapeutically relevant, equal quantal doses of light at each wavelength. Reactive species were detected in glutamate stressed cells treated with the light, using DCFH-DA and H2O2 sensitive fluorescent dyes.&#160;
We successfully delivered light at a range of physiologically and therapeutically relevant wavelengths and intensities, to cultured cells exposed to glutamate as a model of CNS injury. While the fluences of R/NIR-LT used in the current study did not exert an effect on ROS generated by the cultured cells, the method of light delivery is applicable to other systems including isolated mitochondria or more physiologically relevant organotypic slice culture models, and could be used to assess effects on a range of outcome measures of oxidative metabolism.

Method for the Assessment of Effects of a Range of Wavelengths and Intensities of Red/near-infrared Light Therapy on Oxidative Stress In Vitro

Non-coherent Xenon light was passed through narrow-band interference and neutral density filters to deliver light of varying wavelength and intensity to cultured cells. This protocol was used to assess the effects of red/near-infrared light therapy on production of reactive species in vitro: no effects were observed using the tested parameters.

Red/near-infrared light therapy (R/NIR-LT), delivered by laser or light emitting diode (LED), improves functional and morphological outcomes in a range of ...