IRE (Irreversible Electroporation)—the technology in detail
Every process and every binding force in our body is based on electromagnetic interactions on a microscopic level. Hormones, proteins, DNA cell walls, etc., they are all being held together, binding and interacting by smartly arranged differences in potential of carbon based molecules. So it’s not surprising that external electrical fields can cause a multitude of effects. Strongly pulsed electric fields start to prove to be an extremely potent tool for interacting with our biological matrix, among the applications is tissue selective cancer treatment.
Non-Thermal Irreversible Electroporation is a special case of the so-called pulsed electric field treatment. PEFs (Pulsed Electric Fields) provide local field strengths so high that the binding forces on cell walls break, causing nanometer sized pores. This disrupts the very purpose of the cell design—homeostasis. Normally, the cell recovers from these wall disruptions in seconds to minutes. However, if the amount and size of the pores reach a certain threshold, the damage done by the homeostasis loss is too severe and becomes irreversible—hence IRE (Irreversible Electroporation). Still, the timing of the pulses is short enough to not cause significant joules heating (depending on tissue conductivity, number of pulses and volumetric configuration), hence the term Non-Thermal Irreversible Electroporation (NT-IRE).
IRE (Irreversible Electroporation) for cancer treatment—from macroscopic to microscopic and back
There are several ways to reach the high electrical field threshold required for permanent membrane breakdown (several hundred volts per centimeter). Different application systems for different purposes have been designed over the years.
Clinically, the two most common commercial systems able to produce the parameters required for IRE are the AngioDynamics NanoKnife IRE ablation system and the IGEA Cliniporator system.
However, only NanoKnife has CE and FDA specifically for IRE.
Figure 1: The tools for (Irreversible) Electroporation in clinical environment.
A: NanoKnife is the only medical device currently approved for IRE.
B: The Cliniporator Vitae does have the technical ability to perform IRE, however it was designed for ECT (Electrochemotherapy), which is based on Reversible Electroporation.
C: Sterile electrode pairs are brought into the cancerous area, normally without any cuts or surgery (depending on the type of intervention).
D: Electrical fields between each two electrodes determine the treatment field. Strength and length of the pulses determine whether it is Reversible Electroporation, Non-Thermal Irreversible Electroporation or another type of Electroporation.
The high local electrical field strengths required for IRE can never be applied on very large areas or the whole body. It needs to be a localizable treatment field. Localizing the area you want to treat is a science of itself, normally done by diagnostic and/or interventional radiologists with many years of experience. Once an agreement has been reached between the specialist physicians, electrodes are inserted into the cancerous area.
Figure 2: Image based diagnostic is the essential tool for planning a treatment.
A: A focal prostate cancer lesion.
B: Computer simulation of the electrical field using a defined electrode setup to ensure full coverage of the cancer.
While the placing of the electrodes is normally the most time-intensive part of the procedure, the electrodes themselves do nothing without proper controlling of correct potential differences and timing done by a microprocessor inside the pulse generator (i.e. NanoKnife or Cliniporator).
The process itself is incredibly simple and immensely complex at the same time: one electrode is being put on an electrical positive potential relative to ground (body) and the other electrode equals negative potential. Table 1 shows a list of the parameters recommended by AngioDynamics, manufacturers of NanoKnife, while even small variations can influence a multitude of mechanisms, from electrochemistry to immunology.
Typical voltage 3000 Volt (anode +1500V, cathode -1500V)
Typical time per pulse 90 microseconds
Typical number of pulses 90
Typical interval between pulses 1 second
Typical distance between electrodes 2 cm
Typical exposure length of electrodes 2 cm
Table 1: List of typical parameters for Irreversible Electroporation in clinical use
The problem of local field distribution is described by Laplace equation. The complexity of the problems is manifold. At first, solving Laplace equation in 3 dimensions is not in every case intuitive, especially when a superposition of several sequences needs to be taken into account. Also, D(Vector) is not constant but tissue has an inhomogeneous conductivity both in terms of spatial dimension and in time. Next, the process is not fully described by using Laplace equation. At least electrochemical and thermal effects on pore formation (next step) need to be taken into account. Only very powerful computers can make approximations. This is not a serious issue. Magnetic Resonance Imaging, Positron Emission Tomography or focused radiation therapies run into similar mathematical/physical problems where solutions can only be approximated. Still, they are some of the most valuable tools medicine has to offer. This is similar in Electroporation: whilst exact treatment field calculations elude our current computational power, this is not necessary to use IRE efficiently for cancer because it is not possible to treat cancer with a micrometer precision. It is more important to understand the effects involved and know which structures react in which way to the different effects involved in IRE.
Fig.3: Strong local electrical fields and currents cause a plethora of effects in the body. Among others, Reversible Electroporation (RE), Irreversible Electroporation (IRE), thermal damage by joules heating and electrochemical effects. It is a fine balance between field strength, conductivity and timing to reach the desired effect at the right place.
Figure 4: Computer simulation of the electrical field distribution in a default two electrode setup. Red are approximately areas where Irreversible Electroporation would take place when using 8 pulses. The color gradient area is the region where one would expect Reversible Electroporation and hence the possibility to bring in Electrochemotherapy or Gene Therapy. Though the electrical field is the primary source of cell death, several coupled physical and chemical phenomena happen simultaneously in PEFs, all relevant to the treatment volume and treatment effect approximations.
Once the local field is above a threshold, the phospholipid layers defining the cellular membrane cannot withstand the exterior force exhibited by the (I)RE field. In details this process is explained in Figure 6.
Figure 5 shows electron microscope images of these pore formations. Homeostasis is lost. The whole evolutionary design of cells is towards (selective) homeostasis. The state of (temporarily) broken homeostasis is a special but also unstable state. During this state a wide variety of molecules can be inserted into the cell, molecules which normally can not, or can hardly, penetrate into the cell. The cell walls will close afterwards. Most prominent examples are Bleomycin or Cisplatin for ECT or CRISPR based Gentherapy. This is known as Reversible Electroporation. However, if the membrane is disrupted to severely and cannot be repaired, the cell will die. This is the phenomenon known as Irreversible Electroporation, described here.
Figure 5: Electron microscope images showing pores on the cell surface. The diameter of these pores is usually several hundred nanometers in diameter (one nanometer = one-billionth of a meter).
Figure 6: Phases of electroporation. When in neutral state, the cell keeps homeostasis by stable membranes which consist of phospholipid layer, bound together mainly by van-der-Waals forces. An equal transmembrane potential exists between inner and outer cells. Now, an external electrical field is applied (PHASE 1) and the transmembrane potential builds up towards the end of the cell opposite to the E field vector (left image). Depending of the net field strength, the cell membrane can withstand this force for a short period, nanoseconds or a few microseconds [Molecular Dynamic Simulation middle (side view) and right image (top view)]. If the field, and with it the force, is applied for a longer time (PHASE 2) (a few microseconds), water pores start to form in the membrane. If applied for tens of microseconds (PHASE 3), the pores reach a size where they stabilize even if the external field is switched off. Depending on size and count of the pores, one is now talking about RE (Reversible Electroporation, cell will fully recover in seconds or minutes) or IRE (Irreversible Electroporation, cell will die).
Many thanks to Dr. Mounir Tarek for generating these simulations for us, and to the magazine “Spektrum der Wissenschaft”.
The mechanism of pore formation happens to every single cell where this excessive external electrical field is present. But while only cells die, the amino acid structure “collagen”, which makes up 25-30% of our body proteins by forming the so-called extra cellular matrix, stay unaffected, among other bodily structures. This allows nerves and larger vessels to be preserved or gives them the ability to regenerate by not denaturizing their structural matrix. This makes up the essential difference of IRE compared to other ablation modalities: selectively sparing infrastructure, especially blood vessels and nerves, means that for the first time these structures can be included into the treatment field without causing permanent damage to them. Depending on the cancer location, this selectivity can make the essential difference between severe permanent damage (i.e. prostate cancer: incontinence and impotence) or even life and death, for cancer close to major vessels and vital structures (frequently the case, i.e. in pancreatic cancer). Additionally, the penumbra around the area of irreversible electroporation (See Figure 4, rainbow area), can also be used for treatments based on reversible electroporation, like ECT.
Figure 7: An ablated area in the prostate. Vessel wall and nerve trunk are intact. Rubinsky 2007.
In the following hours, days, weeks and month several different immunological mechanisms take place.
Most importantly, the dead cells attract macrophages which “eat” them in an apoptotic-like manner.
An alive cancer has several hiding mechanisms which make cancer cells either invisible to the immune system, deactivate the fighting mechanisms or build barriers against the fighting cells. All these mechanisms are disrupted after the irreversible damage was done to a cancerous area.
However, the surface of the cancer cells are mostly damaged. This makes an important difference, because this way the cleaning macrophages “see” the cancerous structures and build systemic and tumor specific T-Killer cells. This mechanism is known as Danger-Signal immune response to cancer.
Whilst this is a property of extreme interest for cancer therapies, it is not yet clear how the response can be optimized for a significant impact every time. Just like other groups of physicians and scientists involved in this, we have observed cases where this response was drastic and lasting, as in Figure 8. In other cases, this effect seems to cause less or no systemic response. Dendritic cell injections and modulated antibodies might multiply this effect, also low-dose cyclophosphamide shows promising properties.
In summary, the response appears highly individual which is not astonishing: the largest differing part of our Genome is immune system-related and cancer can also have a rather versatile genetic expression profile rendering every case different.
Over the following weeks the necrotic areas are fully removed. Depending on the structure, healthy cells repopulate the intact extra cellular matrix, i.e. smooth muscle cells, endothelia cells and axons. Scarring and side effects are minimized compared to all thermal- or radiation-based procedures.
Figure 8: Immunological response which had a positive effect on the lymph nodes after treatment with IRE.
Combination of IRE (Irreversible Electroporation) and ECT (Electrochemotherapy)
As shown in Figure 4, with every IRE type field comes a much larger RE type field. The seconds and minutes when the cell membrane is open and the cell is accessible can be used for a large variety of molecules and protein structures. It is being done in laboratories dealing with cells, i.e. to transfer genes, every day around the world.
One very powerful drug which can be inserted is Bleomycin or Cisplatin, both chemotherapeutics with a long and positive track record. Both are up to 10,000 times more effective if the cell underwent RE. The drug needs to be only administered once, eliminating almost all of the usual side effects of prolonged chemotherapy treatment plans, but is effective only locally where the RE was done. This is known as ECT (Electrochemotherapy).
Though obvious, combining both IRE and ECT, is strangely not a very common treatment method yet, which is probably due to the fact that both are relatively new methods and based on different patents owned by different companies. The advantages are manifold. Of course the area of effects is much larger, but the advantages go beyond this fact. The properties are very symbiotic in that sense that IRE and ECT have quite different kill mechanisms. IRE induces a reliable but almost instantaneous cell death with a selectivity limited to tissue types.
Bleomycin based ECT is cell selective (mitosis selective), fighting the always dividing cancer cells even more effectively, while sparing cells that are not currently in the phase of mitosis. So the combination of the two yields a treatment with large treatment volumes with a selectivity profile that allows to include areas that could not have been touched with any other known ablation technology, radiation or surgery.
Clinical evidence is frequently misunderstood by the patients. Clinical evidence means that a treatment or a drug has a proven benefit for a specific purpose or disease. When experts talk about low or no clinical evidence for a certain intervention, that does not necessarily mean that it is not effective. Normally effectiveness is already proven a decade ahead in lab models and is usually the very reason why a medical product was made out of it. However, the body is complicated and “effectiveness” for a certain goal (i.e. tumor removal) does not mean “beneficial”, where “beneficial” itself is often hard to define.
Medicine has literally dozens of examples where interventions are being done effectively and still, they have no benefit, depending on the definition. Many of those are even in the guidelines which themselves are, on average, based far below 10% based on class 1 evidence. Not every common practice in medicine is proven. Infamous examples with (hardly) no proven benefit are several orthopedic interventions, cardiological interventions but also holds true for several oncological interventions.
A highly discussed example is prostate cancer itself: in many guidelines (as is the case in Germany) radical ectomy for low-risk Gleason 6 prostate cancer is still recommended explicitly: it is effective (prostate is gone afterwards with the usual problems) but the clinical evidence shows that the patient does not live longer.
So, now let's take a look at IRE:
For some cancers yes, for prostate cancer no. The reason is simple: quickly lethal cancers are easy to make statistics on, slow developing cancers (like prostate cancer) are extremely complicated and multifactorial. The most prominent result of IRE was shown in 2015 by Martin et al. for locally advanced pancreatic cancer: specific patients treated had twice the mean survival time compared to the state of the art chemotherapy plus surgery treatment, if IRE is included into the concept to reduce the tumor mass. This has never been reported before and is a milestone both for pancreatic cancer treatment and for proving that IRE as a technology can treat cancer very efficiently.
IRE can remove prostate cancer lesions. This can be seen on the MRI after one day or latest after one week in every case. It can also be proven by re-biopsy if the patient wishes. Also, we and others have published results from up to 5 years of follow up and “recurrence free survival” (which is very different from survival benefit) and pathology (ectomy after IRE) exists with good results. But: does this yield a statistical survival benefit (lower prostate cancer-specific mortality) after the decades it normally takes a prostate adenocarcinoma to be lethal? That can naturally only be found after a long time and large studies. And even this will not tell much about IRE as an ablation technology, because there are great discrepancies in every step along the way: selection of patient, diagnostic workup quality, treatment planning, pulse sequence, probe placements, skill of the performing doctor, tumor margin planning, follow up intervals and quality, patient compliance, re-treatment, combination treatments (ADT, immunotherapies or even nutrition and lifestyle changes) and so on. Practically, for every permutation of these factors a large decade long trial would be required to prove which one is the best. Very little of it has to do with IRE as an ablation modality. This will take millions of patients undergoing trials.
Partly yes, partly no. It is an ongoing debate and cannot be fully presented here. What is most important when deciding for an experimental method is a good physician who will do multimodal follow-ups, monitor you closely and guide you through the decades. For prostate cancer with IRE, our experience with both IRE and state of the art MRI cancer diagnosis is unmatched worldwide.
Again, partly yes, partly no. These treatments are decades old and millions of patients have been treated this way. Therefore many combinations have been tried with debatable success and quality of evidence. However, even these treatments are constantly being refined: robotic surgeries, more focused radiation beams and so on. Sticking to the standards of evidence-based medicine, one would need to prove survival benefit for every single change. Which would be of course ridiculous in some cases. There always is and needs to be a balance between strict evidence requirement and using facts known from physics and biology, and logic and deductive reasoning to develop better treatments without decade-long delays for the patients who need it now.
Medicine's usual answer: it depends. It depends greatly on the grade and stage of the cancer as well as on what you expect from it. The absolute survival benefit is somewhere between 0-30% in most cases, to extremely simplify the numbers. The side effect profile is known.
Get in touch for a more detailed analysis of survival benefit in your personal case. Talk to us.
Maybe the most important part of the equation is the patient's feeling about it: would you be comfortable using a treatment which is found medically safe with likely better properties than other treatments but is not “evidence-based” for your specific illness and has only some years of follow up with good results?