1. bookVolume 50 (2016): Issue 1 (March 2016)
Journal Details
License
Format
Journal
eISSN
1581-3207
First Published
30 Apr 2007
Publication timeframe
4 times per year
Languages
English
Open Access

Combined local and systemic bleomycin administration in electrochemotherapy to reduce the number of treatment sessions

Published Online: 16 Feb 2016
Volume & Issue: Volume 50 (2016) - Issue 1 (March 2016)
Page range: 58 - 63
Received: 20 Oct 2015
Accepted: 18 Jan 2016
Journal Details
License
Format
Journal
eISSN
1581-3207
First Published
30 Apr 2007
Publication timeframe
4 times per year
Languages
English
Introduction

Electrochemotherapy (ECT) is an ablative approach that is rapidly growing, both in human and veterinary medicine. ECT is based on administration of bleomycin followed by application of an electric field on the tumor that enhances cell permeability to the drug. This technique can increase bleomycin cytotoxicity by 1000 fold. The effectiveness of ECT is approximately 80% objective response (OR) rate.1,2

A meta-analysis of ECT clinical studies in human oncology showed that the overall OR rates vary from 62.6% and 82.2% OR rate depending also on the route of the drug administration, being either intravenous or intratumoral.3 Despite its success related to its low cost and minimum side effects, ECT still has room for improvement. Even with such a high response rate there are 20% of cases on which attention must be focused in order to improve the outcome of the treatment.

The application of ECT in companion animals showed the same pattern of success as in humans, with many studies demonstrating its high efficiency, with a very similar response rate to that of human patients.4,5

The use of companion animals with spontaneous tumors as models for tumor treatment therapy became a generalized practice due to its many advantages. The most important is that these tumors behave similarly to human ones and are thus better preclinical models for testing new therapies. As these animals were exposed to environmental carcinogens, they developed the tumors in the context of an intact immune system that has the same tumor-host interactions.6,7

A study on melanomas in dogs conducted by Spugnini et al. reported 80% effectiveness.8 Another study by Tamzali et al. on spontaneouslyoccurring tumors showed very high effectiveness when treating sarcoid tumors in equines using ECT with local cisplatin in up to 6 sessions of ECT.9 A ganglioneuroblastoma case was published in which a cat with a very small tumor was treated with up to 3 sessions of ECT in order to obtain an OR.10 In large tumors, however, it is often the case that no OR is possible with a single treatment session.11,12

Systemic bleomycin administration consists of injecting the drug into a vein, thus allowing the drug to reach the tumor through the bloodstream and diffuse from the vessels into the tumor.13 On the other hand, local bleomycin administration consists of directly injecting the drug into the tumor tissue, thus allowing it to diffuse from the injecting point to the target. Multiple injections into the tumor can provide an adequate coverage in small tumors13, but the case of large tumors is different where it is very difficult to homogeneously cover them. Tumor vasculature is structurally and functionally abnormal; blood vessels leak and are tortuous, dilated, and saccular and have a random pattern of interconnection.14 In solid tumors, these aberrant vessels determine an increase in the liquid outlet out of these, together with the contribution of the compression caused by the proliferation of cancer cells, leading to an increase in interstitial hydrostatic pressure.15 The heterogeneous flow of blood and interstitial hypertension pose a serious obstacle to the antineoplastic agents, especially in the case of large tumors with a broader vascular system that are more likely to have areas of tumor that cannot be reached by the systemic route.16,17 This characteristic of tumor vessels could lead to an insufficient bleomycin distribution when administered systemically. Repeated ECT sessions could lead to modifications in the characteristics of the tumors, such as its size reduction and changes in its vasculature that improve treatment response after each session. For these reasons, performing many treatment sessions can improve the results obtained in the first session, increasing, however, the cost of the treatment and its risks related to multiple anesthetic procedures. To address this problem, here, we propose combined bleomycin administration, both systemic and local, using companion animals as models for ECT tumor treating.

The aim of this study was to determine whether it is possible to reduce the number of treatment sessions using a combined administration of bleomycin (both systemic and local) vs. systemic bleomycin administration alone in ECT. Accordingly, for the purpose of this work, we selected companion animals with spontaneous tumors.

Patients and methods
Patients

Consent was obtained from the dog’s owner to use the dog’s image in this scientific work and for the treatment of the other patients. In all cases, all recommendations from the Consejo Profesional de Medicos Veterinarios de Buenos Aires (Buenos Aires Veterinary Council) were observed, as well as the relevant local legislation in Argentina, Act No. 14072 which governs veterinary medicine practice.

Twenty-two patients from the oncology service from the Centro de Epecialidades Medicas Veterinarias (CEMV), Buenos Aires, Argentina, were selected. These patients had tumors of a varied histology and had failed to achieve a complete response after an ECT treatment session. We divided them into two groups: eleven received combined bleomycin administration in a second treatment session, and 11 underwent another standard ECT session (control group). The first ECT session in both groups and the second ECT session in the control group were performed in accordance with the Standard Operating Procedure for Electrochemotherapy.13 The patients were allocated on a ‘first come, first served’ basis to the control group first, and from the eleventh patient onwards, they were allocated to the combined administration group. The size of their tumors was calculated by multiplying their two diameters and their height.

The patients underwent a full clinical examination, blood samples were taken, and a biopsy for histological confirmation of the tumor was performed. The histological analysis of the biopsies was performed with hematoxilin-eosin staining. Most patients treated in the first session were expected to require further ECT sessions in order to obtain an objective response because of their tumor size.

Treatment procedure

General anesthesia procedure consisted of premedication with 0.5 mg/kg of xylazine (Xilacina 100®, Richmond, Buenos Aires, Argentina), 2 mg/kg of tramadol (Tramadol®, John Martin, Buenos Aires, Argentina) and induction with 3 mg/kg of propofol (Propofol Gemepe®, Gemepe, Buenos Aires, Argentina). Then maintenance was assured with 2–3% of isofluorane (Zuflax®, Richmond, Buenos Aires, Argentina) and 2 mcg/kg of fentanyl (Fentanilo Gemepe®, Gemepe, Buenos Aires, Argentina). Meloxicam (Meloxicam Denver Farma®, Denver Farma, Munro, Argentina) 0.2 mg/kg was administered for analgesia after the treatment. This scheme of anesthesia provided adequate comfort during the treatment. Prophylactic antibiotic amoxicillin/clavulanic acid (Clavamox® Zoetis®, San Isidro, Argentina) 12.5mg/kg/bid was administered.

ECT with systemic bleomycin administration alone was performed as follows: the patient was anesthetized using general anesthesia, after an intravenous bolus of bleomycin (Blocamicina®, Gador, Buenos Aires, Argentina) at a dose of 15 000 IU/m2 BSA in 30–45 seconds was administered. Eight minutes after the intravenous injection, to allow drug distribution, the pulses were delivered covering the whole tumor surface.

ECT with systemic and local bleomycin administration was performed as follows: the patient was anesthetized using general anesthesia. An intravenous bolus of bleomycin (Blocamicina®) at a dose of 15 000 IU/m2 BSA in 30–45 seconds was administered, after a local injection of bleomycin (Blocamicina®) at a dose of 125 IU/cm3 of tumor was administered.13 The drug was injected into the tumor using a 27G 2.5 cm needle (Terumo, Tokyo, Japan) in a 3 ml syringe (Darling, Korea), and for an even distribution of the drug, the injections were placed 5 mm apart in one plane and 2 or 3 planes of injections were placed 1 cm apart according to the size of the tumor. The injections started at the center of the tumor and continued at its periphery.9 Healthy margins were not injected with bleomycin since they are covered by the systemic administration of the drug; there are no vascular abnormalities in healthy tissue to justify the additional administration.

The pulses were administered using a six needle electrode, consisting of three rows of two needles 2 cm long and 1 mm diameter, each row separated by 4 mm and each column separated by 8 mm. The pulse generator used was a BTX ECM 830 (Harvard Apparatus, Holliston, MA, USA). A train of 8 electric pulses (1000 V/cm, 100 microseconds, 10 Hz) was applied, covering the whole tumor13, beginning at the periphery of the tumor in a circular fashion in order to have maximum drug concentration at the margins and prevent the spreading of tumor cells. The superposition of electric fields was avoided in order to prevent overtreatment of the lesions.

The response to each treatment was evaluated according to the WHO criteria for tumor response18, 30 days after the treatment. A complete response (CR) is obtained when there is a complete disappearance of all known disease, a partial response (PR) when there is a 50% reduction of the tumor or more, a stable disease (SD) when PR or PD criteria are not met, and a progressive disease (PD) when there is a 25% or more increase in the size of the tumor, and no CR, PR or SD is documented before the increase of the disease or new lesions appear. All of this must be confirmed within 4 weeks after the treatment.

After the treatment, the patients returned to the veterinary clinic within 7, 15, 21, 30 and 60 days in order to evaluate response, toxicity and side effects by means of a full clinical examination and questions to their owners.

Results were compared and statistical significance was evaluated using the chi square test.

Results

The total dose of bleomycin in combined treatment was slightly higher than that of systemic administration alone; in both cases, no toxicity or side effects were reported. Table 1 shows the response of the patients in which combined treatment was performed in the second session. Table 2 shows the control group, for which patients the second session was a repetition of the first procedure.

List of group 1 patients treated using combined systemic and local bleomycin administration in the second treatment session

PatientBreedLocation of the tumorWeight (kg)HistologyStageSize (cm3)Response 1 (ECT)Response 2 (S+L)
1Labrador retrieverOral32MastocytomaII10.6PRCR
2Cross-breedOral21Squamous cell carcinomaII36.2SDPR
3Labrador retrieverNasal32Squamous cell carcinomaII43.5PRCR
4YorkshirePerianal5Solid differentiated carcinomaIV173.8SDSD
5Cross-breedElbow12SchwannomaI67.6SDPR
6RottweilerOral37FibrosarcomaI109.5SDCR
7Labrador retrieverNasal38Squamous cell carcinomaIII42.4SDPR
8BoxerOral37FibrosarcomaIII112.2SDPR
9Cocker spanielOral15MelanomaII8.7PRCR
10BeagleOral16MelanomaIII12.4PRCR
11Cocker spanielOral16MelanomaIII26.64PRCR

CR = complete response; ECT = electrochemotherapy; PR = partial response; SD = stable disease; S+L = systemic + local

List of group 2 patients (control) treated using a repetition of the first session

PatientBreedLocation of the tumorWeight (kg)HistologyStageSize (cm3)Response 1 (ECT)Response 2 (ECT)
12Cross-breedOral30MelanomaI158.2PRSD
13Cross-breedOral21SarcomaIII79.76PRSD
14Cross-breedOral20CarcinomaIII96.5PRSD
15Toy PoodleOral5FibrosarcomaII23.23PDPD
16Cross-breedOral11MelanomaII73.8PRSD
17Cross-breedOral16SchwannomaII467.02PDSD
18Cross-breedOral6Squamous cell carcinomaII12.32SDSD
19Labrador retrieverOral32FibrosarcomaII40PRSD
20RottweilerOral34MelanomaII33PRPR
21German ShepherdOral39FibrosarcomaII101.18PRPD
22Cross-breedOral14MelanomaII14.4PRPR

CR = complete response; ECT = electrochemotherapy; PD = progressive disease; PR = partial response; SD = stable disease; S+L = systemic + local

The responses obtained with combined bleomycin administration were significantly different from those of systemic administration alone in selected cases (p < 0.01). In the combined administration group the following response were obtained: CR 54% (6), PR 36% (4), SD 10% (1). In the control group the obtained response were: CR 0% (0), PR 19% (2), SD 63% (7), PD 18% (2). Figure 1 shows a case treated using combined intravenous and intratumoral bleomycin administration in which a CR was obtained.

Figure 1.

Case number 6. (A) before combined treatment, a fibrosarcoma which failed to respond to the first ECT treatment. (B) CR was obtained after combined treatment.

The OR rates obtained were significantly better when using combined treatment compared with the standard ECT treatment (p < 0.01). As seen in Figure 2, in the combined group, 91% (10) of OR (CR+PR) were obtained, and 19% (2) were obtained in the control group.

Figure 2.

Graph shows the objective response rate obtained in the second session, in a comparison between combined bleomycin administration, both systemic and local (S+L), and systemic alone (S Alone).

ECT = electrochemotherapy

It is worth noting that no complete responses were obtained in the control group with two sessions of ECT, as opposed to 54% of CR obtained when applying combined treatment in the second session.

The average tumor size in the control group was 99.9 cm3, while it was 58.5 cm3 in the combined group. In general, the patients were at a lower stage of the disease in the control group compared with the combined group.

Discussion

ECT is based on a physical phenomenon, electroporation, which acts directly on cell membranes, which accounts for its effectiveness in practically all histological types of tumors. In our experience with veterinary patients, we found that large tumors have poorer responses and require further sessions to obtain an objective response. Our hypothesis was that the abnormal vasculature of large tumors impedes proper drug distribution when it is administered intravenously, even though this route of drug administration is prescribed for tumors of this size in standard operating procedure (SOP).13

Based on this hypothesis, we decided to make an approach by combining both systemic and local bleomycin administration to improve drug distribution in the tumor. In this way, local administration can cover areas where vasculature proves insufficient. There are many reasons against considering using a local injection alone to improve results. According to literature, in tumors above 2 cm in diameter, intravenous administration is recommended.13 It is highly challenging to provide proper drug distribution in the tumor by using local administration only, because during its local application, it is easy to leave sections without the adequate drug concentration, and sometimes it is even impossible to reach the base of the lesion.

It is worth mentioning that some authors obtained good response rates with several treatment repetitions. These repetitions lead to changes in the tumor that can improve drug distribution in later applications.12,1922 Here, we obtained good results with only one repetition.

Tamzali et al. obtained very good results with a local injection of cisplatin in multiple applications treating sarcoids. It is important to take into account that this kind of tumors behave like benign tumors, thus giving a veterinarian time to perform multiple treatments. Our scenario is different since these kinds of tumors are significantly large, and the survival of the patients is compromised, so we need to reduce the tumor as fast as possible in order to improve their quality of life. Frequently, patients with large tumors are in bad clinical shape, so it is important to reduce the number of treatment sessions in order to reduce the risk of anesthetic procedures. On the other hand, costs are also a very important issue, as performing many sessions of treatment increases the cost of the procedure, and makes it rather impossible with our resources.

The fact that the tumors in the combined group were smaller could contribute to better responses achieved, but we also have to consider that the stages were higher. Tumor size rather than disease stage is likely to be a better prognostic factor in ECT, but this speculation is yet to be confirmed.

Further study is needed in order to determine in difficult cases whether practitioners should firstly try ECT with systemic bleomycin alone, or directly apply ECT with its combined systemic and local administration. Since the dose of bleomycin used is very low, the greatest risk of the ECT procedure lies in the application of anesthesia. Reducing anesthesia procedures outweighs the risk of adverse reactions related to the accumulated dose of bleomycin.23,24

Figure 1.

Case number 6. (A) before combined treatment, a fibrosarcoma which failed to respond to the first ECT treatment. (B) CR was obtained after combined treatment.
Case number 6. (A) before combined treatment, a fibrosarcoma which failed to respond to the first ECT treatment. (B) CR was obtained after combined treatment.

Figure 2.

Graph shows the objective response rate obtained in the second session, in a comparison between combined bleomycin administration, both systemic and local (S+L), and systemic alone (S Alone).ECT = electrochemotherapy
Graph shows the objective response rate obtained in the second session, in a comparison between combined bleomycin administration, both systemic and local (S+L), and systemic alone (S Alone).ECT = electrochemotherapy

List of group 2 patients (control) treated using a repetition of the first session

PatientBreedLocation of the tumorWeight (kg)HistologyStageSize (cm3)Response 1 (ECT)Response 2 (ECT)
12Cross-breedOral30MelanomaI158.2PRSD
13Cross-breedOral21SarcomaIII79.76PRSD
14Cross-breedOral20CarcinomaIII96.5PRSD
15Toy PoodleOral5FibrosarcomaII23.23PDPD
16Cross-breedOral11MelanomaII73.8PRSD
17Cross-breedOral16SchwannomaII467.02PDSD
18Cross-breedOral6Squamous cell carcinomaII12.32SDSD
19Labrador retrieverOral32FibrosarcomaII40PRSD
20RottweilerOral34MelanomaII33PRPR
21German ShepherdOral39FibrosarcomaII101.18PRPD
22Cross-breedOral14MelanomaII14.4PRPR

List of group 1 patients treated using combined systemic and local bleomycin administration in the second treatment session

PatientBreedLocation of the tumorWeight (kg)HistologyStageSize (cm3)Response 1 (ECT)Response 2 (S+L)
1Labrador retrieverOral32MastocytomaII10.6PRCR
2Cross-breedOral21Squamous cell carcinomaII36.2SDPR
3Labrador retrieverNasal32Squamous cell carcinomaII43.5PRCR
4YorkshirePerianal5Solid differentiated carcinomaIV173.8SDSD
5Cross-breedElbow12SchwannomaI67.6SDPR
6RottweilerOral37FibrosarcomaI109.5SDCR
7Labrador retrieverNasal38Squamous cell carcinomaIII42.4SDPR
8BoxerOral37FibrosarcomaIII112.2SDPR
9Cocker spanielOral15MelanomaII8.7PRCR
10BeagleOral16MelanomaIII12.4PRCR
11Cocker spanielOral16MelanomaIII26.64PRCR

Yarmush ML, Golberg A, Serša G, Kotnik T, Miklavcic D. Electroporationbased technologies for medicine: principles, applications, and challenges. Annu Rev Biomed Eng 2014; 16: 295-320.YarmushMLGolbergASeršaGKotnikTMiklavcicDElectroporationbased technologies for medicine: principles, applications, and challengesAnnu Rev Biomed Eng20141629532010.1146/annurev-bioeng-071813-10462224905876Search in Google Scholar

Marty M, Sersa G, Garbay J, Gehl J, Collins C, Snoj M, et al. Electrochemotherapy - a simple, highly effective and safe treatment of cutaneous and subcutaneous metastases: results of ESOPE (European Standard Operating Procedures for Electrochemotherapy) study. EJC Suppl 2006; 4: 3-13.MartyMSersaGGarbayJGehlJCollinsCSnojMElectrochemotherapy - a simple highly effective and safe treatment of cutaneous and subcutaneous metastases: results of ESOPE (European Standard Operating Procedures for Electrochemotherapy) studyEJC Suppl2006431310.1016/j.ejcsup.2006.08.002Search in Google Scholar

Mali B, Jarm T, Snoj M, Sersa G, Miklavcic D. Antitumor effectiveness of electrochemotherapy: a systematic review and meta-analysis. Eur J Surg Oncol 2013; 39: 4-16.MaliBJarmTSnojMSersaGMiklavcicDAntitumor effectiveness of electrochemotherapy: a systematic review and meta-analysisEur J Surg Oncol20133941610.1016/j.ejso.2012.08.01622980492Search in Google Scholar

Spugnini EP, Baldi F, Mellone P, Feroce F, D’Avino A, Bonetto F, et al. Patterns of tumor response in canine and feline cancer patients treated with electrochemotherapy: preclinical data for the standardization of this treatment in pets and humans. J Transl Med 2007; 5: 48.SpugniniEPBaldiFMellonePFeroceFD’AvinoABonettoFPatterns of tumor response in canine and feline cancer patients treated with electrochemotherapy: preclinical data for the standardization of this treatment in pets and humansJ Transl Med200754810.1186/1479-5876-5-48208202017910745Search in Google Scholar

Cemazar M, Tamzali Y, Sersa G, Tozon N, Mir LM, Miklavcic D, et al. Electrochemotherapy in veterinary oncology. J Vet Intern Med 2008; 22: 826-31.CemazarMTamzaliYSersaGTozonNMirLMMiklavcicDElectrochemotherapy in veterinary oncologyJ Vet Intern Med2008228263110.1111/j.1939-1676.2008.0117.x18537879Search in Google Scholar

Spugnini EP, Fanciulli M, Citro G, Baldi A. Preclinical models in electrochemotherapy: the role of veterinary patients. Future Oncol 2012; 8: 829-37.SpugniniEPFanciulliMCitroGBaldiAPreclinical models in electrochemotherapy: the role of veterinary patientsFuture Oncol201288293710.2217/fon.12.6422830403Search in Google Scholar

London CA. Abstract SY28-01: Spontaneous cancer in dogs: Opportunities for preclinical evaluation of novel therapies. Cancer Res 2011; 71: SY28-01.LondonCAAbstract SY28-01: Spontaneous cancer in dogs: Opportunities for preclinical evaluation of novel therapiesCancer Res201171SY280110.1158/1538-7445.AM2011-SY28-01Search in Google Scholar

Spugnini EP, Dragonetti E, Vincenzi B, Onori N, Citro G, Baldi A. Pulsemediated chemotherapy enhances local control and survival in a spontaneous canine model of primary mucosal melanoma. Melanoma Res 2006; 16: 23-7.SpugniniEPDragonettiEVincenziBOnoriNCitroGBaldiAPulsemediated chemotherapy enhances local control and survival in a spontaneous canine model of primary mucosal melanomaMelanoma Res20061623710.1097/01.cmr.0000195702.73192.a016432452Search in Google Scholar

Tamzali Y, Borde L, Rols M, Golzio M, Lyazrhi F, Teissie J. Successful treatment of equine sarcoids with cisplatin electrochemotherapy: a retrospective study of 48 cases. Equine Vet J 2012; 44: 214-20.TamzaliYBordeLRolsMGolzioMLyazrhiFTeissieJSuccessful treatment of equine sarcoids with cisplatin electrochemotherapy: a retrospective study of 48 casesEquine Vet J2012442142010.1111/j.2042-3306.2011.00425.x21793876Search in Google Scholar

Spugnini EP, Citro G, Dotsinsky I, Mudrov N, Mellone P, Baldi A. Ganglioneuroblastoma in a cat: a rare neoplasm treated with electrochemotherapy. Vet J 2008; 178: 291-3.SpugniniEPCitroGDotsinskyIMudrovNMellonePBaldiAGanglioneuroblastoma in a cat: a rare neoplasm treated with electrochemotherapyVet J2008178291310.1016/j.tvjl.2007.08.01417910926Search in Google Scholar

Valpione S, Campana LG, Pigozzo J, Chiarion-Sileni V. Consolidation electrochemotherapy with bleomycin in metastatic melanoma during treatment with dabrafenib. Radiol Oncol 2015; 49: 71-4.ValpioneSCampanaLGPigozzoJChiarion-SileniVConsolidation electrochemotherapy with bleomycin in metastatic melanoma during treatment with dabrafenibRadiol Oncol20154971410.2478/raon-2014-0035436260925810704Search in Google Scholar

Campana LG, Mocellin S, Basso M, Puccetti O, De Salvo GL, Chiarion-Sileni V, et al. Bleomycin-based electrochemotherapy: clinical outcome from a single institutional experience with 52 patients. Ann Surg Oncol 2009; 16: 191-9.CampanaLGMocellinSBassoMPuccettiODe SalvoGLChiarion-SileniVBleomycin-based electrochemotherapy: clinical outcome from a single institutional experience with 52 patientsAnn Surg Oncol200916191910.1245/s10434-008-0204-818987914Search in Google Scholar

Mir LM, Gehl J, Sersa G, Collins CG, Garbay JR, Billard V, et al. 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 Cliniporator TM by means of invasive or non-invasive electrodes. EJC Suppl 2006; 4: 14-25.MirLMGehlJSersaGCollinsCGGarbayJRBillardVStandard operating procedures of the electrochemotherapy: instructions for the use of bleomycin or cisplatin administered either systemically or locally and electric pulses delivered by the Cliniporator TM by means of invasive or non-invasive electrodesEJC Suppl20064142510.1016/j.ejcsup.2006.08.003Search in Google Scholar

Jain RK. Normalization of tumor vasculature: an emerging concept in antiangiogenic therapy. Science 2005; 307: 58-62.JainRKNormalization of tumor vasculature: an emerging concept in antiangiogenic therapyScience2005307586210.1126/science.110481915637262Search in Google Scholar

Padera TP, Stoll BR, Tooredman JB, Capen D, di Tomaso E, Jain RK. Pathology: cancer cells compress intratumour vessels. Nature 2004; 427: 695.PaderaTPStollBRTooredmanJBCapenDdi TomasoEJainRKPathology: cancer cells compress intratumour vesselsNature200442769510.1038/427695a14973470Search in Google Scholar

Kumar V, Abbas AK, Aster JC. Robbins basic pathology. Elsevier Health Sciences; 2012.KumarVAbbasAKAsterJCRobbins basic pathologyElsevier Health Sciences201210.33029/9704-6467-0-KRB-2022-1-1036Search in Google Scholar

Warren BA. The vascular morphology of tumors. In: Peterson HI, editor. Tumor blood circulation: angiogenesis, vascular morphology and blood flow of experimental and human tumors. Boca Raton FL: CRC Press Inc.; 1979. p. 1-47.WarrenBAThe vascular morphology of tumors Peterson HIeditorTumor blood circulation: angiogenesis, vascular morphology and blood flow of experimental and human tumorsBoca Raton FLCRC Press Inc.197914710.1201/9780429283024-1Search in Google Scholar

WHO handbook for reporting results of cancer treatment. Geneva, Switzerland: WHO Offset Publications; 1979; 48: 22-7.WHO handbook for reporting results of cancer treatmentGeneva, SwitzerlandWHO Offset Publications197948227Search in Google Scholar

Jaroszeski M, Gilbert R, Perrott R, Heller R. Enhanced effects of multiple treatment electrochemotherapy. Melanoma Res 1996; 6: 427-33.JaroszeskiMGilbertRPerrottRHellerREnhanced effects of multiple treatment electrochemotherapyMelanoma Res199664273310.1097/00008390-199612000-000049013480Search in Google Scholar

Testori A, Tosti G, Martinoli C, Spadola G, Cataldo F, Verrecchia F, et al. Electrochemotherapy for cutaneous and subcutaneous tumor lesions: a novel therapeutic approach. Dermatol Ther 2010; 23: 651-61.TestoriATostiGMartinoliCSpadolaGCataldoFVerrecchiaFElectrochemotherapy for cutaneous and subcutaneous tumor lesions: a novel therapeutic approachDermatol Ther2010236516110.1111/j.1529-8019.2010.01370.x21054709Search in Google Scholar

Matthiessen LW, Johannesen HH, Hendel HW, Moss T, Kamby C, Gehl J. Electrochemotherapy for large cutaneous recurrence of breast cancer: a phase II clinical trial. Acta Oncol 2012; 51: 713-21.MatthiessenLWJohannesenHHHendelHWMossTKambyCGehlJElectrochemotherapy for large cutaneous recurrence of breast cancer: a phase II clinical trialActa Oncol2012517132110.3109/0284186X.2012.68552422731832Search in Google Scholar

Sersa G, Cufer T, Paulin SM, Cemazar M, Snoj M. Electrochemotherapy of chest wall breast cancer recurrence. Cancer Treat Rev 2012; 38: 379-86.SersaGCuferTPaulinSMCemazarMSnojMElectrochemotherapy of chest wall breast cancer recurrenceCancer Treat Rev2012383798610.1016/j.ctrv.2011.07.006Search in Google Scholar

Jules-Elysee K, White D. Bleomycin-induced pulmonary toxicity. Clin Chest Med 1990; 11: 1-20.Jules-ElyseeKWhiteDBleomycin-induced pulmonary toxicityClin Chest Med19901112010.1016/S0272-5231(21)00668-7Search in Google Scholar

Cohen IS, Mosher MB, O’Keefe EJ, Klaus SN, De Conti RC. Cutaneous toxicity of bleomycin therapy. Arch Dermatol 1973; 107: 553-5.CohenISMosherMBO’KeefeEJKlausSNDe ContiRCCutaneous toxicity of bleomycin therapyArch Dermatol1973107553510.1001/archderm.1973.01620190029007Search in Google Scholar

Recommended articles from Trend MD

Plan your remote conference with Sciendo