Electrochemotherapy Changes in Tumor Microenvironment of Cutaneous and Subcutaneous Metastases in Melanoma Patients

Official title

Electrochemotherapy Induces Changes in the Tumor Microenvironment of Cutaneous and Subcutaneous Metastases in Patients With Cutaneous Melanoma

Overview

In the last 10 years, the treatment of metastatic cutaneous melanoma has changed dramatically. The new systemic treatment with immunotherapy has led to a dramatic improvement in quality of life and overall survival. Systemic treatment means that the patient receives the drug as an infusion into a vein. Unfortunately, investigators know that immunotherapy is not equally successful in all patients. Recent studies have shown that the success of the treatment is not only influenced by the cellular composition of the metastasis, but also by its surroundings. This is called tumor microenvironment. Depending on the differences in the composition of this microenvironment, some metastases can be described as immunologically hot and others as immunologically cold. Immunologically hot metastases respond better to immunotherapy than immunologically cold metastases. Studies have shown that with some interventions can change the tumor microenvironment from being immune-cold to being immune-hot. Electrochemotherapy is one of the interventions that might improve the efficacy of immunotherapy in cutaneous melanoma. Electrochemotherapy is an established method for the local treatment of tumors, in which only a certain tumor is treated with special electrodes, to which a weak electric current is applied. Investigators hypothesize that electrochemotherapy stimulates the body's own immune response and enables more effective treatment. Since immunotherapy also stimulates the body's own immune response to cutaneous melanoma cells, the interaction of the two drugs could be even more successful. Recent research results support this assumption. The primary objective is to evaluate the changes in the tumor microenvironment of cutaneous and subcutaneous melanoma metastases induced by electrochemotherapy, based on the histologic analysis of treated and untreated metastases before and after treatment. The secondary aim is to determine whether the changes in the tumor microenvironment differ depending on the chemotherapeutic agent used. The results will help Investigators better understand the synergistic effects of electrochemotherapy and immunotherapy on cutaneous melanoma metastases. The combination of systemic immunotherapy and electrochemotherapy could become an important treatment method for patients with metastatic melanoma.

Detailed description

The study is prospective. The primary objective is to evaluate the changes in the tumor microenvironment of cutaneous and subcutaneous melanoma metastases induced by electrochemotherapy (ECT), based on the histologic analysis of treated and untreated metastases before and after treatment. The secondary aim is to determine whether the changes in the tumor microenvironment differ depending on the chemotherapeutic agent used.

In the study 10-15 patients will be enrolled and devided in two arms, ECT with bleomycin and ECT with cysplatin.

ECT will be offered to patients with cuteaneous melanoma and at least 5 in-transit or distant cutaneous and/or subcutaneous melanoma metastases regardless of previous treatments. The decision will be made in a multidisciplinary tumor board. The choice of chemotherapeuthic drug will depend on the size and number of lesions to be treated. Inclusion in the study has no influence on the decision regarding the timing of treatment with immunotherapy. Treatment with immunotherapy will later be included as a factor in the statistical analysis.

ECT will be performed according to the standard operating procedures for the treatment of cutaneous and subcutaneous tumors with ECT. ECT will be performed within 8 - 28 minutes after intravenous bolus administration of bleomycin (15.000 IU/m2 BSA) or directly after the intratumorally administration of cysplatin (0,5-2 mg/cm3 tumor). CliniporatorTM (IGEA S.P.A., Carpi, Italy) will be used to apply the pulses (8 pulses, 1300 V/cm, 100 μs, 5 kHz). Triggering of the electrical pulses will be synchronized with ECG signals, through the ECG triggering device AccuSync to avoid delivery of pulses in vulnerable period of the heart. The type of electrode used will be selected according to the size and location of the tumors.

One cutaneous/subcutaneous metastasis will be excised before ECT. One treated cutaneous/subcutaneous metastasis will be excised 2-4 and 9-13 days after the procedure. An untreated cutaneous/subcutaneous metastasis will be excised on day 9-13. The excisions will be performed under local anesthesia. All patients will be enrolled in the study after the procedures and the study have been explained to them in detail and they have signed an informed consent form. A venous blood sample will be taken at the same time points (before ECT, 2-4 days and 9-13 days after ECT).

Histological examination, assessment of the degree of regression and the presence of tumor infiltrating lymphocytes (TIL) will be performed according to standardized procedures on 2-3 μm thick tissue sections, previously fixed in formalin and embedded in paraffin (FFPE), stained with the hematoxylin-eosin (HE) staining method.

Immunohistochemical characterization of the tumor microenvironment will be performed on 2-4 μm thick tissue sections pre-fixed in formalin and embedded in paraffin. Investigators will use commercially available primary monoclonal antibodies to define the tumor inflammatory infiltrate, stroma and vasculature. We will use the following antibodies: CD3, CD4, CD8, CD56, CD163, FoxP3, ERG, PGM1, CD274 (PD-L1). The choice of antibodies used and the method of pathohistologic analysis may change depending on the results. Specific binding of primary antibodies will be visualized using the recommended three-step detection system OptiView DAB IHC Detection Kit (Cat. No. 760-700; manufactured by Ventana ROCHE inc., Tucson, AZ, USA) according to the manufacturer's instructions. The analysis will be performed by two independent pathologists.

Investigators will also collect the information about previous treatments for cutaneous melanoma and photographic documentation of the effectiveness of ECT treatment. Patients will also fill out internationally recognized, validated quality of life questionnaires (EORTC QLQ-C 30 and EQ-5D-5L) at entollment, after ECT, 3 months, 6 months and 12 months after ECT and then once a year during the follow-up period.

Interventions

• Procedure Electrochemotherapy with Intratumoral Cysplatin
  ECT will be performed directly after the intratumorally administration of cysplatin (0,5-2 mg/cm3 tumor). CliniporatorTM (IGEA S.P.A., Carpi, Italy) will be used to apply the pulses (8 pulses, 1300 V/cm, 100 μs, 5 kHz). Triggering of the electrical pulses will be synchronized with ECG signals, through the ECG triggering device AccuSync to avoid delivery of pulses in vulnerable period of the heart. The type of electrode used will be selected according to the size and location of the tumors.
• Procedure Electrochemotherapy with Intravenous Bleomycin
  ECT will be performed within 8 - 28 minutes after intravenous bolus administration of bleomycin (15.000 IU/m2 BSA). CliniporatorTM (IGEA S.P.A., Carpi, Italy) will be used to apply the pulses (8 pulses, 1300 V/cm, 100 μs, 5 kHz). Triggering of the electrical pulses will be synchronized with ECG signals, through the ECG triggering device AccuSync to avoid delivery of pulses in vulnerable period of the heart. The type of electrode used will be selected according to the size and location of the tum

Primary outcome measures

• Change in Tumor-Infiltrating Lymphocytes (TIL) Score Assessed by MIA Scoring System (Azimi et al.) [Time frame: Before electrochemotherapy (baseline), 2-4 days after electrochemotherapy, and 9-13 days after electrochemotherapy]
• Lymphocyte and Macrophage Distribution Density in Tumor Microenvironment Assessed by Park CH Method [Time frame: Before electrochemotherapy (baseline), 2-4 days after electrochemotherapy, and 9-13 days after electrochemotherapy]
• Number of Immune Marker-Positive Cells per mm² in Tumor Tissue Assessed by Immunohistochemistry (IHC) [Time frame: Before electrochemotherapy (baseline), 2-4 days after electrochemotherapy, and 9-13 days after electrochemotherapy]

Secondary outcome measures (2)

• Difference in Change of Tumor-Infiltrating Lymphocytes (TIL) Score (MIA Scoring) Between Bleomycin and Cisplatin Electrochemotherapy [Time frame: Before electrochemotherapy (baseline), 2-4 days after electrochemotherapy, and 9-13 days after electrochemotherapy]
• Difference in Immune Cell Density and Immune Marker-Positive Cells per mm² Between Bleomycin and Cisplatin Electrochemotherapy [Time frame: Before electrochemotherapy (baseline), 2-4 days after electrochemotherapy, and 9-13 days after electrochemotherapy]

Eligibility criteria

Inclusion criteria

• more than 4 cytologically and/or histologically confirmed intransit or distant cutaneous/subcutaneous cutaneous melanoma metastases
• ECT should be proposed as a treatment in the multidisciplinary tumor board
• cutaneous/subcutaneous melanoma metastases, that can be excised under local anesthesia with primary wound closure, minimal morbidity of the procedure (risk of complications < 5%) and nocosmetic or functional consequences of the procedure
• stage IIIB, IIIC or IV of the disease
• age over 18 years
• performance status World Health Organization more than 2
• patients must give informed consent

Exclusion criteria

• age less than 18 years
• polimorbidity
• performance status World Health Organization more than 2
• high risk for intervention under general anesthesia;
• wound closure would require coverage with a skin graft or local flap;
• undesirable cosmetic or functional consequences would be expected (face, extensor side of joints)
• patients incapable of understanding the aim of the study or disagree with the entering into the clinical study

Criteria are shown verbatim from the registry (in English). Final eligibility is always assessed by the study center.

Healthy volunteers: No

Study design

Allocation

Non-randomized

Model

Factorial

Masking

Open label

Primary purpose

Basic science

Study locations

Slovenia · 1 center

• Institute of Oncology Ljubljana — Ljubljana

Publications

• Zadnik V, Primic Zakelj M, Lokar K, Jarm K, Ivanus U, Zagar T. Cancer burden in slovenia with the time trends analysis. Radiol Oncol. 2017 Feb 22;51(1):47-55. doi: 10.1515/raon-2017-0008. eCollection 2017 Mar 1. PMID 28265232
• Littman DR. Releasing the Brakes on Cancer Immunotherapy. Cell. 2015 Sep 10;162(6):1186-90. doi: 10.1016/j.cell.2015.08.038. PMID 26359975
• Goggins CA, Khachemoune A. The use of electrochemotherapy in combination with immunotherapy in the treatment of metastatic melanoma: a focused review. Int J Dermatol. 2019 Aug;58(8):865-870. doi: 10.1111/ijd.14314. Epub 2018 Nov 26. PMID 30479009
• Garbe C, Amaral T, Peris K, Hauschild A, Arenberger P, Basset-Seguin N, Bastholt L, Bataille V, Del Marmol V, Dreno B, Fargnoli MC, Forsea AM, Grob JJ, Hoeller C, Kaufmann R, Kelleners-Smeets N, Lallas A, Lebbe C, Lytvynenko B, Malvehy J, Moreno-Ramirez D, Nathan P, Pellacani G, Saiag P, Stratigos AJ, Van Akkooi ACJ, Vieira R, Zalaudek I, Lorigan P; European Dermatology Forum (EDF), the European A PMID 35623961
• Quaglino P, Mortera C, Osella-Abate S, Barberis M, Illengo M, Rissone M, Savoia P, Bernengo MG. Electrochemotherapy with intravenous bleomycin in the local treatment of skin melanoma metastases. Ann Surg Oncol. 2008 Aug;15(8):2215-22. doi: 10.1245/s10434-008-9976-0. Epub 2008 May 23. PMID 18498012
• Kunte C, Letule V, Gehl J, Dahlstroem K, Curatolo P, Rotunno R, Muir T, Occhini A, Bertino G, Powell B, Saxinger W, Lechner G, Liew SH, Pritchard-Jones R, Rutkowski P, Zdzienicki M, Mowatt D, Sykes AJ, Orlando A, Mitsala G, Rossi CR, Campana L, Brizio M, de Terlizzi F, Quaglino P, Odili J; InspECT (the International Network for Sharing Practices on Electrochemotherapy). Electrochemotherapy in the PMID 28118487
• Campana LG, Valpione S, Mocellin S, Sundararajan R, Granziera E, Sartore L, Chiarion-Sileni V, Rossi CR. Electrochemotherapy for disseminated superficial metastases from malignant melanoma. Br J Surg. 2012 Jun;99(6):821-30. doi: 10.1002/bjs.8749. Epub 2012 Apr 17. PMID 22508342
• Cadossi R, Ronchetti M, Cadossi M. Locally enhanced chemotherapy by electroporation: clinical experiences and perspective of use of electrochemotherapy. Future Oncol. 2014 Apr;10(5):877-90. doi: 10.2217/fon.13.235. PMID 24799067

Identifiers

NCT: NCT06388252 · ERID-KSOPR-0049/2023 · 0120-297/2023/3

Primary sources (government registries)

• ClinicalTrials.gov (US NIH)

View this study on ClinicalTrials.gov ↗