Patent Grant
12214189
Treatment options for nonresectable tumors are restricted due to multiple clinical factors, most notably the presence of tumors near critical structures (large blood vessels and nerve bundles), extensive tumor volumes, and/or metastases. Alternate therapies like microwave ablation, radiofrequency ablation, and cryoablation are also limited by tumor location, and thermal therapies are indiscriminate and can easily damage these critical structures. In contrast, electroporation-based therapies (EBTs) are appealing and have proven advantageous for treating or ablating nonresectable tumors due to their nonthermal mechanisms of cell death, which spare proteinaceous structures including nerves and vasculature.
Clinically, EBTs are applied using one or more array of needle electrodes placed in and around the target tissue site. High amplitude (up to 3000 V), short duration (50-100 μs) pulsed electric fields (PEFs) are applied across the electrodes, exposing target tissues to high local field strengths. This results in an increased voltage drop across the cell membrane (transmembrane potential) and gives rise to the creation of defects on the cell membrane. Depending on the pulsing protocol, these defects are either transient or can lead to irrevocable damage.
In a systematic review, electrochemotherapy (ECT), which utilizes reversible electroporation (RE) for enhanced drug delivery, demonstrates an increased overall complete response rate of 59.4% compared to 8.0% with chemotherapy alone, regardless of tumor type. Conversely, irreversible electroporation (IRE) utilizes higher field strengths and increased pulse number to irreversibly disrupt the cell membrane. As the electric fields applied for IRE also encompass fields which generate RE, IRE can be utilized as a combinatorial therapy to ablate a central tumor core with peritumoral RE for enhanced delivery of adjuvant molecular agents. Notably, combinatorial treatment of locally advanced pancreatic cancer with standard-of-care and IRE demonstrated nearly double median overall survival compared to standard-of-care alone. In addition, preclinical trials in a spontaneous canine GBM model have yielded complete responses, demonstrating the effectiveness of IRE as a therapy for intracranial tumors. (Rossmeisl, John H., et al. “Safety and feasibility of the NanoKnife system for irreversible electroporation ablative treatment of canine spontaneous intracranial gliomas.” J. neurosurgery 123.4 (2015): 1008-1025.)
More recently, a second generation IRE therapy known as High Frequency IRE (H-FIRE) has emerged as an ablation modality that incorporates beneficial aspects of nonthermal ablation improving upon traditional IRE. H-FIRE utilizes bursts of bipolar pulses (˜0.5-10 μs) to destabilize cellular membrane structures within the therapeutic field, inhibiting tumor growth. H-FIRE for the treatment of spontaneous intracranial malignancies, for example, is highly efficacious due to compounding effects that alter the highly resistive, invasive, and immunosuppressive environment protecting glioblastoma (GBM) and other brain tumors.
H-FIRE forms a predominantly nonthermal ablation within heterogenous tumors such as GBM, regardless of chemotherapeutic resistance. In addition, prior in vitro studies demonstrate lower therapeutic electric fields are required to induce cell death in malignant brain cell lines compared to healthy brain cell lines, suggesting preferential targeting of malignant phenotypes.
Sub-H-FIRE electric fields are known to cause a reversible electroporation (RE) effect where cells are temporarily permeabilized to larger, normally impermeable chemotherapeutics. In vitro experiments have demonstrated cell-impermeable dye uptake within hours of treatment with RE fields.
Recent investigations have elucidated a long-lived disruption of the blood-brain-barrier (BBB), resulting in enhanced molecular diffusion of impermeable hydrophilic molecules into the brain parenchyma. Finally, recent investigations have elucidated a shift in the tumor microenvironment from immunosuppressive to pro-inflammatory after treatment with an EBT, suggesting that combinatorial H-FIRE and immunotherapy may have a synergistic effect. Thus, tumor ablation with H-FIRE provides multiple avenues for the treatment of non-resectable, highly resistive tumors.
Despite widespread use, EBTs face a unique challenge: intraoperative monitoring of treatment progression towards the determination of a clinical endpoint. Current approaches to determine extent of ablation rely either on postoperative procedures, including imaging with MRI and ultrasound techniques or intraoperative electrical characterization techniques based on a pre-defined change in tissue resistance/current. (W. van den Bos, D. M. de Bruin, A. van Randen, M. R. Engelbrecht, A. Postema, B. Muller, I. Varkarakis, A. Skolarikos, C. Savci-Heijink, R. Jurhill et al., “MRI and contrast-enhanced ultrasound imaging for evaluation of focal irreversible electroporation treatment: results from a phase i-ii study in patients undergoing ire followed by radical prostatectomy,” European radiology, vol. 26, no. 7, pp. 2252-2260, 2016.) For example, an absolute change in current/resistance is used to determine a clinical endpoint. The current implementation of this technique, using 50-100 μs IRE/ECT pulses, utilizes direct current (DC) current/resistance measurements which are highly coupled (electroporation+Joule heating) and would make it impossible to differentiate between electroporation induced changes in impedance and temperature-induced changes in impedance. Here, the inventors provide a method which uses a high-frequency reference, which is not susceptible to electroporation effects (
Within the β-dispersion frequency band (˜1 kHz-100 MHz), biological tissue can be represented as a 3-domain system, where a high impedance cell membrane separates the intracellular and extracellular spaces. (D. Voyer, A. Silve, L. M. Mir, R. Scorretti, and C. Poignard, “Dynamical modeling of tissue electroporation,” Bioelectrochemistry, vol. 119, pp. 98-110, 2018; Q. Castellvi, B. Mercadal, and A. Ivorra, “Assessment of electroporation by electrical impedance methods,” in Handbook of electroporation. Springer-Verlag, 2016, pp. 671-690; O. G. Martinsen and S. Grimnes, Bioimpedance and bioelectricity basics. Academic press, 2011.) Prior to electroporation (EP), the intact cell membrane impedes low frequency currents, restricting current flow to the extracellular domain (
The analysis of tissue impedance with bursts of bipolar pulses can be characterized into two categories: 1) intra-burst (in-pulse) impedance measurements, the impedance analysis of the EBT waveform, and 2) inter-burst impedance measurements, the impedance analysis at discrete timepoints between therapeutic PEFs. An application for intra-burst impedance has focused on quantifying changes in tissue conductivity during the EBT pulses (N. Beitel-White, S. Bhonsle, R. Martin, and R. V. Davalos, “Electrical characterization of human biological tissue for irreversible electroporation treatments,” in 2018 40th Annual International Conference of the IEEE Engineering in Medicine and Biology Society (EMBC). IEEE, 2018, pp. 4170-4173; A. Ivorra, B. Al-Sakere, B. Rubinsky, and L. M. Mir, “In vivo electrical conductivity measurements during and after tumor electroporation: conductivity changes reflect the treatment outcome,” Physics in Medicine & Biology, vol. 54, no. 19, p. 5949, 2009), aimed towards the creation of accurate pretreatment planning models (Y. Zhao, S. Bhonsle, S. Dong, Y. Lv, H. Liu, A. Safaai-Jazi, R. V. Davalos, and C. Yao, “Characterization of conductivity changes during high-frequency irreversible electroporation for treatment planning,” IEEE Transactions on Biomedical Engineering, vol. 65, no. 8, pp. 1810-1819, 2017; R. E. Neal II, P. A. Garcia, J. L. Robertson, and R. V. Davalos, “Experimental characterization and numerical modeling of tissue electrical conductivity during pulsed electric fields for irreversible electroporation treatment planning,” IEEE Transactions on Biomedical Engineering, vol. 59, no. 4, pp. 1076-1085, 2012).
As mentioned previously, inter-burst impedance measurements have been used to gauge the extent of EP. While H-FIRE addresses intricacies associated with current IRE technology (i.e., H-FIRE mitigates muscle excitation, field distortions in heterogenous tissues, and potential cardiac arrythmias), challenges in determining a clinical endpoint with all EBTs still exist. Proposed solutions towards determining a clinical endpoint of EBTs include monitoring changes in bulk tissue impedance/resistance and changes in tissue conductivity distribution. This includes:
While these technologies have been successful in predicting cell kill in their respective experimental setups, there are limitations in the equipment required to implement these procedures. For example, although these technologies are successful in mapping tissue impedance changes following treatment, there exists difficulties in integrating these technologies with existing pulse generators, there is typically additional cost or expense associated with additional equipment, and the impedance spectrum acquisition timeframe (˜10 s) is typically much larger than that between pulse periods (˜1 s) used with EBTs.
Here, the present inventors introduce Fourier Analysis SpecTroscopy (FAST) as an impedance spectroscopy methodology for monitoring tissue impedance changes during EBTs in real-time. Specifically, the development of both diagnostic FAST, aimed towards monitoring inter-burst impedance, and therapeutic FAST, aimed towards inducing tissue EP while simultaneously monitoring high voltage intra-burst tissue impedance (
To this end, methods for rapid bioimpedance measurements have been previously proposed. In summary, rapid EIS measurements are dependent on applying low-voltage or low-current stimulus, subsequent Fourier Transform, followed by analysis in the frequency domain. Above all else, these methods should be performed to minimize inclusion of significant nonlinearities (membrane resealing). Several stimulation signals have been proposed, including multisine waves (B. Sanchez, G. Vandersteen, R. Bragos, and J. Schoukens, “Optimal multisine excitation design for broadband electrical impedance spec-troscopy,” Measurement Science and Technology, vol. 22, no. 11, p. 115601, 2011), Gaussian pulses (M. Min, U. Pliquett, T. Nacke, A. Barthel, P. Annus, and R. Land, “Broadband excitation for short-time impedance spectroscopy,” Physio-logical measurement, vol. 29, no. 6, p. S185, 2008), rectangular chirps (M. Min, A. Giannitsis, R. Land, B. Cahill, U. Pliquett, T. Nacke, D. Frense, G. Gastrock, and D. Beckmann, “Comparison of rectangular wave excitations in broad band impedance spectroscopy for microfluidic applications,” in World Congress on Medical Physics and Biomedical Engineering, Sep. 7-12, 2009, Munich, Germany. Springer, 2009, pp. 85-88), maximum length binary sequences (S. Gawad, T. Sun, N. G. Green, and H. Morgan, “Impedance spectroscopy using maximum length sequences: Application to single cell analysis,” Review of Scientific Instruments, vol. 78, no. 5, p. 054301, 2007), and white-noise (S. C. Creason, J. W. Hayes, and D. E. Smith, “Fourier transform faradaic admittance measurements iii. comparison of measurement efficiency for various test signal waveforms,” Journal of Electroanalytical chemistry and interfacial electrochemistry, vol. 47, no. 1, pp. 9-46, 1973). Particularly in the field of electroporation, only modest works have been conducted to investigate inter-burst impedance changes throughout the entirety of treatment.
Previously, García-Sánchez et al. proposed utilization of a multi-sine burst for impedance analysis between 5 kHz to 1.313 MHz at 21 discrete frequencies. (T. García-Sánchez, A. Azan, I. Leray, J. Rosell-Ferrer, R. Bragos, and L. M. Mir, “Interpulse multifrequency electrical impedance measurements during electroporation of adherent differentiated myotubes,” Bioelectrochemistry, vol. 105, pp. 123-135, 2015.) Preference to using rectangular waveforms, over sinusoidal excitation signals (B. Sanchez, G. Vandersteen, R. Bragos, and J. Schoukens, “Basics of broadband impedance spectroscopy measurements using periodic excitations,” Measurement Science and Technology, vol. 23, no. 10, p. 105501, 2012), is such that rectangular waveforms are easily integrated into existing pulse generator topologies for EBTs as the pulse widths implemented are similar to those delivered with nanosecond PEFs, high-frequency bipolar PEFs, and monopolar PEFs. Ultimately, the inventors aim to minimize the excitation of cardiomyocytes, skeletal muscle fibers, and nerve fibers during impedance characterization with diagnostic FAST; for example through the use of a charge balanced bipolar chirp waveform, the stimulation of excitable tissues will be kept to a minimum. This would further extend applicability into techniques such as cardiac ablation. FAST introduces a novel application of high-frequency tissue impedance measurements as an indicator of the extent of Joule heating effects during EP. Although low-frequency impedance measurements are sensitive to both EP effects and Joule heating, the inventors have found that high frequency currents, which short the membrane reactance, are less sensitive to EP effects and can uniquely act to distinguish thermal effects (
Previously, the inventors utilized a Fourier analysis to quantify intra-burst impedance changes during H-FIRE therapy. (S. Bhonsle, M. F. Lorenzo, A. Safaai-Jazi, and R. V. Davalos, “Characterization of nonlinearity and dispersion in tissue impedance during high-frequency electroporation,” IEEE Transactions on Biomedical Engineering, vol. 65, no. 10, pp. 2190-2201, 2017.) By fitting the resulting data to a dispersive parallel RC (resistance and capacitance) tissue model, this technique allowed for quantifying the ex vivo porcine tissue conductivity/permittivity response at varying applied electric fields with an end goal directed towards pre-treatment planning. The goal was to show that the electric field distribution was more homogenous by determining the conductivity function for predicting the electric field.
Here, the inventors' initial findings are extended to develop diagnostic FAST for monitoring inter-burst electrical impedance spectra directed towards monitoring treatment outcome with EBTs and therapeutic FAST for monitoring intra-burst impedance directed towards characterizing biological tissue response during EP. Their findings suggest acquisition of an impedance spectrum (˜0.1 kHz-100 MHz), such as a high-bandwidth inter-burst impedance spectrum (between 1.8 kHz-4.93 MHz) and intra-burst impedance spectrum (between 18.3 kHz-1.96 MHz) is possible at >100 discrete frequencies per spectrum and at a capture rate <<1 s. Through the modification of existing H-FIRE waveforms, the inventors demonstrate bipolar pulse schemes of pulse width 1 μs-1 ms enable FAST to capture electrical impedance content at frequencies between 1 kHz-5 MHz. This technique not only enables real-time EIS but allows for novel applications for high-frequency impedance as a parameter to delineate thermal effects from that of EP during EBTs. FAST technologies can be used to monitor EBT treatment outcomes (e.g., when an expected endpoint of treatment has been reached and/or the success of a treatment, such as whether the desired ablation effect has been achieved), EBT treatment progress, and/or detect or warn of thermal effects. FAST technologies are especially suited to provide for such monitoring in real-time during an EBT treatment, which can be very helpful in knowing when to alter treatment parameters, or when to halt treatment temporarily (such as to avoid excess temperatures), or when to stop treatment completely.
Embodiments of the invention include Aspect 1, which is a method for monitoring administration of electrical pulses comprising: obtaining a baseline impedance spectrum; administering a plurality of electrical pulses; obtaining one or more additional impedance spectrum; identifying any impedance spectrum change relative to the baseline; and monitoring the administering to determine if a desired endpoint is reached as indicated by the impedance spectrum change, and i) adjusting one or more parameters of, ii) stopping, iii) halting, and/or iv) continuing the administering based on the monitoring.
Aspect 2 is the embodiment of Aspect 1, wherein the endpoint for irreversible electroporation is a point during the administering where electroporation no longer contributes to any impedance spectrum change as evidenced by the obtaining of a flat impedance spectrum.
Aspect 3 is the method of Aspect 1 or 2, further comprising halting the administering to allow tissue temperature to reach a desired level, then resuming the administering to the desired endpoint.
Aspect 4 is the method of any of Aspects 1-3, comprising: delivering a low-voltage, wideband signal of electrical pulses; and monitoring treatment outcome through monitoring inter-burst impedance by capturing voltage and current and performing discrete Fourier transform analysis.
Aspect 5 is the method of any of Aspects 1-4, wherein impedance is captured within a frequency range of above 0.1 kHz to 100 MHz, such as between 1.8 kHz and 4.93 MHz.
Aspect 6 is the method of any of Aspects 1-5, wherein delivering of the electrical pulses comprises applying one or more low-voltage pulses interleaved between one or more high-voltage pulses.
Aspect 7 is the method of any of Aspects 1-6, wherein delivering of the electrical pulses comprises applying pulses in the range of 0.1 μs to 10 ms, such as at a high frequency signal of 1-50-1-50 μs, appended to a low frequency signal of 250-10-250-10 μs.
Aspect 8 is the method of any of Aspects 1-7, further comprising: delivering one or more high-voltage burst of pulsed electric fields; and monitoring tissue response through monitoring high-voltage intra-burst impedance by capturing voltage and current and performing discrete Fourier transform analysis.
Aspect 9 is the method of any of Aspects 1-8, wherein impedance is captured within a frequency range of above 0.1 kHz to 100 MHz, such as between 18.3 kHz and 1.96 MHz.
Aspect 10 is the method of any of Aspects 1-9, wherein the delivering comprises a high-frequency irreversible electroporation burst scheme of pulse width and intra-phase delay ranging from 0.1 μs to 10 ms, and inter-pulse delay ranging from 0.1 μs to 1 s, such as delivering high-frequency irreversible electroporation using a 2-5-2 μs scheme, followed by a 100 μs delay.
Aspect 11 is the method of any of Aspects 1-10, wherein the baseline impedance spectrum and/or the additional impedance spectrum is obtained by one or more of: reference to an impedance spectrum based on standard impedance values for a particular material or tissue; measuring impedance of a material or tissue over a selected frequency band; measuring voltage and/or current and calculating impedance therefrom; and/or calculating impedance as a function of frequency using the formula:
Aspect 12 is the method of any of Aspects 1-11, further comprising using the impedance spectrum change measured at high frequencies to predict a temperature change, such as in tissue, relating to the administering of the electrical pulses.
Aspect 13 is the method of any of Aspects 1-12, wherein the impedance spectrum change indicates one or more of: whether irreversible or reversible electroporation of a tissue has, is or will occur; whether chemical cell death and/or decellularization has, is or will occur; whether death and/or decellularization has, is or will occur due to a physical disruption; whether a tissue is healthy or cancerous; whether a tissue has damage from a stroke and/or traumatic brain injury; whether cell lysis has, is or will occur as evidenced by flattening of the impedance spectrum with no recovery following pulse cessation; whether cell necrosis has, is or will occur as evidenced by flattening of the impedance spectrum with minimal recovery following pulse cessation; and/or whether cell apoptosis has, is or will occur as is evidenced by flattening of the impedance spectrum with moderate recovery following pulse cessation.
Aspect 14 is the method of any of Aspects 1-13, wherein the change in the impedance indicates: whether degradation of a coating has, is or will occur; and/or whether a coating of a material has corrosion and/or a level of the corrosion.
Aspect 15 is the method of any of Aspects 1-14, wherein the monitoring comprises: monitoring tissue decellularization and/or cell death; monitoring gene-transfection efficiency and uptake; monitoring thermal and/or non-thermal tissue ablation for cardiac arrythmias; and/or monitoring cell lysis for immunotherapies.
Aspect 16 is a treatment monitoring system for administering electrical pulses comprising: one or more electrical pulse generator(s); one or more probe(s) capable of connection with the electrical pulse generator(s); one or more controller(s) capable of controlling one or more of the electrical pulse generator(s) and/or one or more of the probe(s) to: administer a plurality of electrical pulses; obtain a baseline impedance spectrum; obtain one or more additional impedance spectrum; and identify any impedance spectrum change relative to the baseline.
Aspect 17 is the treatment monitoring system of any of Aspect 16, further comprising a processing module with a processor in combination with memory and computer-executable instructions configured to process the impedance spectra using a Fourier Transform algorithm.
Aspect 18 is the treatment monitoring system of Aspect 16 or 17, wherein: one or more of the pulse generator(s) is capable of delivering high-voltage pulses; and one or more of the pulse generator(s) is capable of delivering low-voltage pulses.
Aspect 19 is a treatment monitoring system (such as that of any of Aspects 16-18), wherein: one or more controller(s) is a microcontroller capable of connection with: a first 5V H-Bridge circuit for connection with a high-voltage pulse generator; a 15V H-Bridge circuit for connection with a low-voltage pulse generator; and a second 5V H-Bridge circuit for connection with two Reed relays on a high-voltage circuit (HVRR) and two Reed relays on a low-voltage circuit (LVRR); wherein the microcontroller is capable of: triggering the Reed relays on the low-voltage circuit to close; triggering the low-voltage generator to deliver pulses; ceasing the LVRR trigger signal to open the LV and HV circuits; triggering the HVRR Reed relays on the high-voltage circuit to close; triggering the high-voltage generator to deliver pulses.
Aspect 20 is the treatment monitoring system of any of Aspects 16-19, wherein one or more of the controller(s) is capable of i) adjusting one or more parameters of, ii) stopping, iii) halting, and/or iv) continuing the triggering of the low-voltage and/or high-voltage generators based on the impedance spectrum change.
Aspect 21 is a system comprising: one or more probe(s) providing functionality for: delivering a plurality of electrical pulses to a tissue; and measuring electrical impedance relating to the tissue; wherein the functionality is on the same probe or different probes; an impedance analyzer coupled to one or more of the impedance measuring probes; a low voltage power supply and a high voltage power supply coupled to one or more of the probes and configured to deliver a low voltage and/or high voltage energy to the probe(s); one or more waveform generator coupled to one or more of the probes and the low and/or high voltage power supplies; and one or more switch coupled to the low voltage and high voltage power supplies, and configured to perform the delivering of the plurality of electrical pulses in the form of low voltage pulses and/or high voltage pulses, and configured to enable switching between HV and LV.
The accompanying drawings illustrate certain aspects of embodiments of the present invention, and should not be used to limit the invention. Together with the written description, the drawings serve to explain certain principles of the invention.
Reference will now be made in detail to various exemplary embodiments of the invention. It is to be understood that the following discussion of exemplary embodiments is not intended as a limitation on the invention. Rather, the following discussion is provided to give the reader a more detailed understanding of certain aspects and features of the invention.
Definitions:
The term “pulse” refers to an electrical signal with a single phase (monopolar, unipolar) or more than one phase (bi-polar). If bi-polar, there can be a delay between phases or the switch between phases can be immediate (no intra-pulse delay).
The term “burst” refers to a set of pulses, a group of pulses, or a pulse group.
The term “intra-pulse delay” refers to the condition where no energy is applied for a period of time during the bipolar pulses.
The term “inter-pulse delay” refers to the condition where no energy is applied for a period of time between one bipolar pulse or set of bipolar pulses and another bipolar pulse.
The term “intra-burst delay” refers to the condition where no energy is applied for a period of time between one or more bursts.
The term “inter-burst delay” refers to the condition where no energy is applied for a period of time within a burst and in some cases may be the same as an intra- or inter-pulse delay.
The term “cycled pulsing scheme” or “cycles” refers to a pulse scheme in which the total number of pulses are delivered over more than one cycle. The total number of pulses per cycle is calculated by dividing the total number of desired pulses by the number of cycles. The term may be used interchangeably with “cycled pulsing protocol,” “cycled pulsing sequence,” “cycled pulsing,” “cycled pulsing paradigm,” “cycled pulsing embodiment,” “cycled pulse sequencing,” “cycled pulse paradigm,” or “cycled pulsing pattern.” For example, a cycled pulsing scheme is shown in
The term “total on time” or “combined signal duration” or “energized time” refers to the time associated with energizing an electrode. For example, a single 1-50-1-50 μs burst scheme would have a total on time of 2 μs for each burst, whereas a 250-10-250-10 μs burst would have a total on time of 500 μs for each burst.
The term “pulse protocol” or “pulsing scheme” or “pulsing protocol” or “pulse scheme” refers to a protocol defined by any one or more of or all of the following: the number of pulses; the duration of each pulse; any inter-pulse, intra-pulse, inter-burst, or intra-burst delay; the number of bursts; and the number of cycles, if applicable.
The term “saturation” refers to an impedance measurement or spectrum matching or converging with another impedance measurement or spectrum. For example, low frequency impedance can be monitored for saturation to the high frequency impedance, meaning a low frequency impedance measurement can be taken and compared with a previous baseline and/or reference high frequency impedance measurement.
Embodiments of the invention provide a Fourier Analysis SpecTroscopy (FAST) technique as an impedance spectroscopy methodology for monitoring impedance changes in a material or tissue, such as during electroporation-based therapies (EBTs) in real-time. Included within embodiments are a diagnostic FAST methodology and a therapeutic FAST methodology.
The term “diagnostic FAST” refers to a pulse scheme designed for monitoring inter-burst impedance of a material or tissue, such as during EBTs, including IRE and/or H-FIRE treatments. Diagnostic FAST can be achieved by delivering a low-voltage (0 V to 100 V), wideband signal (e.g., comprising rectangular bipolar pulses) and performing voltage and current capture followed by discrete Fourier transform for analysis in the frequency domain. Diagnostic FAST can be applied prior to treatment, to determine the impedance spectrum of the tissue in an intact state, during treatment in between high voltage pulses, to continually monitor changes in impedance due to electroporation pulses, immediately after treatment to measure the final state of the tissue, and in the time following treatment to measure the recovery of the cell membrane and recovery of the impedance spectrum. This will be described in more detail below.
In embodiments, the low-voltage electrical pulses/bursts can be applied using a voltage of above 0 V to 100 V, such as up to 10 V, up to 15 V, up to 20 V, up to 30 V, up to 40 V, up to 50 V, up to 60 V, up to 70 V, up to 80 V, up to 90 V, or from 5-85 V, or from 12-55 V, or from 35-75 V, or from 15-45 V, or any range in between any of these ranges or endpoints, including as endpoints any number encompassed thereby. Additionally, although rectangular pulses are more typical, the signal can comprise a waveform with any step, square, sinusoidal, ramp, Gaussian, or sinc function having constant, increasing, or decreasing frequency, or any arbitrary signal designed to achieve a desired frequency spectrum, such as in the range of 0.1 kHz to 100 MHz.
Diagnostic FAST comprises a pulse protocol (typically administering at a low-voltage) constructed by concatenating a high-frequency signal to low-frequency signal to form the final waveform: positive phase−intra-phase delay−negative phase−inter-pulse delay+positive phase−intra-phase delay−negative phase−inter-pulse delay. The set of high-frequency signal(s) (comprising: positive phase−intra-phase delay−negative phase−inter-pulse delay) can be delivered first or after the low-frequency signal(s) (comprising: positive phase−intra-phase delay−negative phase−inter-pulse delay). For example, the pattern can be a set of high-frequency signal(s)+a set of low-frequency signal(s), or low-frequency signal(s)+high frequency signal(s). If desired, multiple pulses, such as rectangular bipolar pulse signals, can be concatenated to form a continuous chirp like that in
The term “therapeutic FAST” refers to a pulse scheme designed to induce tissue EP while monitoring high voltage intra-burst impedance changes in real time. Therapeutic FAST can be achieved by delivering a high-voltage (100 V to 15,000 V) burst of bipolar PEFs and is an adaptation of a traditional high-frequency IRE burst, modified to maximize the frequency bandwidth and resolution to enable intra-burst impedance spectroscopy. In embodiments, the high-voltage electrical pulses/bursts can be applied using a voltage of 100 V to 15,000 V, such as from 500 V up to 3,000 V, and/or from 1,000 V up to 2,000 V, such as up to 250 V, up to 300 V, up to 350 V, up to 600 V, up to 650 V, up to 800 V, up to 1,200 V, up to 1,500 V, up to 15,000 V, up to 7,500 V, from 4,000 V to 12,000 V, or any range in between any of these ranges or endpoints, including as endpoints any number encompassed thereby. In embodiments, the electrical pulses can be administered using a frequency ranging from 100 Hz to 100 MHz, such as in the Hz range from 100 Hz or 1 Hz up to 100 Hz, or from 2 Hz to 100 Hz, or from 3 Hz to 80 Hz, or from 4 Hz to 75 Hz, or from 15 Hz to 80 Hz, or from 20 Hz to 60 Hz, or from 25 Hz to 33 Hz, or from 30 Hz to 55 Hz, or from 35 Hz to 40 Hz, or from 28 Hz to 52 Hz, or any range in between any of these ranges or endpoints, including as endpoints any number encompassed thereby. Additionally, pulses can be administered using a frequency in the kHz or MHz range, such as from 1 kHz to 10 kHz, or from 2 kHz to 8 kHz, or from 3 kHz to 5 kHz, or from 4 kHz to 15 kHz, or from 6 kHz to 20 kHz, or from 12 kHz to 30 kHz, or from 25 kHz to 40 kHz, or from 5 kHz to 55 kHz, or from 50 kHz to 2 MHz, including any range in between, such as from 75 kHz to 150 kHz, or from 100 kHz to 175 kHz, or from 200 kHz to 250 kHz, or from 225 kHz to 500 kHz, or from 250 kHz to 750 kHz, or from 500 kHz to 1 MHz, or any range in between any of these ranges or endpoints, including as endpoints any number encompassed thereby.
FAST schemes can be employed to measure the electrical impedance of testing loads which include, but are not limited to, biological tissues. The bandwidth (frequency limits) and the resolution (number of data points within the bandwidth) of the obtained FAST impedance spectrum are dependent on the pulsing schemes applied to the tissue. The characteristic frequency of each burst scheme determines the lowest frequency at which impedance data is attained, the characteristic frequency being defined as:
fchar=1/(2*pulse width[μs]+intra-phase delay[μs]+interpulse delay[μs]) kHz.
Therefore, pulsing parameters can be modified to a user-desired frequency bandwidth. A method to verifying frequency content entails taking the Fourier Transform and identifying the high-power signal in the frequency spectrum. The high-power signal is processed, and these frequencies constitute the frequencies at which impedance capture is possible.
Fourier Analysis SpecTroscopy (FAST) can be used as a methodology utilizing modified EBT waveforms to conduct low voltage inter-burst (diagnostic FAST) and high-voltage intra-burst (therapeutic FAST) impedance spectroscopy. Diagnostic FAST is the state of the tissue following pore resealing, while therapeutic FAST is a snapshot of the impedance during the pulse, a state when the pores are forming/formed.
For example, a 1-50-1-50+250-10-250 μs diagnostic FAST burst scheme can be used to measure frequencies ranging from above 0.1 kHz to 100 MHz, such as between ˜2 kHz-5 MHz (
A therapeutic FAST/H-FIRE burst scheme can be used to ablate and capture impedance information with FAST, for example simultaneously. A 2-5-2-100 μs pulse protocol can be used as the therapeutic FAST scheme, with changes in tissue impedance being monitored preferably in real-time (
Non-square waveforms (i.e. pulsed triangular waveforms, continuous sawtooth waveforms, multisine bursts, and/or multistage waveforms—
In embodiments, the real impedance data matches that attained from a commercial potentiostat (
Using embodiments of the invention, recovery dynamics can now be explored. A slow tissue impedance recovery (back to baseline) will signify dead/dying tissue, whereas a quick recovery can suggest reversible or minimal electroporation, with such analyses helpful in determining when a particular treatment endpoint has been reached, and/or when a particular treatment should be modified/adjusted, halted or stopped.
Diagnostic FAST can be used to provide a patient specific endpoint for electroporation-based therapies. While the existence of the beta dispersion within an impedance spectrum of a densely populated cell suspension/tissue is known, FAST allows for detecting the magnitude of the high frequency impedance. Once this value is determined, a low frequency impedance measurement can be monitored for its saturation to the high frequency impedance reference; this will signify ablation of cells within a therapeutic field, as this is an indication of cell membrane damage. The magnitude of this impedance will vary patient to patient, though the saturation of the low frequency to the high frequency impedance can serve as a marker for the endpoint of treatment. For example, as shown in
This relationship, saturation of the low frequency (˜5 kHz) to high frequency (˜2 MHz) impedance, is specific to peripheral tumor tissue, calcified tumor tissue, necrotic tissues, healthy/tumor ischemic tissues, traumatic brain injury, fibrotic tissues, tissue states prior to and after chemotherapy, and tissue states prior to and after radiation. This technique is also applicable to the classification of tissues, such as identifying/determining between various tissue types such as brain, liver, prostate, kidney, pancreas, and tumor tissues arising from unique electrical characteristics of each tissue.
Diagnostic FAST can be fine-tuned and utilized to monitor changes in tissue morphology, edema, perfusion, fluid infusion, thermal necrosis, cell death by electrical, mechanical, or thermal means, identifying cell subtypes, identifying intracellular structures and morphology, gauging efficacy of drug delivery, integrity of the blood-brain-barrier, and tissue heterogeneity. For example, with respect to edema, methods of the invention are capable of detecting increases in conductivity due to edema influx, which is an indication of a positive immune response to the EP treatment. In some embodiments, the methods of treating/monitoring can include treating tissue and/or cells (e.g., a tumor or a cancer) within a target site in a subject by administering a plurality of electrical pulses to the target site which can induce non-thermal electroporation, such as irreversible electroporation (IRE), of the treatment site; measuring a treatment parameter, including, but not limited to, impedance or an impedance spectrum; detecting a change in the measured parameter such as a change in impedance; and performing an additional downstream or secondary treatment as a result of a change in impedance that indicates a positive immune response (such as edema), wherein the downstream or secondary treatment step can include, but is not limited to, tumor resection, thermal ablation, a secondary non-thermal ablation, chemotherapy, radiation therapy, immunotherapy, biologic therapy, genetic therapy (gene editing), and combinations thereof.
In particular, for example, diagnostic FAST can be used to monitor tissue decellularization/cell death as the impedance spectrum/dispersion flattens. This technique can be used for, but is not limited to, monitoring tissue ablation such as irreversible electroporation, chemical cell death/decellularization (e.g., by surfactants, acids, and/or bases), disruption by physical means (such as by high-intensity focused ultrasound (HIFU), Histotripsy, and/or laser ablation), monitoring gene-transfection efficiency and/or uptake, monitoring tissue ablation (nonthermal, thermal) for cardiac arrythmias, monitoring cell lysis for immunotherapies, and monitoring mechanisms of cell death. Prior to tissue damage/decellularization, the impedance spectrum will feature a prominent dispersion. Following tissue damage, the dispersion will flatten, indicative of low cellular integrity or cellular density.
While prior literature has shown EIS as a potential tool for monitoring electroporation, the equipment, complexity, and more importantly the time required to implement EIS substantially limits applicability and does not currently allow for real-time measurements. This is true if the application of EIS is for monitoring impedance changes during treatment, as opposed to before and/or immediately after a series of ˜100 pulses are delivered. In addition, this invention includes using electrical measurements to monitor temperature changes with existing IRE technology.
With respect to monitoring cell death, lysis will be represented as a flattening of the impedance spectrum/dispersion with no recovery following pulse cessation. As cell lysis involves immediate destruction of the cell membrane, the measurement of impedance recovery, or lack thereof, will be possible on within minutes after treatment. Necrosis will be represented as a flattening of the impedance spectrum/dispersion with minimum recovery following pulse cessation. This assumes pore-formation does not recover and cell is essentially in a lysed state. Apoptosis will be represented as a flattening of the impedance spectrum/dispersion with moderate recovery following pulse cessation. This assumes pore-formation recovery, where the cell dies due to intracellular signaling. As this process occurs on a timescale of hours following treatment, impedance measurements with FAST can be conducted to monitor recovery of the cell membrane within minutes following the end of treatment. Pro-inflammatory forms of cell death, such as necroptosis/necrosis, will aid in determination of administration of immunologic agents.
High frequency tissue impedance measurements can be used to approximate changes in tissue temperature and gauge nonthermal ablation. For example, a 2-5-2-100 μs therapeutic FAST scheme can be used to monitor changes in high-frequency tissue impedance due to temperature. Since changes in temperature are approximated as having a linear impact on the tissue impedance, changes in tissue temperature can be approximated by monitoring the changes in high frequency impedance and using an appropriate temperature coefficient of resistance for the tissue in question:
ZT=Z·(1+α·ΔT) (1)
Here, ZT is the conductivity of the tissue at an elevated change in temperature ΔT, Z the baseline conductivity, and α the temperature coefficient of resistance. For potatoes, an alpha value of 2.25%/° C. was used.
As explained in greater detail below, the inventors employ: 1) numerical methods to examine various FAST schemes in regards to the maximum attainable frequency range and resolution, 2) a flat-plate electrode configuration using potato tissue to validate FAST-measured impedance against a commercial potentiostat using the selected diagnostic and therapeutic FAST from numerical methods, 3) a two-needle configuration in potato tissue to monitor impedance changes during IRE therapy and validate FAST-measured impedance against a commercial potentiostat, 4) a flat-plate electrode configuration to heat potato tissue using therapeutic FAST, with the goal of using the measured impedance to delineate thermal effects from those of EP.
In all cases presented, the extraction of impedance from the numerically simulated or experimentally recorded voltage waveforms V(t) and current waveforms I(t) is as follows. V(t) and I(t) were analyzed in MATLAB vR2018a (MathWorks Inc., Natick, MA, US) using the Fast Fourier Transform (FFT) algorithm, in which the length of the FFT was defined as the next power of 2 from the length of the voltage signal. This resulted in V(f) and I(f), thereafter the magnitude of V(f), labeled as VFFT, was defined. To identify and isolate high-power peaks in VFFT, a peak extraction algorithm in MATLAB was implemented; a single data point was extracted from each high-power peak if the power of the peak was a threshold value 2% of max(VFFT). The data points identified were subsequently extracted from V(f) and I(f), where the impedance was calculated using Ohm's law:
MATLAB functions “real( )” and “imag( )” were used to analyze the real and imaginary parts of the impedance, respectively.
Numerical Testing to Determine the Desired FAST Schemes
Preliminary studies to determine the frequency content of various FAST schemes in the absence of instrument/measured noise were conducted using MATLAB and COMSOL Multiphysics v5.5 (COMSOL Inc., Stockholm, Sweden). Voltage waveforms V(t) of amplitude 15 V were constructed in MATLAB using a series of concatenated rectangular pulses with 80 ns rise/fall-times. These V(t) waveforms were imported into COMSOL for numerical analysis. A 0D circuit model was constructed in the “Electrical Circuit” module for the circuit shown in
Preliminary investigations of various FAST schemes were conducted using MATLAB vR2018a (MathWorks Inc., Natick, MA, US); determination of optimal pulse schemes included minimizing total signal duration (<10 ms) and frequency content following a Fast Fourier Transform (FFT). In MATLAB, ideal voltage waveforms with 8 ns risetimes were produced using a series of concatenated square waves of pulse-widths 1 μs to 1 ms. Similar to H-FIRE bipolar burst schemes, FAST schemes were designed using a (positive phase-intrapulse delay-negative phase) scheme to maintain the clinically beneficial aspects of H-FIRE. Two sets of FAST schemes were constructed to satisfy the following two experimental investigations.
Both diagnostic and therapeutic FAST were produced to follow a positive phase−intra-phase delay−negative phase−inter-pulse delay pattern (
Once ideal voltage waveforms were created, an FFT algorithm was implemented to determine the frequency content and power spectral density (PSD) of various burst schemes. The PSD was computed by taking the magnitude of the voltage FFT squared and dividing by the length of the time vector.
The PSD reveals the frequencies at which data acquisition, the impedance spectrogram, is possible for the 1-50-1-50+250-10-250-10 μs diagnostic FAST scheme (
Based on the results, the desired diagnostic and therapeutic FAST which maximized the frequency range and frequency resolution for impedance capture were identified and selected. In embodiments, the desired frequency range for impedance capture and the corresponding selection of pulsing scheme pulse width, intraphase delay, and interpulse delay (diagnostic FAST) can be determined prior to treatment. The impedance extracted from the low-voltage pulse is then used to inform treatment endpoint, which can be controlled by personal or software/hardware.
Validation of Low-Voltage FAST Against a Commercial Potentiostat in Potato Tissue Using Flat Plate Electrodes
Following computational investigations in MATLAB, therapeutic and diagnostic FAST schemes were characterized using an in vitro potato tuber tissue model. Like biological tissues, potato tissue is composed of cells embedded within a fibrous matrix, this system loosely represents the macroscopic composition of biological tissues and similarly undergo electroporation. As a result, impedance changes due to electroporation and tissue ablation in potatoes resemble that of biological tissues. Potato tissue ablation occurs through an enhanced oxidative mechanism involving the release of intracellular enzymes that results in a rapid black oxidation of the tissue exposed to higher therapeutic fields; this rapidly oxidized tissue area represents the ablative region.
Select FAST schemes were further tested using a vegetal potato tuber model for validation of FAST-measured impedance against a commercial potentiostat. The system shown in
A russet potato was sliced to a thickness of 0.7 cm and further sectioned using a cylindrical cutter of diameter 0.8 cm. This tissue sample was placed between two flat plate electrodes (
Select diagnostic and therapeutic FAST schemes were tested in potato tissue in vitro (
The minimum and maximum frequency at which data was extracted for diagnostic FAST were 1.78 kHz and 4.69 MHz, respectively, with 216 data points fitting within this range. For LV therapeutic FAST, the minimum and maximum frequency for data acquisition were 18.3 kHz and 1.82 MHz, respectively, with 170 data points fitting within this range.
The resultant potato impedance was calculated using Ohm's law; real (tissue resistance) and imaginary (tissue reactance) impedance are shown in
Diagnostic FAST for Monitoring Ablation Outcome During IRE Therapy with Needle Electrodes in Potatoes
Analogous to biological tissue, following PEF treatment, potato tissue undergoes impedance changes due to EP. Therefore, the diagnostic FAST scheme was used to monitor tissue impedance changes and ablation outcome following the application of IRE pulses.
A 2D configuration was implemented to simplify characterization of ablation areas. Potatoes were sectioned uniformly to a 0.7 cm thickness with an ellipsoidal cross section ˜15×10 cm using a generic mandolin cutter. Two, 20-gauge cylindrical stainless-steel needle electrodes were inserted at the center of the sample and maintained at a 1 cm spacing; these electrodes were used for both EIS and tissue ablation with IRE (
Prior to tissue ablation, a baseline impedance spectrum was measured using a Gamry Reference 600 (Gamry, Warminster, PA, US) at a frequency band 1 kHz and 1 MHz at 10 points per decade. Thereafter, the diagnostic FAST scheme was also implemented for comparison to the commercial potentiostat. All low voltage FAST schemes were delivered using an AFG3021C function generator (Tektronix Inc., Beaverton, OR, US). The voltage and current waveforms were recorded using a WaveSurfer 3024z Oscilloscope (Teledyne LeCroy, Chestnut Ridge, New York). For high voltage waveforms the voltage was stepped down using a 1000× high voltage probe (Enhancer 3000, BTX, Holliston, MA) while the current was recorded using a 10× current probe (2877, Pearson Electronics, Palo Alto, California). Alternatively, separate LV and HV generators can be used to administer the LV and HV waveforms, respectively.
Following baseline impedance characterization, 1, 5, 10, 20, 40, and 80 IRE pulses were delivered at 1000 V and 100 μs on-time (n=9); additional impedance measurements were taken following each pulse group. To mitigate thermal effects on the measured impedance spectrum, IRE pulses were delivered in sets of 10 where applicable with a 1-minute delay in between each set. The potatoes were covered in plastic wrap and stored overnight to allow for tissue oxidation. The oxidized area in each sample was used to quantify the ablative region and was measured in ImageJ software.
Transitioning to a needle electrode (2D) configuration,
IRE was delivered at a pulsing rate 1 Hz; of the 6 treatment groups (Table 1), pulses for groups 4-6 were split into sets of 10 and a 1 minute delay added in between sets to allow for impedance capture with FAST (<1 s) and the potentiostat (>10 s), as well as to allow for heat dissipation. All groups demonstrated an IRE ablation, with 1 pulse (1 P) showing the smallest ablation (1.63±0.26 cm2). As the number of pulses was increased, the ablation area increased: 5 P (2.23±0.34 cm2), 10P (3.45±0.49 cm2), 20 P (3.92±0.33 cm2), 40 P (4.44±0.35 cm2), and lastly the 80 P group resolving in the largest measured ablation (4.57±0.29 cm2) (
A one-way ANOVA with Tukey's post hoc multiple comparisons test revealed statistical differences between all treatment groups except for the 10P vs 20 P group (p=0.074) and the 40 P vs 80 P groups (p=0.964). After 20 pulses, there is a slowed progression in ablation size after additional pulses, with the 40 P and 80 P groups showing no statistical differences. Bulk tissue impedance decreased following IRE treatment (
Delineating Temperature Effects from EP Using High Frequency Impedance
It is known that for a cell suspension and biological tissues, low frequency currents are mostly restricted to the extracellular domain as the intracellular contents are shielded by the highly impeditive cell membrane. At higher frequencies within the beta dispersion band, the cell membrane reactance is essentially shorted and resolves in measurements of a state in which the intracellular and extracellular resistance are in parallel. This state is uniquely realized when tissue is uniformly and nonthermally ablated, such as in tissue ablation with IRE. Once a cell is irreversibly electroporated, electrically, the intracellular and extracellular domains blur; EIS measurements no longer contain a beta dispersion and almost resemble a flat line with the low frequency impedance magnitude converging to that of the high frequency impedance magnitude. Therefore, the relatively unchanged high frequency impedance can be used to monitor changes in temperatures during electroporation-based therapies; this frequency lacks any effects of tissue electroporation, thereby isolating the effects of tissue Joule Heating.
During IRE, the low frequency impedance changes are likely attributed to a combination of tissue electroporation as well as Joule Heating; measuring only the low frequency impedance, as is the standard method with the commercial NanoKnife system, will result in a multivariate signal with no means of separation. The present inventors therefore introduce the measurements of high frequency impedance for isolating impedance changes due solely to Joule Heating. In addition, once the temperature effects on impedance are determined, these temperature effects can then be subtracted from those of the low frequency, effectively isolating the changes in tissue impedance due solely to electroporation.
As shown in
As low frequency currents are mostly restricted to the extracellular domain prior to EP, due to a high membrane resistance, membrane permeabilization throughout PEF treatment greatly influences impedance changes. In addition, Joule Heating effects also shift the impedance spectrum as a function of temperature change. Therefore, it is difficult to isolate thermal and EP effects from the measured impedance. High frequency currents, within the β-dispersion band, short the cell membrane reactance and impedance changes are less susceptible to EP-effects (
A therapeutic FAST/H-FIRE waveform of 2-5-2-100 μs pulses was used to simultaneously heat the tissue while resolving in a large enough frequency band to monitor changes in high frequency impedance. H-FIRE waveforms were delivered using a custom bipolar pulse generator (EPULSUS-FBM1-5, Lisboa, Portugal) to output stainless steel electrodes. This generator consists of two unipolar Marx generators capable of producing voltage waveforms with pulse risetimes of 100 ns and a maximum voltage/current output of 5 kV/50 A.
As opposed to the previous 2D electroporation setup, a 1D electroporation setup consisting of flat plate stainless steel electrodes were utilized to expose the tissue to a uniform electric field. A rectangular shape factor of length, width, and thickness dimensions 2 cm×2 cm×7 mm was used. The rectangular shape factor allows for analytical calculation of the tissue conductivity using the following equation: σ=(I·t)/(V·Ac), where I is the induced current, t is the sample thickness, V is the applied voltage, and Ac is the cross-sectional area. The H-FIRE treatment comprised 400 bursts of bipolar pulses, each energized for 100 μs at an electric field of 1,500 V/cm.
A russet potato was sectioned to a rectangular shape of length, width, and thickness 2×2×0.7 cm. Prior to treatment, an impedance spectrum was quantified using a low-voltage therapeutic FAST scheme with energized time 100 μs; this scheme was implemented to match the impedance attained during treatment. Thereafter, high voltage therapeutic FAST was delivered using a custom-built H-FIRE generator; due to pulse-generator limitations, output voltage was restricted to 1200 V with an energized time of 40 μs per burst and 400 bursts delivered. Temperature was monitored using a FLIR A325SC thermal camera (FLIR, Wilsonville, OR, USA). High voltage waveforms were recorded using a 1000 high voltage probe (Enhancer 3000, BTX, Holliston, MA) and current was captured using a 10 current probe (3792, Pearson Electronics, Palo Alto, California).
The difference between pre-treatment inter-burst impedance and the Nth burst intra-burst impedance is used to quantify temperature increase. By assuming temperature increases linearly with a fixed temperature coefficient of resistance, equation (3) was used to calculate ΔT based on changes in tissue impedance:
Here, ΔT(t) is the calculated increase in temperature, Z(t) is the impedance at the Nth burst, Z0 is the pre-treatment impedance, and a the temperature coefficient of resistance. An average α value of 2.8%/° C. was used. (N. Boussetta, N. Grimi, N. I. Lebovka, and E. Vorobiev, ““cold” electroporation in potato tissue induced by pulsed electric field,” Journal of food engineering, vol. 115, no. 2, pp. 232-236, 2013).
Nonlinear regression analysis was performed and a null hypothesis describing “a single curve fit” between the commercial potentiostat and FAST impedance data was tested. Here, a p-value<0.05 was considered statistically significant (null hypothesis rejected). The R2 reported are those relative to the global/shared curve fit between the potentiostat and FAST-measured impedance. The real part of the impedance for all data sets was fit to a 4-parameter logistic regression model, an adaptation to the Cole-Cole equations:
The measured ablations were compared using a one-way ANOVA with a post-hoc Tukey's multiple comparisons test. A p-value<0.05 was considered statistically significant. Statistical analysis was conducted in GraphPad Prism v8.2.
More specifically, a FLIR thermal camera was used to record the increase in temperature at a rate of 10 Hz during treatment (
Therapeutic FAST schemes were recorded on the oscilloscope at a rate 0.5 Hz and subsequently transferred to MATAB for analysis. By assuming that the changes in tissue temperature vary linearly with high frequency tissue impedance (α=2.25%/° C.), equation 1 is used to predict the ΔT based off the experimentally varied voltage and current waveforms (
With respect to the circuit model analogy (
Between low voltage pre-treatment impedance (Z0) and the 1st burst high voltage intra-burst impedance (Z1), a negligible temperature rise was measured ΔT 0.04° C. (
Therefore, the predicted temperature starting at the 400th burst was calculated and is seen in
Low frequency impedance changes are sensitive to EP-effects due to increased cell membrane permeabilization. If high-energy PEFs heat the tissue, this impedance change is a multivariate signal affected by both EP and thermal effects. High frequencies can short the cell membrane reactance and are therefore less susceptible to EP-effects. Potato tissue was uniformly heated (
Numerical Determination of Select Diagnostic and Therapeutic FAST Schemes
Firstly, the parameters Re, Rm, Cm, and Ri fitted to the impedance measurements were determined as 2071.2Ω, 9.71E06Ω, 6.53 nF, and 198.35Ω, respectively. It should be noted that a more accurate fit to the impedance spectrum is attained by replacing the membrane elements Rm∥Cm with a constant phase element, though the Rm∥Cm was selected to allow for time dependent circuit analysis using the circuit element nodes in COMSOL. The numerical V(t) and I(t) from COMSOL were processed in MATLAB and a subset of the results are plotted in
From numerical simulations, two FAST schemes were selected. The diagnostic FAST scheme is a bipolar pulsing scheme consisting of a high frequency signal 1-50-1-50 μs (84 cycles) appended to a low frequency signal 250-10-250-10 μs (2 cycles) for a combined signal duration 9.608 ms (
In embodiments, bipolar or unipolar pulses can be used for diagnostic FAST and/or therapeutic FAST, along with any type of waveform (e.g., a waveform with any step, square, sinusoidal, ramp, Gaussian, or sinc function) having constant, increasing, and/or decreasing frequency, or any arbitrary signal designed to achieve a desired frequency spectrum in the range of above 0.1 kHz to 100 MHz.
The total number of pulses/bursts per diagnostic FAST or therapeutic FAST treatment or total number of pulses/bursts per cycle can range from 1 to 5,000 pulses/bursts, such as from at least 1 up to 3,000 pulses/bursts, or at least 2 up to 2,000 pulses/bursts, or at least 5 up to 1,000 pulses/bursts, or at least 10 up to 500 pulses/bursts, or from 10 to 100 pulses/bursts, such as from 20 to 75 pulses/bursts, or from 30 to 50 pulses/bursts, such as 1, 5, 10, 15, 20, 25, 30, 35, 40, 45, 50, 60, 70, or 90 pulses/bursts, or any range in between any of these ranges or endpoints, including as endpoints any number encompassed thereby.
According to any embodiment of diagnostic or therapeutic FAST, each pair of electrodes can be activated by a pulse train with no delay between pulses in the pulse train. In other embodiments, one or more delays can be introduced, such as a delay between one or more pulses in the pulse train, and/or a delay between the activation of one or more pair of electrodes, and/or a delay between one or more of the cycles. The delay can be on the order of microseconds or seconds, such as one to one thousand microseconds, such as 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 15, 20, 25, 30, 35, 40, 45, 50, 75, 100, 150, 200, 250, 300, 350, 400, 450, 500, 600, 700, 800, 900, or 1,000 microseconds or one to several seconds such as 1, 1.5, 2, 2.5, 3. 3.5, 4, 4.5, 5, 5.5, 6, 6.5, 7, 7.5, 8, 8.5, 9, 9.5, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 22, 24, 26, 28, 30 seconds or more. Cumulatively, the one or more delays may be on the order of seconds or minutes.
Likewise, where cycled pulsing paradigms are used for diagnostic or therapeutic FAST, the number of cycles can be any number of cycles, such as zero cycles, or from 1-100 cycles, or from 2-50 cycles, or from 3-40 cycles, or from 4-30 cycles, or from 5-20 cycles, or from 10-15 cycles, or any range in between any of these ranges or endpoints, including as endpoints any number encompassed thereby.
The therapeutic FAST scheme is a modified H-FIRE burst scheme to include an extended inter-pulse delay (e.g., 100 μs): 2-5-2-100 μs burst scheme (25 cycles) energized for 100 μs (
An FFT algorithm was implemented to attain V(f) and I(f); the magnitude of V(f), labeled VFFT, is shown for the diagnostic FAST scheme (
Diagnostic FAST demonstrates frequency content ranging from ˜2 kHz to 5 MHz; 204 data points were extracted within this frequency range (
Broadband Impedance Spectroscopy with Diagnostic FAST
A diagnostic FAST waveform consisting of a high frequency signal 1-50-1-50 μs (84 cycles) appended to a low frequency signal 250-10-250-10 μs (2 cycles) was identified to reliably capture impedance with a frequency range spanning 1.8 kHz-4.9 MHz at 216 discrete frequencies. A broadband impedance spectroscopy is achievable using pulsing parameters currently applied in EBTs.
Although the distribution of frequencies is neither linearly nor logarithmically spaced (B. Sanchez and R. Bragos, “Fast electrical impedance spectroscopy for moving tissue characterization using bilateral quasilogarithmic multisine bursts signals,” in 4th European Conference of the International Federation for Medical and Biological Engineering. Springer, 2009, pp. 1084-1087), nonlinear regression demonstrated the real part of the impedance acquired from FAST does not deviate significantly from that of a calibrated commercial potentiostat (
Therapeutic FAST Allows for High-Bandwidth Intra-burst Impedance Spectroscopy
The therapeutic FAST waveform is proposed to permeabilize/ablate biological cells while simultaneously allowing for high-bandwidth intra-burst impedance spectroscopy. The selected therapeutic FAST is a high voltage 2-5-2-100 μs burst scheme, an H-FIRE burst scheme modified to include an extended inter-pulse delay following the negative polarity pulse. This extended inter-pulse delay increases the resolution of the impedance spectrum, allowing for intra-burst impedance spectroscopy between 18.3 kHz to 1.96 MHz (
Monitoring Change in Temperature Using Tissue Electrical Impedance
In contrast to impedance change at low-frequencies being sensitive to both EP effects and Joule heating, the inventors have found that high-frequency impedance measurements, whose corresponding electric currents short the membrane reactance, are less sensitive to EP effects and can uniquely act to distinguish thermal effects. The flat-plate electrode configuration (
To demonstrate monitoring of temperature, 300 bursts of bipolar pulses (
A 6th order Butterworth filter was applied to exclude frequency components above cutoff frequency 5 MHz. A linear approximation for Joule heating is assumed relating the impedance and temperature change by means of the temperature coefficient of resistance α.
Zi+1=Zi·(1+α(T−T0)) (6)
As this analysis is conducted for impedance changes attributed to both electroporation and thermal effects, the term Δθ is utilized, as opposed to ΔT, to represent this relationship. Equation 6 is rewritten as:
Zi+1=Zi·(1+α(θ−θ0)) (7)
Through algebraic manipulation, Equation 7 can be converted into Equation 8.
Defining FAST-Controlled Pulsing Endpoint or Pulsing Intervals
A circuit model analogy describing tissue response to pulsed electric fields is described by Voyer et al. (D. Voyer et al. “Dynamical modeling of tissue electroporation.” Bioelectrochemistry 119 (2018): 98-110). Here, it can be discerned that once a cell membrane is fully electroporated (i.e., a lysed state), the electrical impedance is a function of only the intracellular resistance and extracellular resistance. This phenomenon is reflected by a theoretical flat impedance spectrum in which electroporation would no longer contribute to impedance changes (
In embodiments, for example, a clinical endpoint for electroporation can be defined when low-frequency impedance measurements, either a single frequency or a range of frequencies between 0.1 kHz to 500 kHz, continually decreases to a value within 20% of the reference or baseline high-frequency impedance measurements, either a single frequency or a range of frequencies between 500 kHz to 100 MHz. This is visually depicted as a flattening of the impedance spectrum during electroporation treatment.
Alternatively, or in addition, a clinical endpoint can be defined when the present low-frequency impedance measurements, either a single frequency or a range of frequencies between 0.1 kHz to 500 kHz, is unchanged compared to a prior low-frequency measurement, such as within a window of approximately 1-10%, such as within 5%. In this clinical endpoint, the low-frequency impedance measurement does not decrease to the magnitude of the high-frequency reference and does not satisfy criteria for clinical endpoint defined in above. However, the tissue is still “fully-electroporated.” Pulsing in this scenario is terminated to avoid thermal damage. The following equation can be used to calculate the percent change in the present low-frequency impedance relative to the prior measurement:
Here, Z0 is the baseline low-frequency impedance measurement, Zi is the ith pulse/burst in the treatment, and Zi−1 is the pulse/burst previous to the ith pulse/burst in the treatment.
In the event the impedance profile does not saturate following a set of pulses, where the number of pulses is defined either by a predetermined number of pulses or a FAST-calculated ΔT, treatment can be adjusted, stopped, and/or halted to allow for heat dissipation to avoid or prevent excessive tissue heating. The adjusting or stopping/halting of the treatment can be performed automatically by the system and/or the system can provide prompts to the user through a graphical user interface that provide information and/or options to the user on how to proceed. Once the tissue temperature has reached a desirable level, pulsing can continue. This methodology can be repeated until the pulsing endpoint is met (flat impedance profile). A theoretical, representative pulsing profile for which multiple pulsing sets might be used is depicted in
In embodiments, for example, the halting/pausing of electroporation treatment can be defined as delivering a pre-determined number of pulses/bursts (0-1,000) across one or more electrode/probe pair combinations. Once this value is reached, treatment can be paused for a pre-determined time (e.g., 0-600 s), as shown in
Alternatively, or in addition, the halting/pausing of electroporation treatment can be defined as reaching a pre-determined increase in temperature (e.g., 0-50° C.) across one or more electrode/probe pair combinations. This increase in temperature is measured using either a temperature measurement device (fiber optic temperature sensor, thermocouple, etc.) or by using high-frequency impedance measurements to predict temperature change. Once this temperature increase is reached, treatment will be paused for a pre-determined time (e.g., 0-600 s) or until a temperature decrease (e.g., 0-50° C.) criteria is met. This process will be repeated until the clinical endpoint, such as determined from diagnostic FAST impedance measurements, is reached.
System for Administering FAST Protocol
Embodiments of the present invention can include one or more components as illustrated in
For example, a treatment protocol according to the invention could include a plurality of electrodes disposed on any number of probes. According to the desired treatment and/or data acquisition pattern, the plurality of electrodes can be disposed in various positions relative to one another. In a particular example, a plurality of electrodes can be disposed in a relatively circular or square or rectangular pattern. Any configuration of electrodes is possible and the arrangement need not be circular, square or rectangular, but any shape periphery can be used, including triangular, depending on the area to be treated, including any regular or irregular polygon shape, including convex or concave polygon shapes. Any of the electrodes can be a ground electrode and any of the other electrodes in the plurality can be energized. Any number of electrodes can be in the plurality such as from about 1 to 20. Indeed, even 3 electrodes can form a plurality of electrodes, or 4 electrodes can be disposed in a manner to provide two electrode pairs (each pair comprising one ground and one electrode capable of being energized). During treatment, methods of treating can involve energizing the electrodes in any sequence, such as energizing one or more electrode simultaneously, and/or energizing one or more electrode in a particular sequence, such as sequentially, in an alternating pattern, in a skipping pattern, and/or energizing multiple electrodes but less than all electrodes simultaneously, for example.
In embodiments, each probe includes either a monopolar electrode or bipolar electrodes. The amount of exposure of an active portion of the electrode can be adjusted by retracting or advancing an insulating sleeve relative to the electrode. See, for example, U.S. Pat. No. 7,344,533, which is incorporated by reference herein in its entirety. The pulse generator(s) are connected to a treatment control computer 40 having input devices such as keyboard 12 and a pointing device 14, and an output device such as a display device 11, including a graphical user interface (GUI), for viewing information obtained from the FAST protocol. One or more probe is used to treat a lesion, tissue, or area/region of interest (ROI) 300 inside a patient 15 and/or to perform diagnostic and/or therapeutic FAST monitoring in conjunction with such treatment. An imaging device 30 includes a monitor 31 for viewing the lesion 300 inside the patient 15 in real time and for monitoring the diagnostic and/or therapeutic FAST monitoring. Examples of imaging devices 30 include ultrasonic, CT, MRI and fluoroscopic devices as are known in the art.
The present invention includes computer software (treatment monitoring module 54) which assists a user to plan for, execute, and review the results of a medical treatment procedure, as will be discussed in more detail below. For example, the treatment monitoring module 54 assists a user to plan for a medical treatment procedure by enabling a user to more accurately position each of the probes 22 of the therapeutic energy delivery device 20 in relation to the tissue, ROI, or lesion 300 in a way that will generate the most effective treatment zone, and/or provide options for the practitioner/user concerning whether and how to adjust treatment, and/or halt or stop treatment based on the impedance changes being measured by way of the diagnostic and/or therapeutic FAST monitoring. The treatment monitoring module 54 can display the progress of the treatment, such as monitoring with FAST, in real time and can display the results of the treatment procedure and/or results of the diagnostic or therapeutic FAST after it is completed. This information can be displayed in a manner such that it can be used for example by a physician to determine whether the treatment was successful and/or whether it is necessary or desirable to re-treat the patient, continue to treat the patient, or stop treatment based on the FAST results.
Any non-transitory computer-readable media can be used to store the software and/or the output of the software for a particular treatment protocol.
For purposes of this application, the terms “code”, “software”, “program”, “application”, “software code”, “computer readable code”, “software module”, “module” and “software program” are used interchangeably to mean software instructions that are executable by a processor. The “user” can be a physician or other medical professional. The treatment monitoring module 54 executed by a processor outputs various data including text and graphical data to the monitor 11 associated with the generator 10.
Referring now to
In one embodiment, the computer 40 is built into the voltage generator(s) 10. In another embodiment, the computer 40 is a separate unit which is connected to the voltage generator(s) through the communications link 52. In a preferred embodiment, the communication link 52 is a USB link. In one embodiment, the imaging device 30 is a standalone device which is not connected to the computer 40. In the embodiment as shown in
It should be noted that the software can be used independently of the pulse generator(s) 10. For example, the user can monitor the treatment by way of FAST in a different computer as will be explained below and then save the treatment parameters to an external memory device, such as a USB flash drive (not shown). The data from the memory device relating to the treatment parameters can then be downloaded into the computer 40 to be used with the generator 10 for treatment. For example, the data can be evaluated by a human to determine or estimate favorable treatment protocols for a particular patient or programmed into a device for implementing the particular protocol.
In another embodiment, an electronic drive system for delivering bipolar electroporation signals is schematically depicted in
Other systems are available in the literature for generating bipolar pulses, and the invention should not be limited to the system described above. For example, De Vuyst et al. built a generator around an NE555 timer configured as an astable multivibrator capable of producing up to 50 kHz bipolar pulses. De Vuyst, E., M. De Bock, E. Decrock, M. Van Moorhem, C. Naus, C. Mabilde, and L. Leybaert, In situ bipolar Electroporation for localized cell loading with reporter dyes and investigating gap junctional coupling. Biophysical Journal, 2008. 94(2): p. 469-479. However, the frequency of the pulses administered according to embodiments of the invention are an order of magnitude greater, which is easily met by the bandwidth of the AFG 3011. Additionally, the MOSFET switches provide an excellent means to produce high-frequency pulses for high voltage switching. However, MOSFETs are not the only semiconductor devices that can be utilized to produce a pulse. Bipolar Junction Transistors (BJTs), Insulated Gate Bipolar Transistors (IGBTs), and Junction Field Effect Transistors (JFETs) are examples of some of the semiconductor devices that may be used to produce an output pulse.
Embodiments of the invention include an electrical energy monitoring system comprising: one or more probes/electrodes; one or more low voltage generator; one or more high voltage generator; wherein the low voltage and high voltage generators are in operable connection with the probes/electrodes; wherein the low and/or high voltage generators are capable of generating a plurality of electrical pulses; wherein the system is configured to cause electroporation of tissue, obtain one or more low-frequency and/or high-frequency impedance measurement and/or impedance spectrum, identify any change in impedance relative to a reference impedance measurement, and based on the change determine whether a desired endpoint of treatment is reached.
For example, a treatment monitoring system according to the invention for administering electrical pulses can comprise: one or more electrical pulse generator(s); one or more probe(s) capable of connection with the electrical pulse generator(s); one or more controller(s) capable of controlling one or more of the electrical pulse generator(s) and/or one or more of the probe(s) to: administer a plurality of electrical pulses; obtain one or more impedance measurement or spectrum; and identify any impedance change relative to a reference impedance measurement. Additionally, treatment monitoring systems for administering electrical pulses according to embodiments can comprise: one or more probe configured to deliver electrical energy; a low-voltage pulse generator, and optionally a high-voltage pulse generator; an impedance analyzer in communication with one or more of the probes; wherein the impedance analyzer is configured to: obtain one or more impedance measurement or spectrum; and identify any impedance change relative to a reference impedance measurement; a treatment monitoring module configured to adjust, halt or stop delivering of the electrical energy based on the impedance change.
The treatment control module may control the delivery of electrical energy based on the various functions/outputs of the FAST technology as described above. Also, the module is connected to GUI allowing a user to receive real-time feedback on the FAST outputs and provides user options to adjust/halt/stop/continue delivery of electrical pulses based on this feedback.
FAST Board
A FAST board was developed to interlace high-voltage ECT/IRE/H-FIRE pulses with low-voltage diagnostic FAST pulses. This board comprises a microcontroller, a high-voltage pulse generator, one or more relays (here, 4 Reed relays), an H-Bridge low-voltage pulse generator, and driving circuitry (with two additional H-Bridge circuits).
In the device, the microcontroller (Arduino Uno) is used to synchronize all trigger signals. The Arduino Uno is a logic board and cannot supply the necessary current to sustain a 5V/15V signal. Therefore, commercial H-Bridge circuits were used in combination with power supplied by an external DC power supply to produce the 5 V and 15 V signals needed to drive the Reed relays, high-voltage pulse generator, and low-voltage diagnostic FAST pulse generator. In embodiments, the timing is such that there is ˜500 ms delay between the high-voltage and low-voltage pulsing. Any amount of delay between administering high-voltage and low-voltage pulses can be used depending on a particular application. In embodiments, the delay between a high-voltage pulse and a low-voltage pulse is preferably at minimum of about 1 ms and up to however long is desired, such as about 10 s. By adjusting the delay, a single low-voltage pulse can be applied between the high-voltage pulses or a plurality of low-voltage pulses, such as 1,000 low-voltage pulses can be applied (
At all times, the Reed relays form an open circuit unless triggered by the microcontroller. In embodiments, the microcontroller can trigger in the following order:
The use of Reed Relays allows for the physical isolation of the low voltage and high voltage circuitry, so as to not pulse high voltage into the low voltage side. One H-bridge circuit is used to drive the EPULSUS high-voltage generator with a 5V monopolar trigger signal. In the event the Reed Relays malfunction and the HVRR do not close, a 1 kW resistor load (here, two 500 W resistors placed in series) is placed in parallel with the tissue load to prevent high-voltage pulsing into an open circuit. A second H-Bridge is used to drive four reed relays each at 5V. The final H-Bridge is used to deliver 15V diagnostic FAST across the tissue load. The microcontroller synchronizes the timing of these circuits. An exemplary timing protocol is given in
Validation of the FAST board was conducted using four resistors of varying resistance: 5, 50, 500, and 5,000 W. A diagnostic FAST comprising a pulsing scheme of 1-50-1-50 μs (×84)+250-10-250-10 μs (×2) (
The FAST board enables synchronous pulsing as demonstrated in
Other Potential Applications for FAST
Extrapolating these findings to clinical EP, it is possible to describe an EBT where a series of diagnostic FAST interlaced with a series of therapeutic FAST are used to measure high-bandwidth intra-burst and inter-burst impedance throughout treatment. This combination of pulsing can be used to continually monitor the absolute change in tissue impedance with a high-frequency reference to subtract thermal effects, like that shown in
Once temperature effects on impedance are determined, this impedance can then be subtracted to effectively isolate changes in tissue impedance due solely to EP. In a flat plate configuration, this may be further extended to utilizing high frequency impedance to predict and monitor temperature rise during treatment. Finally, recovery dynamics (inter-burst and intra-burst impedance) can be further explored. Previously, Neal et al. described the use of a combination low-frequency (kHz) and high-frequency (MHz) impedance to approximate the nonelectroporated and fully electroporated tissue conductivity for purposes of predicting the electric field distribution and informing treatment planning algorithms. In contrast, here, the inventors have found that change in impedance can be used for determining whether and how to proceed with electroporation therapy. Here, a diagnostic FAST can be utilized for such an approximation, and therapeutic FAST to verify the intra-burst impedance spectrum saturates to this high frequency impedance, as was the case for the potato tissue tested in
Furthermore, cell lysis accomplished with therapeutic FAST can potentially be monitored using the β-dispersion hypothesis. The intra-burst impedance spectrum saturates to that of Re Ri once a high enough voltage is reached, fully bypassing the cell membrane. Once a cell is lysed (i.e. cell membrane is fully compromised), cell lysis is confirmed once the intra-burst impedance spectrum is matched to the inter-burst impedance spectrum. Though cell death with IRE varies from cell lysis—necroptosis—apoptosis, this phenomenon again presents novel opportunities of monitoring treatment progression. Tissue impedance changes during EBTs are indicative of treatment progression from baseline. Therefore, Fourier Analysis SpecTroscopy (FAST) is provided as a methodology for monitoring tissue impedance changes during EP-based therapies in real-time. A diagnostic FAST (1-50-1-50+250-10-250-10 μs), aimed towards monitoring inter-burst impedance, demonstrated impedance capture between 1.8 kHz-4.93 MHz at a resolution 216 data points within this frequency range. A therapeutic FAST (2-5-2-100 μs), aimed towards inducing tissue EP while simultaneously monitoring high voltage intra-burst impedance, demonstrated impedance capture between 18.3 kHz-1.96 MHz at a resolution 170 data points within this frequency range. Therapeutic FAST was used to identify a frequency at which EP effects on tissue impedance are minimized, 1.21 MHz in the case of potatoes.
Additional FAST Waveform Considerations
As discussed previously, the impedance data obtained using FAST matches that from a commercial potentiostat, and the FAST method can be used to translate impedance information into a waveform used for H-FIRE treatment. Another embodiment of the invention includes a method to quantity a specific waveform for treatment with known frequency points gathered from the FAST method.
To determine the theoretical plot of the burst scheme, the Unit Step function in Mathematica was used to define a magnitude spectrum around frequencies of interest in combination (
In the example shown in
Cycled Pulsing FAST Protocol
In embodiments of the invention, multiple electrodes, e.g., an electrode array, can be used to deliver the electroporation pulses and/or the diagnostic FAST pulses. With an electrode array, one or more of the electrical pulses can be administered using a “cycled pulsing” protocol. Examples of cycled pulsing protocols are provided in
Although protocols with an array of four probes are illustrated, any number of electrodes can be used, including a single probe comprising any number of electrodes and/or multiple electrodes arranged in an electrode array, such as 2, 3, 4, 5, 6, 7, 8, 9, or 10 electrodes and so on. In a “cycled pulsing” protocol, active pairs of electrodes are alternated until a total number of desired pulses have been applied. In these examples, a select number of H-FIRE pulses are administered. For example, electrodes 1 and 4 (Table 2, Group 1—see
Example Scenarios for Clinical Implementation of FAST
This treatment constitutes an IRE treatment using a pair (2) of needle electrodes placed into the desired target tissue (tumor). The applied voltage, electrode spacing, and electrode exposure are defined by the clinician. The pulse width is also defined by the clinician. The number of pulses to be applied and duration of treatment is dictated by the FAST technique.
A clinician will insert the IRE electrodes into the tumor tissue. The clinician will initiate the pulse generator software and a low-voltage diagnostic FAST will be automatically implemented to acquire a baseline impedance spectrum of the patient. A high-frequency reference, ˜10 MHz, will serve to quantify the clinical endpoint and will be stored in the pulse generator software.
High-voltage pulsing will commence. A series of pulses will be applied, where diagnostic FAST is interlaced in between each high voltage pulse. The pulse generator is pre-programmed with a halting criterion defining an increase in 5° C. at the electrode-tissue interface as measured using a fiber optic temperature sensor. Pulsing will continue until either the halting criteria is met, or the clinical endpoint is reached.
Clinical Endpoint:
The software continually verifies if the clinical endpoint criteria is met:
The low-frequency impedance measurement, ˜5 kHz, falls within 10% of the reference high-frequency impedance measurement.
The change in low-frequency impedance, Zi−1−Zi (where i is the last pulse delivered and i−1 is the pulse prior to that) referenced to the impedance Zi−1[(Zi−1−Zi)/Zi−1*100%] falls within 5%.
Halting Criteria:
The software halts pulsing for a preprogrammed time such as 10 s to allow for heat dissipation. Following this delay, pulsing will commence.
Pulsing continues intermittently in this way, until one of the two clinical endpoints is met.
Once the clinical endpoint is met, a final diagnostic FAST is delivered to measure the end state of tissue impedance.
This treatment constitutes an IRE treatment using a pair (2) of needle electrodes placed into the desired target tissue (tumor). The applied voltage, electrode spacing, and electrode exposure are defined by the clinician. The pulse width is also defined by the clinician. The number of pulses to be applied and duration of treatment is dictated by the FAST technique.
A clinician will insert the IRE electrodes into the tumor tissue. The clinician will initiate the pulse generator software and a low-voltage diagnostic FAST will be automatically implemented to acquire a baseline impedance spectrum of the patient. A high-frequency reference, ˜10 MHz, will serve to quantify the clinical endpoint and will be stored in the pulse generator software.
High-voltage pulsing will commence. A series of pulses will be applied, where diagnostic FAST is interlaced in between each high voltage pulse. The pulse generator is pre-programmed with a halting criterion defining application of 25 pulses prior to halting, followed by a 20 seconds delay to allow for heat dissipation. This method of pulsing will continue until the clinical endpoint is reached.
Clinical Endpoint:
The software continually verifies if the clinical endpoint criteria is met:
The low-frequency impedance measurement, ˜5 kHz, falls within 10% of the reference high-frequency impedance measurement.
The change in low-frequency impedance, Zi−1−Zi (where i is the last pulse delivered and i−1 is the pulse prior to that) referenced to the impedance Zi−1[(Zi−1−Zi)/Zi−1*100%] falls within 5%.
Pulsing continues intermittently in this way, until one of the two clinical endpoints is met.
Once the clinical endpoint is met, a final diagnostic FAST is delivered to measure the end state of tissue impedance.
The diagnostic FAST pulses can be applied at any time, for example, before, during and/or after any of the electroporation pulses are delivered. Preferably, diagnostic FAST is used in between and/or following any part of the electroporation treatment, such as between individual pulses and/or between bursts of pulses. Diagnostic FAST can also be administered between a single electrode pair or between several electrode pairs.
The present invention has been described with reference to particular embodiments having various features. In light of the disclosure provided above, it will be apparent to those skilled in the art that various modifications and variations can be made in the practice of the present invention without departing from the scope or spirit of the invention. One skilled in the art will recognize that the disclosed features may be used singularly, in any combination, or omitted based on the requirements and specifications of a given application or design. When an embodiment refers to “comprising” certain features, it is to be understood that the embodiments can alternatively “consist of” or “consist essentially of” any one or more of the features. Other embodiments of the invention will be apparent to those skilled in the art from consideration of the specification and practice of the invention.
It is noted in particular that where a range of values is provided in this specification, each value between the upper and lower limits of that range is also specifically disclosed. The upper and lower limits of these smaller ranges may independently be included or excluded in the range as well. The singular forms “a,” “an,” and “the” include plural referents unless the context clearly dictates otherwise. It is intended that the specification and examples be considered as exemplary in nature and that variations that do not depart from the essence of the invention fall within the scope of the invention. Further, all of the references cited in this disclosure are each individually incorporated by reference herein in their entireties and as such are intended to provide an efficient way of supplementing the enabling disclosure of this invention as well as provide background detailing the level of ordinary skill in the art.
The present application relies on the disclosure of and claims priority to and the benefit of the filing date of U.S. Provisional Patent Application No. 62/895,652, filed Sep. 4, 2019 and U.S. Provisional Patent Application No. 62/878,194, filed Jul. 24, 2019, both of which are hereby incorporated by reference herein in their entireties. Additionally, the present application is related to U.S. Pat. Nos. 8,465,484, 8,814,860, 8,926,606, 8,992,517, 9,198,733, 9,283,051, 9,598,691, 9,867,652, 10,117,707, 10,154,874, 10,238,447, 10,245,098, 10,245,105, 10,272,178, 10,286,108, 10,292,755, 10,448,989, 10,470,822, 10,471,254, 10,537,379, and 10,694,972; U.S. Patent Publication Nos. 2013/0184702, 2015/0289923, 2019/0029749, 2019/0069945, 2020/0093541, 2019/0133671, 2019/0175248, 2019/0175260, 2019/0223938, 2019/0232048, 2019/0233809, 2019/0256839, 2019/0282294, 2019/0328445, 2019/0351224, 2019/0376055, 2020/0046432, and 2020/0197073; International Patent Publication Nos. WO2009/134876, WO2010/118387, WO2010/151277, WO2011/047387, WO2012/0088149, WO2012/071526, WO2015/175570, and WO2020/061192; U.S. patent application Ser. Nos. 13/958,152, 16/865,031, 16/865,772, and 16/915,760, each of which is incorporated by reference herein in its entirety.
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| Number | Date | Country | |
|---|---|---|---|
| 20210023362 A1 | Jan 2021 | US |
| Number | Date | Country | |
|---|---|---|---|
| 62895652 | Sep 2019 | US | |
| 62878194 | Jul 2019 | US |
