Electrochemotherapy is now in routine clinical use to treat cutaneous metastases of any histology, and is listed in national and international guidelines for cutaneous metastases and primary skin cancer. Electrochemotherapy is used by dermatologists, surgeons, and oncologists, and for different degrees and manifestations of metastases to skin and primary skin tumours not amenable to surgery. This treatment utilises electric pulses to permeabilize cell membranes in tumours, thus allowing a dramatic increase of the cytotoxicity of anti-cancer agents. Response rates, often after only one treatment, are very high across all tumour types. The most frequent indications are cutaneous metastases from malignant melanoma and breast cancer. In 2006, standard operating procedures (SOPs) were written for this novel technology, greatly facilitating introduction and dissemination of the therapy. Since then considerable experience has been obtained treating a wider range of tumour histologies and increasing size of tumours which was not originally thought possible. A pan-European expert panel drawn from a range of disciplines from dermatology, general surgery, head and neck surgery, plastic surgery, and oncology met to form a consensus opinion to update the SOPs based on the experience obtained. This paper contains these updated recommendations for indications for electrochemotherapy, pre-treatment information and evaluation, treatment choices, as well as follow-up.

Epidermolysis Bullosa (EB) is a rare group of diseases caused by genetic variants in skin structural proteins. EB is characterized by varying degrees of skin fragility, blisters and impaired wound healing, and is classified based on the ultrastructural levels of skin cleavage-simplex, junctional, dystrophic, and Kindler Syndrome. Squamous cell carcinoma (SCC) is the most severe complication and most common cause of death of patients with EB, particularly in those with recessive dystrophic Epidermolysis Bullosa (RDEB). To date, the first line of treatment of SCC in patients with RDEB is surgery, despite the high risk of recurrence. Radiotherapy and systemic therapy have been avoided due to its skin toxicity. Recently, electrochemotherapy (ECT) has been proposed as a potential treatment. We report eight sessions of ECT using bleomycin for treatment of SCC in five patients with EB. After 8 weeks all patients showed an objective response. Four patients (seven ECT sessions) had a complete response. The treatment was well tolerated, with mild adverse effects, such as local pain, erythema, and ulceration. Our results demonstrate that ECT is a potential treatment for SCC in patients with RDEB.

Anorectal malignant melanoma (AMM) is a rare malignant tumor. Surgery remains the gold standard but new adjuvant treatments to allow local sphincter-saving are warranted. Electrochemotherapy (ECT) is an alternative to surgery in selected cohorts of patients. To evaluate safety and efficacy of ECT in a retrospective series of patients with primary or recurrent AMM in terms of local disease control, local progression free and overall survival. Seven primary and one recurrent AMM underwent ECT. Patients were followed at 1 and 2 months and at the longest available follow-up with clinical examination and/or ultrasound. One month after ECT 6/8 (75%) patients showed complete response, 1/8 partial response (12.5%) and 1/8 stable disease (12.5%), confirmed at 2 months. Bleeding stopped in all patients, and pain was absent or mild/moderate in all patients. No serious adverse events were observed. At 1 year of follow-up seven out of eight patients were alive (87.5%), four were disease-free and three were alive with disease. At the longest available follow-up (mean 4.9 ± 2.0 years) five out of eight (62.5%) of patients were still alive. Our study showed that ECT is well tolerated and effective in the treatment of patients with anal melanoma with good local control of disease.

Background and Objectives Kaposi's sarcoma (KS) is a locally aggressive mesenchymal tumor that involves the lymphovascular system, with a tendency to become multifocal. Electrochemotherapy (ECT) is considered a valuable treatment option in selected patients with cutaneous and subcutaneous KS lesions.Methods We report a retrospective study that included 14 classic and endemic KS patients that underwent ECT sessions for the treatment of KS cutaneous and subcutaneous lesions at our institution. ResultsAccording to Response Evaluation Criteria in Solid Tumors (RECIST) version 1.1 criteria, our patients had an overall response rate (ORR) of 100% to the ECT treatment. A complete response (CR) was obtained in 92.8% of patients after one or more ECT sessions. Only one patient had a progressive disease (PD). The treatment was well tolerated with a low complication rate, mainly transitory local pain or skin ulceration.Conclusions ECT represents a locoregional therapy for containment and symptomatic control of classic and endemic KS cutaneous and subcutaneous lesions. Further studies including different subtypes of KS patients should also be performed.

Introduction We started to perform Electrochemotherapy (ECT) in Lisbon since February 2008. We initially treated mainly Melanoma patients but with the growing knowledge on this technique we treat now different kind of presentations in pathologies of the skin, of the mucosa and even intraabdominal progression of oncological diseases. In our point of view the surgical management of cutaneous and subcutaneous tumours, especially metastatic lesions, can be difficult for the surgeon. The treatment may be complex regarding the type, the location or even the number of these lesions. In this cases ECT is a good option and is now a standard procedure in our Institute, giving us the chance to treat less aggressively the patient when we talk about advanced skin cancer or skin involvement by other types of tumours [1-3]. Materials and methodsSince 19 February of 2008 we selected 113 patients to the procedure. We perform ECT under the ESOPE protocol. The patients were treated by Electrochemotherapy using either bleomycin or cisplatin in low doses followed by application of electric pulses to the tumours by the CE labelled electric pulse generator CliniporatorTM (IGEA S.r.l., Carpi, Italy), in order to potentiate cytotoxicity of theChemotherapeutics using plate or needle electrodes. We used the N-50-5I finger prototype for mucosal approach. ResultsWe have already performed 129 sessions of ECT since that. We have made 4394 electroporations with a maximum of 124 applications in a single sessions and a maximum of 7 sessions in the same patient. The ECT treatments were mainly for lower limbs and trunk disease (84% of all treatments). We perform mainly palliative management (84%). The mucosal patients that we treat (a primary melanoma of the anal canal and a recurrence of a vulvar melanoma) allow us to avoid amputation surgeries. One of the patients that we treat perform intraabdominal ECT (3 sessions). He had now a follow up of 12 month with an acceptable control of the disease. The complete response rate was 88% in our series with an overall response rate of 97%. During the follow up we only confirm the histological response in the mucosal lesions. The response of the intraabdominal patient treated was evaluated by PET-scan at week 4 and 10. We had 13.5% of complications (pain-4% and scar-10%) that we think are related with some over treated lesions. RESULTSECT is a simple and effective technique and allows us to reduce the necessity of multiple surgeries in this group of patients. The complication rate is low. The application of the technique in other areas than the skin is possible and could be an option in the future in combination with other surgical and medical approaches. References 1 Mir LM, Glass LF, Sersa G, Teissié J, Domenge C, Miklavcic D, et al. Effective treatment of cutaneous and subcutaneous malignant tumours byelectrochemotherapy.

Background Skin metastases are an important co-morbidity in melanoma. Despite broad adoption, electrochemotherapy implementation is hindered by a lack of treatment indications, uncertainty regarding procedural aspects, and the absence of quality indicators. An expert consensus may harmonize the approach among centres and facilitate comparison with other therapies. Methods An interdisciplinary panel was recruited for a three-round e-Delphi survey. A literature-based 113-item questionnaire was proposed to 160 professionals from 53 European centres. Participants rated each item for relevance and degree of agreement on a five-point Likert scale, and received anonymous controlled feedback to allow revision. The items that reached concordant agreement in two successive iterations were included in the final consensus list. In the third round, quality indicator benchmarks were defined using a real-time Delphi method. Results The initial working group included 122 respondents, of whom 100 (82 per cent) completed the first round, thus qualifying for inclusion in the expert panel (49 surgeons, 29 dermatologists, 15 medical oncologists, three radiotherapists, two nurse specialists, two clinician scientists). The completion rate was 97 per cent (97 of 100) and 93 per cent (90 of 97) in the second and third rounds respectively. The final consensus list included 54 statements with benchmarks (treatment indications, (37); procedural aspects, (1); quality indicators, (16)). Conclusion An expert panel achieved consensus on the use of electrochemotherapy in melanoma, with a core set of statements providing general direction to electrochemotherapy users to refine indications, align clinical practices, and promote quality assurance programmes and local audits. The residual controversial topics set future research priorities to improve patient care.

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