Exploring the efficacy of tumor electric field therapy against glioblastoma: An in vivo and in vitro study.

AIMS Tumor electric fields therapy (TTFields) is emerging as a novel anti-cancer physiotherapy. Despite recent breakthroughs of TTFields in glioma treatment, the average survival time for glioblastoma patients with TTFields is <2 years, even when used in conjugation with traditional anti-cancer therapies. To optimize TTFields-afforded efficacy against glioblastoma, we investigated the cancer cell-killing effects of various TTFields paradigms using in vitro and in vivo models of glioblastoma. METHODS For in vitro studies, the U251 glioma cell line or primary cell cultures prepared from 20 glioblastoma patients were treated with the tumor electric field treatment (TEFT) system. Cell number, volume, and proliferation were measured after TEFT at different frequencies (100, 150, 180, 200, or 220 kHz), durations (24, 48, or 72 h), field strengths (1.0, 1.5, or 2.2V/cm), and output modes (fixed or random sequence output). A transwell system was used to evaluate the influence of TEFT on the invasiveness of primary glioblastoma cells. For in vivo studies, the therapeutic effect and safety profiles of random sequence electric field therapy in glioblastoma-transplanted rats were assessed by calculating tumor size and survival time and evaluating peripheral immunobiological and blood parameters, respectively. RESULTS In the in vitro settings, TEFT was robustly effective in suppressing cell proliferation of both the U251 glioma cell line and primary glioblastoma cell cultures. The anti-proliferation effects of TEFT were frequency- and "dose" (field strength and duration)-dependent, and contingent on the field sequence output mode, with the random sequence mode (TEFT-R) being more effective than the fixed sequence mode (TEFT-F). Genetic tests were performed in all 20 primary glioblastoma cultures, and 6 different genetic traits were identified in 12 primary cultures. However, TEFT exhibited comparable anti-proliferation effects in all primary cultures regardless of their genetic traits. TEFT also inhibited the invasiveness of primary glioblastoma cells in transwell experiments. In the in vivo rat model of glioblastoma brain transplantation, treatment with TEFT-F or TEFT-R at frequency of 200 kHz and field strength of 2.2V/cm for 14 days significantly reduced tumor volume by 42.63% (TEFT-F vs. control, p = 0.0002) and 63.60% (TEFT-R vs. control, p < 0.0001), and prolonged animal survival time by 30.15% (TEFT-F vs. control, p = 0.0415) and 69.85% (TEFT-R vs. control, p = 0.0064), respectively. The tumor-bearing rats appeared to be well tolerable to TEFT therapies, showing only moderate increases in blood levels of creatine and red blood cells. Adverse skin reactions were common for TEFT-treated rats; however, skin reactions were curable by local treatment. CONCLUSION Tumor electric field treatment at optimal frequency, strength, and output mode markedly inhibits the cell viability, proliferation, and invasiveness of primary glioblastoma cells in vitro independent of different genetic traits of the cells. Moreover, a random sequence electric field output confers considerable anti-cancer effects against glioblastoma in vivo. Thus, TTFields are a promising physiotherapy for glioblastoma and warrants further investigation.