Extravasation induced by energy delivery to tissue

Abstract

To provide extravasation induced by energy delivery to tissue.SOLUTION: Devices, systems, and methods for treating a target tissue of a patient are provided. Such devices, systems, and methods include delivering energy, such as pulsed electric field energy or other energy types, to a target tissue area to induce extravasation of fluid. In some instances, extravasation is edema or edema-like in which capillaries leak fluid into the surrounding tissue. In some embodiments, the induced edema increases the local concentration of the molecule in the target treatment area and increases the availability of the molecule. Similarly, the effects of edema (e.g., increased interstitial pressure) also increase the availability of molecules. It will be appreciated that a relatively small increase in transcapillary fluid filtration will induce a large rise in interstitial fluid pressure because the target tissue cannot readily increase interstitial volume. This creates a pressure gradient that urges the molecules into the target tissue cells.SELECTED DRAWING: Figure 5C

Description

[Technical Field]

[0001] (CROSS-REFERENCE TO RELATED APPLICATIONS)

[0001] This application claims priority to and the benefit of U.S. Provisional Patent Application No. 63 / 209,335, entitled "Induced Extravasation by Energy Delivery to Tissue," filed June 10, 2021, and also claims priority to and the benefit of U.S. Provisional Patent Application No. 63 / 061,114, entitled "Enhanced Transfer with Pulsed Electric Fields," filed August 4, 2020, U.S. Provisional Patent Application No. 63 / 061,091, entitled "Pulsed Electric Fields in the Eye," filed August 4, 2020, and U.S. Provisional Patent Application No. 63 / 209,335, entitled "Induced Extravasation by Energy Delivery to Tissue," filed June 10, 2021, which claims priority to and the benefit of U.S. Provisional Patent Application No. 63 / 061,114, entitled "Enhanced Transfer with Pulsed Electric Fields," filed August 4, 2020, U.S. Provisional Patent Application No. 63 / 061,091, entitled "Pulsed Electric Fields in the Eye," filed August 4, 2020, and U.S. Provisional Patent Application No. 63 / 209,335, entitled "Induced Extravasation by Energy Delivery to Tissue," filed August 4, 2021. This application is a U.S. continuation-in-part of PCT / US2021 / 044469 entitled "A METHOD FOR CARRYING OUT THE INVENTION THAT CAN BE USED IN A CARDIAC SYSTEM WHILE IN THE BODY." The disclosures of all of the foregoing applications are incorporated herein by reference in their entireties. [Background technology]

[0002]

[0002] Cells in the body regularly die, and new cells divide to replace them. However, when cells divide uncontrollably and serve no useful purpose, a mass of tissue known as a tumor can appear. A tumor is a group of abnormal cells that forms a growth or lump. They can start in any one of many cells throughout the body. Tumors grow and behave differently depending on whether they are cancerous (malignant), non-cancerous (benign), or pre-cancerous. Malignant tumors grow beyond their normal boundaries, invading adjacent parts of the body and / or spreading to other organs. The latter process, called metastasis, is the leading cause of cancer death. Neoplasia and malignant tumors are common names for cancer.

[0003]

[0003] There are many types of cancer treatments. The type of treatment received depends on the type and stage of the cancer. Some people with cancer receive only one type of treatment. However, most people receive a combination of treatments, for example, surgery with chemotherapy and radiation therapy. Chemotherapy is a type of cancer treatment that uses chemotherapy drugs as part of a standardized chemotherapy regimen. Chemotherapy may be given with curative intent or with the goal of prolonging life or alleviating symptoms. Chemotherapy is one of the major categories in medical oncology, a branch of medicine that specializes in the drug treatment of cancer.

[0004]

[0004] Traditional chemotherapy drugs are cytotoxic by inhibiting cell division (mitosis), but cancer cells vary greatly in their sensitivity to these drugs. Chemotherapy can often be thought of as a way to inflict damage or stress on cells, which can lead to cell death if apoptosis is initiated. Many of the side effects of chemotherapy can be traced back to damage to normal cells—i.e., cells of the bone marrow, digestive tract, and hair follicles—that rapidly divide and are therefore sensitive to cytostatic drugs. As a result, the most common side effects of chemotherapy are myelosuppression (reduced blood cell production and therefore immunosuppression), mucositis (inflammation of the digestive tract mucosa), and alopecia (hair loss). Because of their effects on immune cells (especially lymphocytes), chemotherapy drugs are often used to treat many diseases caused by harmful overactivity of the immune system against itself (so-called autoimmunity). These include rheumatoid arthritis, systemic lupus erythematosus, multiple sclerosis, vasculitis, and many others.

[0005]

[0005] Therapies using specific molecular or genetic targets to inhibit growth-promoting signals from traditional endocrine hormones (mainly estrogens in breast cancer and androgens in prostate cancer) have been developed and are now referred to as hormone therapies. In contrast, other inhibition of growth signals, such as those associated with receptor tyrosine kinases, is called targeted therapy. The use of drugs (whether chemotherapy, hormone therapy, or targeted therapy) usually constitutes systemic cancer therapy, in that the agents are introduced into the bloodstream and thus, in principle, can address cancer at any anatomical location within the body. Systemic therapy is often combined with other modalities, such as radiation therapy, surgery, or hyperthermia, that constitute local cancer therapy (i.e., treatments whose effectiveness is limited to the anatomical area in which they are used).

[0006]

[0006] Systemic therapy plays an important role in the management of patients diagnosed with cancer, but the use of many of these agents is clearly associated with long-term toxicity in long-term survivors. Current and future challenges include the appropriate delivery of cytotoxic agents (and other components of multimodal anticancer treatment regimens) to maximize therapeutic efficacy while limiting both acute and long-term side effects. The sequential use of several different chemotherapy agents is increasingly common to overcome tumor resistance, for example, in patients with metastatic colon and breast cancer, with evidence demonstrating improved overall survival. That said, these patients often accumulate significant exposure to multiple chemotherapy agents and are therefore at high risk for cumulative treatment-related side effects. Paradoxically, the patient's ability or willingness to tolerate such side effects, rather than uncontrolled disease or the absence of promising active anticancer treatments, can rapidly become the limiting factor for treatment success in this population.

[0007]

[0007] Therefore, improved therapies for cancer and other tumors are desirable. Such therapies should be safe, effective, and reduce complications. Furthermore, such therapies should be applicable to therapies involving the transfer of various types of molecules, particularly macromolecules, into cells. At least some of these objectives are achieved by the systems, devices, and methods described herein. [Brief explanation of the drawings]

[0008] In the drawings, which are not necessarily to scale, like numbers in different figures may describe like components. Like numbers with different subscripts may represent different instances of like components. The drawings generally illustrate, by way of example, and not by way of limitation, various embodiments discussed in this document.

[0009] [Figure 1]

[0009] A tumor in the lung of a patient is shown. [Figure 2]

[0010] 1 shows a schematic representation of the distribution of pulmonary arteries throughout the lungs. [Figure 3]

[0011] An endoluminal approach to the tumor is shown, with the bronchoscope advanced through the trachea and right main bronchus towards the tumor. [Figure 4]

[0012] 1 shows the distal end of the bronchoscope being advanced through the lung passages to reach the tumor. [Figure 5A]

[0013] It is shown that a small number of molecules enter the target tissue area, while a significant amount remains within the blood vessels. [Figure 5B]

[0014] Modulated energy is delivered from the energy delivery portion to the target tissue area, as indicated by the dashed lines. [Figure 5C]

[0015] Extravasation refers to the bathing of the target tissue area with fluid and solutes, including molecules from the blood vessels. [Figure 6]

[0016] 1 shows an energy delivery unit inserted into a tumor. [Figure 7]

[0017] It shows that what was once a tumor is now a debris field extending outwards to the periphery. [Figure 8A]

[0018] Dendritic cells and other immune cells are shown migrating into the debris field from adjacent intact lung tissue (as indicated by arrows). [Figure 8B]

[0019] Dendritic cells and other immune cells are shown migrating from the debris field back into the surrounding lung tissue (as indicated by arrows). [Figure 9]

[0020] Dendritic cells and other immune cells are shown entering afferent lymphatic vessels. [Figure 10]

[0021] The primary tumor site, which is now a debris field, is shown along with nearby lymph nodes and activated T cells draining from the lymph nodes. [Figure 11]

[0022] It has been shown that dendritic cells and other immune cells migrate through lymphatic vessels to lymph nodes, activated T cells migrate to the heart, and activated T cells migrate to distant locations within the body. [Figure 12]

[0023] Activated T cells migrating to metastatic tumors in the liver are shown. [Figure 13]

[0024] 1 illustrates one embodiment of an energy delivery system for delivering energy to a target tissue area. [Figure 14A]

[0025] 10 shows an exemplary waveform of pulsed electric field energy provided by the generator's energy delivery algorithm used to induce extravasation. [Figure 14B]

[0025] An exemplary waveform of pulsed electric field energy provided by the generator's energy delivery algorithm used to induce extravasation is shown. [Figure 15A]

[0026] 1 illustrates an exemplary waveform provided by the generator's energy delivery algorithm used to perform a therapeutic treatment. [Figure 15B]

[0026] An exemplary waveform provided by the generator's energy delivery algorithm used to perform a therapeutic treatment is shown. [Figure 16A]

[0026] An exemplary waveform provided by the generator's energy delivery algorithm used to perform a therapeutic treatment is shown. [Figure 16B]

[0026] An exemplary waveform provided by the generator's energy delivery algorithm used to perform a therapeutic treatment is shown. [Figure 17]

[0027] 1 illustrates one embodiment of a waveform configured for tumor treatment. [Figure 18A]

[0028] 1 illustrates an embodiment of a pressure sensor. [Figure 18B]

[0028] An embodiment of a pressure sensor is shown. [Figure 18C]

[0028] An embodiment of a pressure sensor is shown. [Figure 19]

[0029] 1 illustrates three exemplary timing embodiments of molecule delivery relative to treatment delivery. [Figure 20]

[0030] The results of laboratory studies are presented. [Figure 21A]

[0031] 1 shows molecules and energy being locally delivered from an energy delivery device. [Figure 21B]

[0031] Molecules and energy delivered locally from an energy delivery device are shown. [Figure 22]

[0032] 1 shows an energy delivery device including a shaft having an energy delivery portion near its distal end that includes a plurality of tines. [Figure 23]

[0033] 1 illustrates an energy delivery device including an energy delivery portion having a basket shape configured for treating target tissue intraluminally. [Figure 24]

[0034] 1 illustrates another embodiment of an energy delivery device including an energy delivery portion having a shape configured to treat target tissue within a lumen, the energy delivery portion including at least two protrusions, each protrusion extending radially outward to contact the lumen wall. [Figure 25]

[0035] 1 illustrates another embodiment of an energy delivery device including an energy delivery portion having a shape configured for treating target tissue intraluminally, the energy delivery portion including an expandable member, such as an inflatable balloon, having electrodes mounted or embedded therein. [Figure 26]

[0036] 1 illustrates an embodiment of an energy delivery device, where the energy delivery portion has a fingertip shape configured to contact the lumen wall. Summary of the Invention

[0010]

[0037] Described herein are embodiments of devices, systems, and methods for treating target tissue within the body. The invention also relates to the following numbered clauses:

[0011]

[0038] 1. A system for treating a target tissue area of ​​a patient, comprising: an energy delivery device having at least one energy delivery portion configured to be positioned near a target tissue area within a patient; A system comprising: a generator in electrical communication with at least one energy delivery unit, the generator including at least one energy delivery algorithm configured to provide an electrical signal of deliverable pulsed electric field energy to the at least one energy delivery unit to induce extravasation within a target tissue area.

[0039] 2. The system of claim 1, wherein the induced extravasation is sufficient to bias molecules delivered to the target tissue area to enter cells of the target tissue area.

[0040] 3. The system of claim 2, wherein the molecule comprises a drug, a chemotherapeutic agent, an immunotherapeutic agent, and / or a monoclonal antibody.

[0041] 4. The system of claim 2, wherein the molecule comprises an auxiliary substance including polymer nanoparticles, liposomes, PEG-modified liposomes, lipofectamine, cell-penetrating peptides (CPC), dimethyl sulfoxide (DMSO), cholesterol, or other substances known to interact with the fluidity and dynamics of cell membranes.

[0042] 5. The system of any of claims 2 to 4, wherein the energy delivery device is configured to deliver molecules to a target tissue area of ​​a patient.

[0043] 6. The system of any of claims 1 to 5, wherein extravasation delivers molecules from the vasculature in the target tissue area to the interstitial space around cells in the target tissue area.

[0044] 7. The system of any of claims 1 to 6, further comprising a controller configured to control delivery of pulsed electric field energy in response to at least one component.

[0045] 8. The system of claim 7, wherein at least one component includes a sensor that senses the flux of molecules being delivered to the patient.

[0046] 9. The system of claim 7, wherein at least one component includes a sensor that senses pressure in a syringe pump configured to deliver molecules to a patient.

[0047] 10. The system of claim 7, wherein at least one component includes a timer, and wherein the controller executes delivery of pulsed electric field energy at a predetermined time after initiation of molecule delivery to the target tissue area.

[0048] 11. The system of any of claims 7 to 10, wherein the controller effects delivery of pulsed electric field energy throughout molecule delivery to the target tissue area.

[0049] 12. The system of any of claims 7 to 11, wherein the controller effects delivery of pulsed electric field energy throughout molecule delivery to the target tissue area and lasts 200-300% longer than molecule delivery.

[0050] 13. The system of any of claims 7 to 11, wherein the controller executes delivery of pulsed electric field energy throughout additional molecule delivery that occurs during a period of time after molecule delivery.

[0051] 14. A system as described in any one of claims 1 to 13, wherein the electrical signal of pulsed electric field energy deliverable to at least one energy delivery portion to induce extravasation in the target tissue area also causes cell death in the target tissue area.

[0052] 15. The system of claim 14, wherein the signal includes at least two packets of biphasic pulses separated by an inter-packet delay.

[0053] 16. The system of claim 15, wherein each packet includes 10 to 40 biphasic pulses.

[0054] 17. The system of claim 16, wherein each of the biphasic pulses is separated by a cycle delay of 1000 μs.

[0055] 18. The system of any of claims 15 to 17, wherein each packet has an on time of 70 to 100 μs.

[0056] 19. The system of any of claims 15 to 18, wherein the at least two packets include between 50 and 200 packets.

[0057] 20. A system according to any of claims 15 to 19, wherein the inter-packet delay is in the range of 3 to 6 seconds.

[0058] 21. A system according to any one of claims 15 to 20, wherein the electrical signal has a voltage in the range of 3000V to 6000V.

[0059] 22. A system according to any one of claims 15 to 21, wherein the signal has a frequency in the range of 100 to 400 kHz.

[0060] 23. The system of any of claims 1 to 13, wherein the generator further comprises at least one additional energy delivery algorithm configured to provide an additional electrical signal of pulsed electric field energy deliverable to the at least one energy delivery portion to cause cell death within the target tissue area.

[0061] 24. The system of claim 23, wherein the electrical signal is comprised of a plurality of pulses having a pulse width greater than 500 μs.

[0062] 25. The system of claim 24, wherein at least one of the plurality of pulses is separated by a delay of between 10 μs and 10 seconds.

[0063] 26. The system of claim 24, wherein each of the plurality of pulses is biphasic.

[0064] 27. The system of claim 26, wherein at least one of the plurality of pulses is separated by a delay of between 1 μs and 1 second.

[0065] 28. A system as described in any of claims 23 to 27, wherein the additional electrical signal comprises a plurality of pulses forming a packet, each of the plurality of pulses having a duration of 0.5 to 200 μs, and the packet having a cumulative on-time of 1 to 200 μs.

[0066] 29. The system of claim 28, wherein the additional electrical signal includes between 40 and 100 packets.

[0067] 30. The system of any of claims 1 to 29, wherein the target tissue area comprises cells of the digestive system, including the liver, pancreas, stomach, intestines, and / or colon.

[0068] 31. The system of any of claims 1 to 29, wherein the target tissue area comprises tissue of the respiratory system, including the lungs, airways, bronchial passages, and / or alveolar sacs.

[0069] 32. The system of any of claims 1 to 29, wherein the target tissue area comprises cells of the reproductive system, including the vagina, uterus, cervix, fallopian tubes, ovaries, testes, penis, epididymis, vas deferens, urethra, prostate, seminal vesicles, and / or bulbourethral glands.

[0070] 33. A system according to any preceding claim, wherein the target tissue area comprises at least a portion of a tumor or abnormal growth.

[0071] 34. A system according to any one of claims 1 to 33, wherein the energy delivery unit is configured to function monopolarly.

[0072] 35. A system for treating a target tissue area of ​​a patient, comprising: an energy delivery device configured to deliver energy to the target tissue area and configured to deliver a plurality of molecules to the target tissue area; a generator in electrical communication with the generator, the generator including at least one energy delivery algorithm configured to provide an electrical signal of pulsed electric field energy deliverable to at least one energy delivery section that induces extravasation within a target tissue area, the extravasation being sufficient to urge molecules delivered to the target tissue area to enter cells of the target tissue area.

[0073] 36. The system of claim 35, further comprising a controller that coordinates the delivery of the pulsed electric field energy and the delivery of the plurality of molecules.

[0074] 37. The system of claim 36, wherein the controller initiates delivery of pulsed electric field energy at a predetermined time after initiation of delivery of the plurality of molecules.

[0075] 38. The system of any of claims 36-37, wherein the controller effects simultaneous delivery of pulsed electric field energy and molecules to the target tissue area throughout treatment of the target tissue area.

[0076] 39. The system of claim 38, wherein the electrical signal of pulsed electric field energy deliverable to at least one energy delivery portion to induce extravasation within the target tissue area also causes cell death within the target tissue area, and wherein treatment of the target tissue area includes cell death within at least a portion of the target tissue area.

[0077] 40. The system of any of claims 36-39, wherein the controller effects delivery of pulsed electric field energy throughout molecule delivery to the target tissue area and lasts 200-300% longer than molecule delivery.

[0078] 41. A system according to any of claims 36 to 40, wherein the controller executes delivery of pulsed electric field energy throughout additional molecule delivery that occurs during a period of time following molecule delivery.

[0079] 42. A system as described in any one of claims 1 to 41, wherein the electrical signal of pulsed electric field energy deliverable to at least one energy delivery portion to induce extravasation in the target tissue area also causes cell death in the target tissue area.

[0080] 43. The system of claim 42, wherein the signal includes at least two packets of biphasic pulses separated by an inter-packet delay.

[0081] 44. The system of claim 43, wherein each packet includes between 10 and 40 biphasic pulses.

[0082] 45. A system according to any of claims 43 to 44, wherein each of the biphasic pulses is separated by a cycle delay of 1000 μs.

[0083] 46. ​​A system as described in any of claims 43 to 45, wherein each packet has an on time of 70 to 100 μs.

[0084] 47. A system according to any of claims 43 to 46, wherein the at least two packets comprise between 50 and 200 packets.

[0085] 48. A system according to any of claims 43 to 47, wherein the inter-packet delay is in the range of 3 to 6 seconds.

[0086] 49. A system according to any one of claims 43 to 48, wherein the electrical signal has a voltage in the range of 3000V to 6000V.

[0087] 50. A system according to any of claims 43 to 49, wherein the signal has a frequency in the range of 100 to 400 kHz.

[0088] 51. The system of claim 35, wherein the electrical signal is comprised of multiple pulses having a pulse width greater than 500 μs.

[0089] 52. The system of claim 51, wherein at least one of the plurality of pulses is separated by a delay of between 10 μs and 10 seconds.

[0090] 53. The system of claim 51, wherein each of the plurality of pulses is biphasic.

[0091] 54. The system of claim 53, wherein at least one of the plurality of pulses is separated by a delay of between 1 μs and 1 second.

[0092] 55. The system of claim 35, wherein the generator further comprises at least one additional energy delivery algorithm configured to provide an additional electrical signal of pulsed electric field energy deliverable to the at least one energy delivery portion to cause cell death within the target tissue area.

[0093] 56. The system of claim 55, wherein the additional electrical signal is comprised of a plurality of pulses forming a packet, each of the plurality of pulses having a duration of 0.5 to 200 μs, and the packet having a cumulative on-time of 1 to 200 μs.

[0094] 57. A system according to any of claims 55 to 56, wherein the additional electrical signal comprises 40 to 100 packets.

[0095] 58. A system according to any of claims 35 to 57, wherein the target tissue area comprises cells of the digestive system, including the liver, pancreas, stomach, intestine, and / or colon.

[0096] 59. The system of any of claims 35 to 57, wherein the target tissue area comprises tissue of the respiratory system, including the lungs, airways, bronchial passages, and / or alveolar sacs.

[0097] 60. The system of any of claims 35 to 57, wherein the target tissue area comprises cells of the reproductive system, including the vagina, uterus, cervix, fallopian tubes, ovaries, testes, penis, epididymis, vas deferens, urethra, prostate, seminal vesicles, and / or bulbourethral glands.

[0098] 61. A system according to any of claims 35 to 60, wherein the target tissue area comprises at least a portion of a tumor or abnormal growth.

[0099] 62. A system according to any one of claims 35 to 61, wherein the energy delivery unit is configured to function monopolarly.

[0100] 63. A system for killing cells in a target tissue area of ​​a patient, comprising: an energy delivery device having at least one energy delivery portion configured to be positioned near a target tissue area within a patient; A system comprising: a generator in electrical communication with at least one energy delivery unit, the generator including at least one energy delivery algorithm configured to provide an electrical signal of deliverable pulsed electric field energy to the at least one energy delivery unit to induce extravasation in a target tissue area and kill cells in the target tissue area.

[0101] 64. The system of claim 63, wherein the induced extravasation is sufficient to urge molecules delivered to the target tissue area into cells of the target tissue area.

[0102] 65. The system of claim 64, wherein the molecule comprises a drug, a chemotherapeutic agent, an immunotherapeutic agent, and / or a monoclonal antibody, and at least some of the cells are killed by the entry of the molecule.

[0103] 66. A system according to any of claims 63 to 65, wherein the energy delivery device includes at least one sensor.

[0104] 67. The system of claim 66, wherein at least one sensor is configured to monitor the effects of extravasation and provide sensor feedback data.

[0105] 68. The system of claim 67, wherein the system includes a mechanism for providing the sensor feedback data or information based on the sensor feedback data to a user.

[0106] 69. The system of claim 68, wherein the generator includes a processor configured to modify or switch to a different energy delivery algorithm at least one based on sensor feedback data to transmit energy that regulates the induction of extravasation.

[0107] 70. A system according to any of claims 63 to 65, wherein the system includes at least one sensor.

[0108] 71. The system of claim 70, wherein the at least one sensor includes a sensor that monitors pressure, temperature, impedance, resistance, capacitance, conductivity, pH, optical properties, coherence, echogenicity, fluorescence, electric permittivity, optical permittivity, and / or conductance.

[0109] 72. A method for modulating a target tissue area in a patient, comprising: positioning at least one electrode near a target tissue area; delivering pulsed electric field energy to the target tissue area via at least one electrode; The method, wherein the pulsed electric field energy is configured to induce extravasation that produces edema in the target tissue area.

[0110] 73. The method of claim 72, further comprising delivering a plurality of molecules to the patient such that induced extravasation increases the concentration of molecules from the plurality of molecules in the target tissue area.

[0111] 74. The method of claim 73, wherein the pulsed electric field energy is configured to treat the target tissue area, and wherein delivery of the plurality of molecules is performed throughout delivery of the pulsed electric field energy to treat the target tissue area.

[0112] 75. The method of claim 74, wherein treating the target tissue area includes killing cells within the target tissue area.

[0113] 76. The method of claim 75, wherein the target tissue area comprises a tumor, and killing cells in the target tissue area comprises substantially destroying the tumor.

[0114] 77. The method of claim 73, wherein the pulsed electric field energy is configured to treat the target tissue area, and wherein delivery of the plurality of molecules is performed only during a first portion of the delivery of the pulsed electric field energy to treat the target tissue area.

[0115] 78. The method of claim 77, wherein the first portion comprises 25-33% of the delivery of pulsed electric field energy to treat the target tissue area.

[0116] 79. The method of claim 73, wherein the pulsed electric field energy is configured to treat the target tissue area, and wherein delivery of the plurality of molecules is performed only during a first portion of the delivery of the pulsed electric field energy to treat the target tissue area and a last portion of the delivery of the pulsed electric field energy to treat the target tissue area.

[0117] 80. The method of claim 79, wherein the first portion comprises 25% of the delivery of pulsed electric field energy to treat the target tissue area, and the second portion comprises 25% of the delivery of pulsed electric field energy to treat the target tissue area.

[0118] 81. The method of claim 72, wherein the target tissue area is near the patient's vasculature, and the energy is configured to induce extravasation of fluid from the vasculature, causing edema in the target tissue area.

[0119] 82. The method of claim 81, further comprising delivering a plurality of molecules to the vasculature, wherein the energy is configured to induce extravasation of a portion of the plurality of molecules with the fluid.

[0120] 83. The method of claim 72, wherein the target tissue area is near a lymphatic vessel of the patient, and the energy is configured to induce extravasation of fluid from the lymphatic vessel, causing edema in the target tissue area.

[0121] 84. The method of claim 72, wherein the target tissue area comprises cells of the digestive system, including the liver, pancreas, stomach, intestines, and / or colon.

[0122] 85. The method of claim 72, wherein the target tissue area comprises cells of the respiratory system, including the lungs, airways, bronchial passages, and / or alveolar sacs.

[0123] 86. The method of claim 72, wherein the target tissue area comprises cells of the reproductive system, including the vagina, uterus, cervix, fallopian tubes, ovaries, testes, penis, epididymis, vas deferens, urethra, prostate, seminal vesicles, and / or bulbourethral glands.

[0124] 87. The system of claim 72, wherein the target tissue area comprises at least a portion of a tumor or abnormal growth.

[0125] 88. The method of claim 72, further comprising delivering a second energy to the target tissue area via at least one electrode, the second energy configured to ablate the target tissue area.

[0126] 89. The method of claim 88, wherein the second energy comprises pulsed electric field ablation energy.

[0127] 90. The method of claim 88, wherein the second energy comprises microwave ablation energy, radiofrequency ablation energy, cryoablation energy, and / or high intensity focused ultrasound (HIFU) energy.

[0128] 91. The method of claim 72, wherein the target tissue area is near the patient's vasculature, and the energy is configured to induce extravasation of fluid from the vasculature, causing edema in the target tissue area.

[0129] 92. A method for increasing the concentration of a plurality of molecules near target cells in a patient, comprising: introducing a plurality of molecules into a patient; positioning at least one electrode within the patient; and delivering pulsed electric field energy via at least one electrode to induce extravasation to increase the concentration of a plurality of molecules between the target cells.

[0012]

[0130] These and other embodiments are described in detail in the following description taken in conjunction with the accompanying drawings.

[0013] (References)

[0131] All publications, patents, and patent applications mentioned in this specification are herein incorporated by reference to the same extent as if each individual publication, patent, or patent application was specifically and individually indicated to be incorporated by reference. DETAILED DESCRIPTION OF THE INVENTION

[0014]

[0132] Devices, systems, and methods are provided for improving the treatment of target tissues within a patient's body, particularly for improving the treatment of tumors within a patient's body. Tumors are typically treated by a variety of methods, including the delivery of chemotherapy or other molecules to the tumor site, either systemically or locally. The devices, systems, and methods described herein provide improved outcomes, particularly related to improved uptake of molecules into cells, ultimately increasing cell death, and improving tumor elimination.

[0015]

[0133] Such devices, systems, and methods include delivering energy, such as pulsed electric field energy (PEF) or other suitable energy type, to induce extravasation of fluids, and optionally extravasation of molecules, into a target tissue area. In some examples, the energy is the same as the treatment energy, while in other examples, the energy is different, such as a particular conditioning energy. If the energies are the same, both may be PEF energy; if the energies are different, the conditioning energy may be PEF energy and the treatment energy may be PEF energy with a different waveform or treatment parameters, or the energies may be different types, such as microwave ablation, radiofrequency ablation, cryoablation, and / or high intensity focused ultrasound (HIFU).

[0016]

[0134] In some embodiments, PEF energy is used to treat damaged, diseased, abnormal, obstructed, cancerous, or unwanted tissue (e.g., a tumor, a benign tumor, a malignant tumor, a cyst, or a region of diseased tissue). The energy is delivered in a non-thermal manner (i.e., below the threshold for causing thermal ablation). As a result, the extracellular matrix, if present, is preserved, and the target tissue maintains its structural architecture, including blood and lymphatic vessels. Sensitive structures, such as biological lumens, blood vessels, and nerves, that are essential for maintaining tissue integrity and functionality, can therefore be preserved. This offers many advantages. First, it enables the treatment of tissues that are often considered untreatable by conventional methods. Target tissues located near sensitive structures are typically untreatable by surgical methods because the tissue cannot be completely and effectively surgically separated from the sensitive structures. Similarly, many conventional non-surgical treatments are contraindicated due to the potential for damage to sensitive structures or because the proximity of the treatment to sensitive structures makes the treatment ineffective. Furthermore, the ability to treat tissue near sensitive structures provides a more comprehensive treatment since no malignant margins are left near the sensitive structures, and the structural architecture remains after the tissue has been treated, allowing for the natural influx of biological elements such as components of the immune system or the introduction of various drugs to facilitate therapeutic intervention.

[0017]

[0135] It will be appreciated that throughout this specification, energy that induces extravasation will be referred to as conditioning energy, but in some instances, conditioning energy may also be therapeutic energy. Extravasation typically arises from nearby vasculature, lymphatics, or other tissues receiving the energy. In some instances, extravasation is edema or edema-like, causing capillaries to leak fluid into surrounding tissue. Edema occurs when abnormal amounts of fluid accumulate within tissue, either within cells (cellular edema) or within the collagen-mucopolysaccharide matrix distributed in the interstitial space (interstitial edema). The devices, systems, and methods described herein focus on swelling of the extracellular matrix, i.e., interstitial edema. Spontaneous interstitial edema can occur as a result of abnormal changes in pressure (hydrostatic and oncotic pressure) acting on microvascular walls, changes in molecular structure that create barriers to fluid and solute flux in the endothelial wall, manifested as changes in hydraulic conductivity and the osmotic reflection coefficient of plasma proteins, or changes in the lymphatic outflow system. However, the devices, systems, and methods described herein induce edema or extravasation through the delivery of specific energy. In some instances, extravasation of fluid from blood vessels carries molecules delivered intravenously into the target tissue area. In other instances, molecules are delivered locally or regionally, such as by injection, and extravasation of fluid from blood vessels concentrates the molecules in the extravasation area. Yet other instances utilize extravasation alone without delivering molecules, for example, to tailor the target tissue area for treatment.

[0018]

[0136] Induced extravasation has a variety of beneficial effects on therapy. Examples of improved therapeutic treatment include, but are not limited to, target tissue modulation, increased molecule availability, increased uniformity of molecule availability, increased access to naturally confined target tissue, creation of larger treatment areas, and reduced likelihood of undesirable side effects, to name a few. Each of these is described in further detail below.

[0019] I. Overview A. Extravasation and treatment

[0137] The devices, systems, and methods described herein are suitable for treating a wide variety of target tissue types in various anatomical locations. In some embodiments, the target tissue is abnormal tissue. Abnormal tissue can take a variety of different forms, such as damaged tissue, diseased tissue, obstructed tissue, cancerous tissue, or unwanted tissue. In some examples, the abnormal tissue is a tumor, such as a benign or malignant tumor, a cyst, or an area of ​​diseased tissue. One of the most troublesome types of abnormal tissue is cancerous. For illustrative purposes, an embodiment relating to the treatment of cancerous tumors in the pulmonary anatomy is provided. However, it will be appreciated that other types of tissue and other body locations can be treated with the same devices, systems, and methods. For example, tissue located sufficiently close to capillaries to be subject to extravasation can be treated. Similarly, tissue located sufficiently close to a lumen for intraluminal access can be treated to benefit from minimally invasive access, such as blood vessels, esophagus, stomach, pancreatic duct, bile duct, small intestine, large intestine, colon, rectum, bladder, urethra, collecting duct, uterus, vagina, fallopian tube, ureter, renal tubule, spinal canal, spinal cord, airway, nasal cavity, mouth, cardiac cavity, intracardiac cavity, renal cavity, and organ lumen. However, it will be appreciated that tissue not sufficiently close to a lumen can be accessed by other methods, such as percutaneous or surgical methods.

[0020]

[0138] FIG. 1 illustrates a tumor T within a lung L of a patient P. The tumor T is located within the right upper lobe of the lung L. As shown in FIG. 2, the pulmonary anatomy is highly vascularized. FIG. 2 also illustrates a schematic representation of the distribution of pulmonary arteries throughout the lung L. Thus, many locations within the lung L are located near blood vessels. FIG. 3 illustrates an endoluminal approach to the tumor T. Here, a bronchoscope 50 is advanced toward the tumor T via the trachea and right mainstem bronchus. FIG. 4 illustrates the distal end of the bronchoscope 50 advanced within the lung passage to reach the tumor T. A catheter, instrument, or energy delivery device 102 is then advanced from the distal end of the bronchoscope 50 toward the tumor T. In this example, the energy delivery device 102 has an elongated shaft 106 with at least one energy delivery portion 108 at its distal end and a handle 110 at its proximal end. The energy delivery device 102 is connectable to a generator 104 as part of a treatment system 100. This will be described in more detail in a later section. Figure 4 shows the energy delivery device 102 emerging from the bronchoscope 50 and pointing towards the lung passageway. In this embodiment, the energy delivery portion 108 has the form of a needle that can pierce the wall of the lung passageway and the tumor T.

[0021]

[0139] 5A-5C illustrate a portion of the lung L of FIG. 1 near the tumor T at multiple stages of an extravasation procedure. In this embodiment, the energy delivery device 102 includes an elongate shaft 106 and an energy delivery portion 108 disposed near the distal end of the elongate shaft 106. As previously described, in this embodiment, the energy delivery portion 108 comprises a single electrode, with a distal tip 103 configured to pierce the tumor T. In other embodiments, the energy delivery portion 108 has an atraumatic tip and is delivered via a separate instrument capable of piercing tissue. As shown in FIG. 5A, the energy delivery portion 108 is positioned within the tumor T near a blood vessel BV, such as a capillary. In this embodiment, molecules 110 are delivered to the target tissue area (e.g., tumor T) via the blood vessel BV, such as by intravenous (IV) administration. Such molecules 110 are specific to the treatment being performed. In this example, the molecules 110 include a chemotherapeutic agent to enhance the therapeutic effect on the tumor T. Such therapeutic enhancements can increase the effectiveness of a therapeutic treatment or improve the ability to treat a larger treatment area, particularly while reducing the potential for thermal damage. It will be appreciated that the examples provided based on cancerous tumors are for illustrative purposes, and that the principles described herein may also be applied to the treatment of other unwanted or diseased tissue. Similarly, other drugs, agents, or molecules (e.g., DNA plasmids, RNA (e.g., messenger RNA (mRNA), small interfering RNA (siRNA), microRNA), oligonucleotides, antisense oligonucleotides (ASOs), proteins, and / or substances that induce genetic or epigenetic changes in cellular behavior) can be delivered in therapeutic treatments of target tissues and are not limited to chemotherapeutic drugs. Such drugs, agents, or molecules are collectively considered molecules. Examples of molecules are further described in a later section. It will be appreciated that in other embodiments, the molecules 110 are delivered by the energy delivery device 102 itself or by a separate device, such as a catheter or needle injection.

[0022]

[0140] FIG. 5A shows that only a few molecules 110 enter the target tissue area, while a significant amount remains within the blood vessel BV. Next, as shown in FIG. 5B, at least one dose of energy is delivered to the target tissue area from the energy delivery unit 108, as indicated by the wavy line 113. Typically, the energy includes a specialized form of PEF energy, although it will be appreciated that other types of specialized energy may be used to generate the desired extravasation. In this embodiment, the specialized PEF energy reversibly disrupts the fluid-barrier functional integrity of endothelial cells within the blood vessel BV, for example, by affecting the hydraulic conductivity and osmotic reflection coefficient of plasma proteins. This disruption reduces the barrier's ability to restrict the movement of fluids and macromolecules from the blood into the interstitium of the surrounding tissue. This results in extravasation, as shown in FIG. 5C, and the target tissue area becomes bathed in fluids and solutes, including molecules 110, from the blood vessel BV. The PEF energy typically disrupts capillaries while causing minimal cell destruction in the target area. However, it will be appreciated that such disruption may be utilized in conjunction with treatments intended to kill cells, such as in the treatment of cancer or abnormal tissue.

[0023]

[0141] This extravasation process can occur over a period of time, such as 5 seconds, or 30 seconds to 15 minutes, although extravasation is typically performed for 30 seconds to 30 minutes. Thus, delivery of the molecule 110 during the extravasation process can be timed in various ways to maximize its benefits. In some instances, it may be desirable to begin delivery of the molecule 110 to the vasculature prior to PEF energy delivery to ensure maximum concentration and availability of the molecule 110 in the bloodstream. In some instances, it may be desirable to deliver the molecule 110 continuously throughout the PEF energy delivery. In other instances, it may be desirable to deliver the molecule at various times or for various time periods during the PEF energy delivery. The length of the extravasation and edema development time period can vary depending on a variety of factors, including the target organ, the parameters used, and the specific goals of the treatment. For example, a molecule 110 that is not provided at high systemic concentrations may provide the greatest extravasation effect before and / or during a treatment procedure. Similarly, a molecule 110 with high bioavailability may provide a low extravasation effect before and / or during a treatment procedure. Typically, it is desirable for the blood vessels BV to be leakiest during periods when the concentration of molecules 110 passing through the blood vessels BV is highest, thereby achieving maximum extravasation of molecules 110 into the interstitial environment of the target tissue area.

[0024]

[0142] Induced extravasation provides a variety of advantages. Exemplary advantages include, but are not limited to, the creation of a larger treatment area, modulation of the treatment area to make it more amenable to therapeutic treatment, increased availability of molecules, increased uniformity of availability of molecules, increased delivery of molecules to naturally restricted locations, for example, through the blood-brain barrier, and reduced likelihood of side effects of the treatment. Each of these is described in more detail in subsequent sections.

[0025]

[0143] In this embodiment, the molecules 110 are intended to be taken up by cells in the target treatment area. In some embodiments, induced extravasation alone is sufficient to increase uptake of the molecules 110 by cells in the target tissue area. In other embodiments, delivery of therapeutic energy further enhances uptake of the molecules 110. In some embodiments, the therapeutic energy comprises PEF energy having a waveform that is different from the pre-conditioning PEF energy. It will be appreciated that in some embodiments, the therapeutic PEF energy is delivered by the same energy delivery unit 108 positioned within the target tissue area. In other embodiments, the therapeutic energy is delivered using a different device.

[0026]

[0144] It will be appreciated that in other embodiments, molecules 110 are not intended for uptake by cells to cause an effect. For example, molecules 110 including ligands, cytokines, tumor necrosis factor (TNF), or vascular endothelial growth factor (VEGF), etc., can be delivered to an area as part of a therapeutic treatment without uptake of these molecules 110. In such instances, extravasation can provide various benefits, such as increased availability and uniformity, despite increased uptake.

[0027]

[0145] In this embodiment, treatment of the tumor T follows the extravasation process. FIG. 6 shows an energy delivery unit 108 inserted into the tumor T. In this embodiment, a specific pulsed electric field (PEF) energy is delivered to the target tissue area via the energy delivery unit 108. Typically, the therapeutic PEF energy is different from the modulating PEF energy. However, it will be appreciated that in some instances, the two energies have the same waveform or other similarities. Such therapy disrupts, eliminates, kills, removes, etc., undesirable cells while preserving non-cellular elements such as collagen, elastin, and matrix proteins. Thus, the integrity and mechanical properties of the tissue and nearby luminal structures are maintained while sufficiently eliminating abnormal or diseased cells and tissue. It will be appreciated that other forms of energy or other treatment modalities may be used to treat the target tissue, such as microwave ablation, radiofrequency ablation, cryoablation, and / or other focal therapies, including high-intensity focused ultrasound (HIFU).

[0028]

[0146] In this embodiment, the PEF energy typically generates various treatment zones extending radially outward from the energy delivery portion 108, as shown in FIG. 6. As shown, the zone closest to the energy delivery portion 108 (i.e., central zone 107) undergoes immediate cell death, such as through necrosis. In this embodiment, the zone surrounding the central zone (i.e., peripheral zone 109) undergoes delayed cell death, such as through programmed cell death. FIG. 7 shows what was previously a tumor T is now a debris field DF extending outward to its periphery 111. The debris field DF is then cleared by the patient P's immune system, as shown in FIGS. 8A-8B. FIG. 8A shows dendritic cells DC and other immune cells migrating (as indicated by arrows) from adjacent intact lung tissue LT into the debris field DF. The dendritic cells DC internalize remaining cellular debris, antigens, and damage-associated molecular patterns (DAMPs). DAMPs are molecules released during cellular stress or tissue injury. They are considered endogenous danger signals because they induce a strong inflammatory response by activating the innate immune system during non-infectious inflammation. Figure 8B shows dendritic cells (DCs) and other immune cells migrating from the debris field (DF) back into the surrounding lung tissue (LT) (as indicated by the arrows). As shown in Figure 9, dendritic cells (DCs) and other immune cells enter the afferent lymphatic vessels (LD) and travel to the nearest tumor-draining lymph node (LN), leading to a network of lymph nodes (LN). Figure 10 shows the site of the primary tumor (T), now in the debris field (DF), along with nearby lymph nodes (LN). This allows activated T cells to flow from the lymph nodes (LN) to the heart (H), which then distributes them throughout the body, including the right upper lobe of the lung (L) where the primary tumor (T) was located. T cells then infiltrate into the debris field (DF) via the vasculature. Residual tumor cells (T) are identified by antigens on their cell surface, and the T cells release perforin and cytotoxins to kill them. Any remaining tumor cells T are killed by perforin and granzymes released from the T cells. In some embodiments, checkpoint inhibitors are provided that support this process.This cell death cycles through the lymph nodes (LNs) and activates more T cells, which can be repeated several times.

[0029]

[0147] Furthermore, T cells may encounter distant metastases. Figure 11 illustrates these steps: (1) dendritic cells (DC) and other immune cells migrate to lymph nodes (LN) via lymphatic vessels (LD), (2) activated T cells migrate to the heart (H), and (3) activated T cells migrate to distant locations within the body. Figure 12 shows that in step (3), activated T cells migrate to metastatic tumors T1 and T2 in the liver (LR). The same process then occurs with metastatic tumors T1 and T2, activating more T cells. This helps eliminate cancerous tumors throughout the patient's body.

[0030]

[0148] It will be appreciated that in some instances, the lymph node itself is the target tissue, such as a lymph node containing cancer cells, including metastatic cancer cells. In such instances, the target lymphatic tissue is treated in the same or similar manner as the tumor T described herein, which also releases activated T cells that migrate throughout the body.

[0031] B. Benefits of Extravasation

[0149] Induced extravasation can have a variety of beneficial effects on therapeutic treatments administered to target tissue areas. Examples of improved therapeutic treatments include, but are not limited to, target tissue modulation, increased molecular availability, increased uniformity of molecular availability, increased access to naturally confined target tissues, creation of larger treatment areas, and reduced likelihood of undesirable side effects, to name a few. In examples where the target tissue area is a cancerous tumor, the therapeutic treatment can include delivery of chemotherapeutic agents and / or delivery of localized treatments, examples of which include microwave ablation, radiofrequency ablation, cryoablation, and / or high-intensity focused ultrasound (HIFU), and pulsed electric field ablation therapy configured to destroy cells. Thus, in these examples, induced extravasation can be considered part of a pre-conditioning or conditioning regimen, utilized in conjunction with therapeutic treatments (e.g., chemotherapy, localized treatment, combined chemotherapy and localized treatment, etc.) to enhance therapeutic efficacy. It will be appreciated that the examples provided based on cancerous tumors are for illustrative purposes, and the principles described herein can be applied to the treatment of other undesirable or diseased tissues. Similarly, other drugs, agents, or molecules (e.g., DNA plasmids, RNA (e.g., messenger RNA (mRNA), small interfering RNA (siRNA), microRNA), oligonucleotides, antisense oligonucleotides (ASOs), proteins, and / or substances that cause genetic or epigenetic changes in cellular behavior) can be delivered in therapeutic treatment of target tissues, and are not limited to chemotherapeutic drugs. Such drugs, agents, or molecules are collectively considered molecules.

[0032]

[0150] In some embodiments, the induced extravasation can function as a virtual or fluid electrode, thereby enabling the generation of a larger treatment area. The extravasated fluid or edema is naturally conductive, and therefore, when it collects within the target treatment area and comes into contact with the energy delivery element 108, it expands the reach of the energy delivery element 108 through the conductive edema fluid. This can increase the size of the ablated lesion, such as width, depth, or volume. This can also enhance the local selectivity of PEF ablation.

[0033]

[0151] In some embodiments, induced edema alters the electrical properties of the intracellular microenvironment of the target tissue area, potentially improving the efficacy and conduction of therapeutic PEF energy through the target tissue area. In particular, induced edema can lower the electric field threshold at which cells undergo cell death, such as through loss of homeostasis or energy depletion. This allows for the use of lower intensities in therapeutic PEF energy protocols, reducing potential thermal effects and generator demands, in addition to enlarging the treatment area. Thus, in some embodiments, induced edema standardizes the target tissue area (e.g., creates a stable impedance environment) prior to therapeutic treatment. While target tissue areas typically have heterogeneous environments on a microscopic scale, the introduction of a conductive fluid creates a more homogeneous environment. High-conductivity fluids flow through low-conductivity conduits, sometimes with connective tissue containing non-conductive air pockets and other structures with widely distributed impedances on a microscopic scale. The more homogeneous the environment, the more consistent the behavior throughout the tissue area, according to the new bulk tissue conductivity. This can be beneficial when providing a partial therapy alone, or when providing a partial therapy in combination with the delivery of a drug or agent-containing molecule.

[0034]

[0152] In some embodiments, the induced edema increases the local concentration of molecule 110 in the target treatment area, increasing the availability of molecule 110. If molecule 110 is delivered via the vasculature, extravasation of molecule 110 from the vasculature increases the local concentration in the target tissue area. Similarly, if molecule 110 is provided by other methods, the effect of edema (e.g., increased interstitial pressure) increases the availability of molecule 110. It will be appreciated that because target tissue cannot easily increase its interstitial volume, a relatively small increase in transcapillary fluid filtration induces a large increase in interstitial fluid pressure. This creates a pressure gradient, which urges molecule 110 into target tissue cells. Similarly, the resulting concentration gradient also urges molecule 110 into target tissue cells.

[0035]

[0153] In some instances, induced extravasation results in improved distribution (e.g., increased uniformity) of molecules 110 throughout the target treatment area. In some instances, induced edema provides a conduit for increasing the distribution rate and ultimate volume distribution of the target substance into the interstitial space, for example, via extravasation or by direct injection of molecules 110 into the target region. As previously described, in some embodiments, induced edema traps molecules within the target tissue area, at least temporarily resisting dilution of the molecules back into the blood or lymphatics. Eventually, the edema naturally drains along the lymphatics. If the edema contains molecules, excess molecules are also drained via the lymphatics. In cases such as cancers where cancer cells migrate along lymphatics, the molecules may be transported to the same lymph nodes where the migratory cancer cells may arrive, potentially preventing metastasis.

[0036]

[0154] In some embodiments, induced extravasation increases access to naturally restricted target tissues. For example, induced extravasation may enable delivery of a substance through a cell-based tissue layer that would otherwise prevent the substance from passing through and reaching the target cell population. For example, molecules 110 delivered to the vitreous humor of the eye typically cannot reach the subretinal space, particularly the retinal pigment epithelium (RPE) and photoreceptor cells (PR). This is due to the tightly coupled ganglion and bipolar cells located between the vitreous humor and the underlying RPE and PR. As a result, various molecules 110, especially large molecules, cannot diffuse through these restrictive layers. Delivery of the modulating energy described herein adjacent to the retinal surface, either deep within the intravitreal space or within a surgically created subretinal bleb, induces extravasation of fluid from the retinal vasculature. The inner retina receives its blood supply from a retinal vasculature connected to the central retinal artery. At the optic nerve head, the central retinal artery divides into several branches, which provide a blood supply for the entire inner retina. The venous portion of the retinal circulation is similarly arranged. The central retinal vein exits the eye via the optic nerve head and pumps blood into the cavernous vein. The diameter of the central retinal artery before it enters the eye, as well as the diameter of its branching arteries, is typically less than 200 mm. Therefore, these vessels are functionally arterioles, and venous vessels are functionally venules. In some embodiments, extravasation of fluid from arterioles, capillaries, the suprachoroidal space, and other regions that may carry molecules 110 accumulates in the suprachoroidal space or retinal cavity, among other regions of the ocular anatomy that allow diffusion between various retinal cell layers. These retinal cell layers may include those targeted in interventional PEF therapy for macromolecule uptake, including gene transfection. The additional fluid in these environments provides excellent pathways for diffusion and dispersion of molecules injected onto the choroid, into blood vessels, into the vitreous, or between retinal cell layers, including ganglion and bipolar cells, allowing for increased transport of molecules 110 from the vitreous into the subretinal space.

[0037]

[0155] In another example, molecules 110 delivered to the vascular system often cannot reach parts of the brain due to the blood-brain barrier. Blood vessels vasculature the central nervous system (CNS) possess a unique property called the blood-brain barrier (BBB), which allows these vessels to tightly control the movement of ions, molecules, and cells between the blood and the brain. This precise control of CNS homeostasis enables proper neural function and protects neural tissue from toxins and pathogens. The physiological barrier is regulated by a set of physical, transport, and metabolic properties possessed by endothelial cells (ECs) that form the blood vessel walls, which are controlled by interactions between various vascular, immune, and neural cells. However, delivery of modulated energy as described herein disrupts the blood-brain barrier, allowing molecules 110 to pass through to cells deeper within the brain. This allows for the use of PEF energy to disrupt the BBB, the inclusion of molecules 110 that act as adjuvants (e.g., calcium, chemotherapy, immunostimulants, charge modulating agents, etc.), or the inclusion of molecules 110 that transfect cells (e.g., chemotherapy or genetic material including RNA, DNA, plasmids, oligos, etc.), to name a few examples.

[0038]

[0156] It will be appreciated that in other embodiments, the molecule 110 is delivered via the cerebrospinal fluid rather than via the vasculature. Such access may be achieved by spinal tap, which may allow direct access of the molecule 110 to regions of the central nervous system, such as the ventricles. PEF may then be used to drive distribution and diffusion of the molecule 110 to regions beyond the ventricle via localized edema. It will be appreciated that in various clinical applications, edema may be used to promote movement and distribution of the molecule 110, regardless of how the molecule 110 was originally delivered. Thus, induced extravasation of fluid may be used as a secondary delivery mechanism to supplement the primary delivery.

[0039]

[0157] In yet another example, molecules 110 delivered to systemic blood vessels often cannot reach the innermost layer of the lumen wall, for example, to treat the blood vessel itself. In some cases, it is difficult for molecules 110 to cross the intima of a blood vessel. Such crossing is typically desired to deliver drugs and other agents to the smooth muscle layer and beyond, which may be desirable in preventing restenosis when treating occluded blood vessels. In some embodiments, modulated energy is transmitted to the lumen wall to cause extravasation of molecules 110 from the lumen through one or more layers of the lumen wall.

[0040]

[0158] In some embodiments, induced extravasation reduces the likelihood of therapeutic device side effects, such as potential arcing and / or thermal effects. This occurs due to the heat sink effect of fluid in the target environment and the conductive nature of most edematous liquids described herein. Thus, in areas where the target electrode may not have ideal electrical contact at the tissue-electrode interface (weak contact, or only partial contact with air or other low-conductivity tissue), the fluid may act as an electrical interface to deliver PEF energy from the electrode into the remaining tissue.

[0041]

[0159] For example, in some cases, electrodes placed in aerated lung parenchymal tissue have sporadic electrical contact with the tissue, resulting in extremely high currents at the tissue contact site. This can result in insufficient PEF energy distribution within the tissue, which can lead to thermal effects such as carbonization and ceramization of the tissue, as well as arcing from the electrode to the tissue. However, after delivering therapeutic or subtherapeutic amounts of PEF energy to the tissue, edematous fluid locally fills the aerated alveolar regions, particularly those closest to the electrode. This fluid then distributes the PEF energy more evenly throughout the tissue. This allows for the delivery of more intense PEF treatment protocol waveforms without potentially causing arcing, burning, or other side effects.

[0042]

[0160] In addition to spreading energy more efficiently, edematous filling in the region that improves electrical continuity at the tissue-electrode interface helps dissipate the energy further before a large voltage drop occurs, essentially increasing the effective surface area of ​​the electrode through a "virtual electrode" effect, thereby reducing the energy intensity required to achieve the same therapeutic effect, thereby reducing generator demands.

[0043]

[0161] It will be appreciated that in some embodiments, the modulating energy increases cellular resistance in the targeted cell area to eventual cell death. This may be desired when treatment involves procedures such as gene transfection rather than ablation. In such instances, uptake of genetic material by the cells is desired, rather than elimination or destruction of the cells. In such instances, the targeted treatment area is subjected to modulating energy that causes fluid extravasation into the area. Cells undergoing sublethal stress are known to generate a reparative and preventative response to the stress, essentially creating resistance and enhancing resilience to subsequent stresses of a similar or different nature. For example, in some embodiments, the modulating energy releases heat shock proteins (HSPs). HSPs are a family of proteins produced by cells in response to exposure to stressful conditions, such as the modulating energies described herein. While initially described in connection with heat shock, HSPs are now known to be released in response to other stresses, including exposure to cold, UV light, and during wound healing or tissue remodeling. Many members of this group perform chaperone functions by stabilizing new proteins to ensure their correct folding or by promoting the refolding of proteins damaged by cellular stress. This increased release is transcriptionally regulated. The dramatic upregulation of heat shock proteins is an essential part of the heat shock response and is primarily induced by heat shock factors (HSFs).

[0044]

[0162] In some embodiments, pre-heating of tissue or cells (prior to delivery of molecules 110) can initiate the release of heat shock proteins that play a role in cell injury, repair, and survival. In such embodiments, a warm solution, such as warm saline, can be injected into the treatment site, and after a waiting period, molecules 110 can be delivered along with the energy delivery. The waiting period can be several minutes, hours, or days after delivery of the warm solution. In some embodiments, the waiting period is 5-30 minutes, 1-2 hours, or 1-2 days.

[0045]

[0163] In some embodiments, tissue or cells are heated using the energy delivery unit 108. In such embodiments, energy is delivered at a controlled rate to maintain a local temperature within a specific range, such as 40-50°C, for treatments of less than 10 minutes. It will be appreciated that heat shock proteins are triggered at approximately 41°C in some embodiments. Therefore, sublethal pulsed electric field delivery can be used prior to a stronger therapeutic pulsed electric field to promote upregulation of heat shock proteins and other damage repair mechanisms. This promotes cellular recovery from pulsed electric field damage and improves the ability to translocate molecules to a meaningful number of cells without undesirable excessive cell death. Thus, in one embodiment, modulated energy is delivered to a targeted treatment area, raising the temperature of at least a portion of the treatment area, for example, to 45°C, thereby inducing extravasation of fluid into the area. Drugs, genes, or other types of molecules can be delivered via intratumoral injection to benefit from the extravasation benefits described herein. A therapy, such as therapeutic PEF energy, is then delivered to the targeted treatment area. Because the cells in the treatment area have been previously conditioned to resist cell death, more cells will survive the treatment protocol, which is beneficial for gene therapy or other types of treatments that rely on cell survival.

[0046] II. Delivery System Embodiments

[0164] As discussed above, the devices, systems, and methods described herein deliver pulsed electric fields (PEF) or other combined lethal or sublethal energy to a target tissue area to generate extravasation and interstitial edema within, and optionally near, the target tissue area, for example, by inducing changes in the endothelial walls of capillaries. FIG. 13 illustrates one embodiment of an energy delivery system 100 for delivering such PEF energy to a target tissue area. In this embodiment, the system 100 includes a specialized energy delivery device 102, a return electrode 106, and a waveform generator 104. In this embodiment, the target tissue area is located within the liver LR of a patient P, although it will be appreciated that such devices, systems, and methods can be used to treat target tissue areas throughout the body. In this embodiment, the energy delivery device 102 includes a flexible, elongated shaft having a distal end that can be advanced intraluminally to the target tissue within the liver LR. As shown, the distal end of the delivery device 102 is advanced from the mouth M through the esophagus E into the stomach S, through the stomach wall, and into the liver LR. In some embodiments, the distal end has a distal tip 103 configured to pierce the stomach wall and / or liver LR. In other embodiments, a separate instrument is used to create a passage through the stomach wall. This instrument is then removed to allow the energy delivery device 102, having an atraumatic tip, to pass through the passage. It will be appreciated that in other embodiments, the energy delivery device 102 is percutaneous.

[0047]

[0165] Examples of systems capable of providing this type of therapeutic treatment are provided in commonly assigned patent application PCT / US2020 / 028844, entitled "DEVICES, SYSTEMS AND METHODS FOR THE TREATMENT OF ABNORMAL TISSUE," which is incorporated herein by reference for all purposes. Other exemplary systems are disclosed in International Patent Application No. PCT / US2017 / 039527, entitled "GENERATOR AND A CATHETER WITH AN ELECTRODE AND A METHOD FOR TREATING A LUNG PASSAGEWAY," which claims priority to U.S. Provisional Application Nos. 62 / 355,164 and 62 / 489,753; International Patent Application No. PCT / US2018 / 067501, entitled "METHODS, APPARATUSES, AND SYSTEMS FOR THE TREATMENT OF DISORDERS," which claims priority to U.S. Provisional Application Nos. 62 / 610,430, filed December 26, 2017, and 62 / 693,622, filed July 3, 2018, and entitled "OPTIMIZATION OF ENERGY DELIVERY FOR and US2018 / 0139900, entitled "Various Applications of Pulmonary Tissue Modification Systems," all of which are incorporated herein by reference for all purposes.

[0048]

[0166] As described above, the regulated PEF energy and optionally the therapeutic energy are delivered to the target tissue via the distal end of the delivery device 102. The proximal end of the delivery device 102 is electrically connected to a waveform generator 104. In some embodiments, the generator 104 is also connected to an external cardiac monitor, allowing energy delivery to be coordinated with cardiac signals sensed from the patient P.

[0049]

[0167] Energy is provided by a generator 104 and delivered to the tissue via an energy delivery unit 108 positioned on, within, or near the target tissue area. Electrical pulses are then delivered via the energy delivery unit 108 near the target tissue. These electrical pulses are provided by at least one energy delivery algorithm 152. In such embodiments, the algorithm 152 defines signal parameters such as the energy amplitude (e.g., voltage) and duration of the applied energy, which may consist of the number of pulses, pulse width, and delay between pulses, to name a few. In some embodiments, one or more of the energy delivery units are small and tend to dissipate a large amount of energy around the electrode. Therefore, optimal energy delivery is desired. Typically, a generator structure recommended for delivering efficient delivery pulses in such instances is a large DC link capacitance with a half transistor bridge. Pulse voltages delivered by power amplifiers (which have limited bandwidth) or exponential decay generators are not desirable for this application.

[0050]

[0168] In some embodiments, a biphasic pulse can be used. In such embodiments, additional parameters may include a switch time between polarities of the biphasic pulse and a dead time between biphasic cycles. Feedback loops and automatic shutoff specifications based on sensor information may also be included. A biphasic waveform is advantageous for reducing muscle stimulation in the patient. This is particularly important in applications where slight movement of the energy delivery unit can easily negate the effectiveness of the procedure. A biphasic waveform includes rapid changes in signal phase / polarity to minimize neural activation during transitions between polarities. Multiple high-speed switching elements (e.g., MOSFETs, IGBT transistors) are desirable, used and configured, for example, in an H-bridge or full-bridge configuration.

[0051]

[0169] 13, in this embodiment, the generator 104 includes a user interface 150, one or more energy delivery algorithms 152, a processor 154, a controller 155, a data storage / retrieval unit 156 (such as a memory and / or database), and an energy storage subsystem 158 that generates and stores the energy to be delivered. In some embodiments, one or more capacitors are used for energy storage / delivery, although any other suitable energy storage elements may be used. Additionally, one or more communication ports may be included.

[0052]

[0170] In some embodiments, the generator 104 includes three subsystems: 1) a high-energy storage system, 2) a high-voltage medium-wave switching amplifier, and 3) a system controller, firmware, and user interface. The generator takes in alternating current (AC) power and feeds multiple direct current (DC) power supplies. The generator's controller allows the DC power supplies to charge a high-energy capacitor storage bank before the start of energy delivery. In some embodiments, at the start of energy delivery, the generator's controller, high-energy storage bank, and biphasic pulse amplifier can operate simultaneously to generate a high-voltage medium-wave output.

[0053]

[0171] It will be appreciated that numerous generator electrical architectures can be employed to implement energy delivery algorithms. In particular, some embodiments employ advanced switching systems that can direct pulsed electric field circuits to energy delivery electrodes separate from the same energy storage and high-voltage delivery systems. Furthermore, generators employed with advanced energy delivery algorithms that employ rapidly varying pulse parameters (e.g., voltage, frequency, etc.) or multiple energy delivery electrodes can utilize modular energy storage and / or high-voltage systems to facilitate highly customizable waveform and geographic pulse delivery paradigms. Furthermore, it will be appreciated that the electrical architectures described herein above are merely exemplary, and that systems that deliver pulsed electric fields may or may not include additional switching amplifier components.

[0054]

[0172] The user interface 150 may include a touch screen and / or more conventional buttons to allow the operator to enter patient data, select a treatment algorithm (e.g., energy delivery algorithm 152), initiate energy delivery, view records stored on the storage / retrieval unit 156, and / or otherwise communicate with the generator 104.

[0055]

[0173] In some embodiments, the user interface 150 is configured to receive operator-defined input. The operator-defined input may include one or more other timing aspects of energy delivery duration, energy delivery pulses, power, and / or operational mode, or combinations thereof. Example operational modes may include (without limitation) system initiation and self-test, operator input, algorithm selection, pre-treatment system status and feedback, energy delivery, post-energy delivery display or feedback, treatment data review and / or download, software update, or any combination or subcombination thereof.

[0056]

[0174] In some embodiments, processor 154 changes and / or switches energy delivery algorithms, monitors energy delivery and sensor data, and reacts to the monitored data via a feedback loop, among other activities. In some embodiments, processor 154 is configured to execute one or more algorithms for implementing a feedback control loop based on one or more measured system parameters (e.g., current), one or more measured tissue parameters (e.g., impedance), and / or a combination thereof.

[0057]

[0175] The data storage / retrieval unit 156 stores data, such as that related to delivered treatments, which can optionally be downloaded by connecting a device (e.g., a laptop computer or thumb drive) to the communications port. In some embodiments, the device has local software used to direct the download of information, such as instructions stored in the data storage / retrieval unit 156 and executable by the processor 154. In some embodiments, the user interface 150 allows an operator to select download of data to devices and / or systems, such as, but not limited to, computer devices, tablets, mobile devices, servers, workstations, and cloud computing devices / systems. Communications ports that allow for wired and / or wireless connectivity not only allow for data downloads as just described, but also allow for data uploads, such as uploading custom algorithms or providing software updates.

[0058]

[0176] As described herein, various energy delivery algorithms 152 may be programmable or pre-programmable within the generator 104 and may be stored, for example, in a memory or data storage / retrieval unit 156. Alternatively, the energy delivery algorithms may be added within the data storage / retrieval unit for execution by the processor 154. Each of these algorithms 152 may be executed by the processor 154.

[0059]

[0177] In some embodiments, the energy delivery device 102 includes one or more sensors that can be used to determine temperature, impedance, resistance, capacitance, conductivity, pH, optical properties (coherence, echogenicity, fluorescence), electrical or optical permittivity, and / or conductance, to name a few. In some embodiments, one or more of the electrodes act as the one or more sensors. In other embodiments, the one or more sensors are separate from the electrodes. Sensor data can be used to plan the procedure, monitor the procedure, and / or provide direct feedback via the processor 154, which can then modify the energy delivery algorithm 152. For example, impedance measurements can be used to determine whether further energy delivery is necessary, as well as to determine the initial dose to apply.

[0060]

[0178] It will be appreciated that in some embodiments, the system 100 includes automated delivery algorithms that dynamically respond and adjust and / or terminate delivery in response to inputs such as temperature, impedance at various voltages or AC frequencies, duration or other timing aspects of energy delivery pulses, power, and / or system status.

[0061]

[0179] In this embodiment, the molecule 110 is delivered systemically via intravenous administration using an IV bag 112. This typically distributes the molecule 110 throughout the patient P's system, including the target tissue in the liver LR. It will be appreciated that in other embodiments, the molecule 110 is delivered locally. In such embodiments, the molecule 110 may be delivered to the vasculature upstream of the arterial system leading to the target organ or tissue area. The molecule 110 then travels downstream via the arterial circulation into the target region. If a bolus injection of the molecule 110 is performed, a sudden stream of the molecule 110 will surge into the target tissue. However, if the molecule 110 is delivered over time using, for example, an infusion pump, a steady, sustained level of the molecule 110 in the target tissue may be achieved. It will be appreciated that in other embodiments, the molecule 110 is delivered by direct injection into the target tissue. In such embodiments, an injection device is inserted into or near the target tissue, e.g., into the parenchyma of the target organ region, and a solution containing the molecule 110 is injected. It will be appreciated that a combination of systemic, regional, and local delivery may alternatively be used.

[0062]

[0180] In some embodiments, the modified PEF energy is delivered before, during, and / or after delivery of the molecule 110, but before the therapeutic treatment to improve the uptake or effect of the molecule 110 on cells in the target tissue area thereafter. Thus, it will be understood that the molecule 110 can be delivered before, during, and / or after delivery of the modified PEF. In other embodiments, the modified PEF energy and the therapeutic PEF energy are the same, and in such instances, the molecule 110 can be delivered before, during, and / or after delivery of the therapeutic PEF energy. Various timing and procedural methodologies are described in more detail in later sections.

[0063] III. Molecules and Enhancements

[0181] As previously mentioned, in some embodiments, devices, systems, and methods are provided for delivering molecules 110, particularly small molecules and / or macromolecules, to cells, such as target cells, within the body. In some embodiments, the cells directly derive a therapeutic benefit from the functionality of the molecule. Such therapeutic benefit may be in the treatment of various disorders.

[0064]

[0182] In some embodiments, the disorder comprises a coagulation disorder such as hemophilia (e.g., hemophilia A or hemophilia B), von Willebrand disease, factor 11 deficiency, a fibrinogen disorder, or vitamin K deficiency. The coagulation disorder can be characterized by a mutation in a gene encoding fibrinogen, prothrombin, factor 5, factor 7, factor 8, factor 10, factor 11, factor 13, or an enzyme involved in post-translational modification or vitamin K metabolism. In some embodiments, the coagulation disorder is characterized by a mutation in FGA, FGB, FGG, F2, F5, F7, F10, F11, F13A, F13B, LMAN1, MCFD2, GGCX, or VKORC1.

[0065]

[0183] In some embodiments, the disorder comprises a neurological disorder, such as a neurodegenerative disease. In some embodiments, the neurodegenerative disease comprises Alzheimer's disease, Parkinson's disease, or multiple sclerosis. In some embodiments, the neurodegenerative disease comprises an autoimmune disease of the central nervous system (CNS), such as multiple sclerosis, encephalomyelitis, paraneoplastic syndromes, autoimmune inner ear disease, or opsoclonus-myoclonus syndrome. The neurological disorder can be a stroke, spinal cord injury, central nervous system disorder, neuropsychiatric disorder, or channelopathy (e.g., epilepsy or migraine). The neurological disorder can be an anxiety disorder, a mood disorder, a childhood disorder, a cognitive disorder, schizophrenia, a substance-related disorder, or an eating disorder. In some embodiments, the neurological disorder is a symptom of a stroke, traumatic brain injury, or spinal cord injury.

[0066]

[0184] In some embodiments, the disorder comprises a lysosomal storage disorder such as Tay-Sachs disease, Gaucher disease, Fabry disease, Pompe disease, Niemann-Pick disease, or mucopolysaccharidosis (MPS).

[0067]

[0185] In some embodiments, the disorder comprises a cardiovascular disorder, such as degenerative heart disease, coronary artery disease, ischemia, angina, acute coronary syndrome, peripheral vascular disease, peripheral arterial disease, cerebrovascular disease, or atherosclerosis. The cardiovascular disorder can be a degenerative heart disease selected from the group consisting of ischemic cardiomyopathy, conduction disorders, and congenital defects.

[0068]

[0186] In some embodiments, the disorder comprises an immune disorder, such as, for example, an autoimmune disorder, which can be type 1 diabetes, multiple sclerosis, rheumatoid arthritis, lupus, encephalomyelitis, paraneoplastic syndromes, autoimmune inner ear disease or opsoclonus-myoclonus syndrome, autoimmune hepatitis, uveitis, autoimmune retinopathy, neuromyelitis optica, psoriatic arthritis, psoriasis, myasthenia gravis, chronic Lyme disease, celiac disease, chronic inflammatory demyelinating polyneuropathy, peripheral neuropathy, fibromyalgia, Hashimoto's thyroiditis, ulcerative colitis, or Kawasaki disease.

[0069]

[0187] In some embodiments, the disorder comprises a liver disease such as hepatitis, Alagille syndrome, biliary atresia, liver cancer, cirrhosis, cystic disease, Caroli syndrome, congenital hepatic fibrosis, fatty liver, galactosemia, primary sclerosing cholangitis, tyrosinemia, glycogen storage disease, Wilson's disease, or endocrine deficiency. The liver disease can be hepatocellular hyperplasia, hepatocellular adenoma, focal nodular hyperplasia, or liver cancer such as hepatocellular carcinoma.

[0070]

[0188] In some embodiments, the disorder comprises cancer, such as a hematological cancer (e.g., acute lymphocytic leukemia, acute myeloblastic leukemia, chronic myelogenous leukemia, Hodgkin's disease, multiple myeloma, and non-Hodgkin's lymphoma), or a solid tissue cancer (e.g., liver cancer, kidney cancer, breast cancer, gastric cancer, esophageal cancer, stomach cancer, intestinal cancer, colon cancer, bladder cancer, head and neck cancer, skin cancer, or brain cancer).

[0071]

[0189] In some embodiments, the disorder comprises a recessively inherited disorder, hi some embodiments, the disorder is a Mendelian disorder.

[0072]

[0190] In some embodiments, the disorder comprises an ocular disease that is a retinal dystrophy (e.g., a Mendelian retinal dystrophy). The retinal dystrophy can include Leber's congenital amaurosis (LCA), Stargardt's disease, pseudoxanthoma elasticum, rod-cone dystrophy, exudative vitreoretinopathy, Joubert syndrome, CSNB-1C, age-related macular degeneration, retinitis pigmentosa, Stickler syndrome, microcephaly and chorioretinitis, retinitis pigmentosa, CSNB2, Usher syndrome, or Wagner syndrome.

[0073]

[0191] In some embodiments, the molecules 110 delivered by the devices, systems, and methods described herein include synthetic DNA vectors, such as those described in WO2019178500, filed March 15, 2019, entitled "Synthetic DNA Vectors and Methods of Use." This publication is incorporated herein in its entirety for all purposes. Such synthetic DNA vectors include non-viral DNA vectors, such as those that, like AAV vectors, confer long-term transduction of quiescent cells (e.g., post-mitotic cells). In some embodiments, such non-viral DNA vectors are the development of in vitro (e.g., cell-free) systems for synthetically generating circular AAV-like DNA vectors (e.g., DNA vectors containing terminal repeat sequences such as DD elements) by isothermal rolling cycle amplification and ligation-mediated circularization (as opposed to, e.g., bacterial expression and site-specific recombination). Such developments enable scalability and improved manufacturing efficiency in the production of circular AAV-like DNA vectors. Furthermore, vectors generated by these methods are designed to overcome many of the problems associated with plasmid DNA vectors, such as those discussed in Lu et al., Mol. Ther. 2017, 25(5):1187-98, which is incorporated herein by reference in its entirety. For example, by eliminating or reducing the presence of bacterial plasmid DNA sequences, such as CpG islands and / or RNAPII termination sites, transcriptional silencing can be reduced or eliminated, resulting in increased persistence of the heterologous gene. Furthermore, by eliminating the presence of immunogenic components (e.g., bacterial endotoxins, DNA, or RNA, or bacterial signatures such as CpG motifs), the risk of stimulating the host immune system is reduced. These benefits are particularly advantageous in the treatment of certain disorders, such as retinal dystrophies (e.g., Mendelian retinal dystrophies).

[0074]

[0192] Thus, such vectors include synthetic DNA vectors that are (i) substantially free of bacterial plasmid DNA sequences (e.g., RNAPII termination sites, origins of replication, and / or resistance genes) and other bacterial signatures (e.g., immunogenic CpG motifs), and / or (ii) can be synthesized and amplified entirely in vitro (e.g., replication in bacteria is unnecessary, e.g., bacterial origins of replication and bacterial resistance genes are unnecessary). In some embodiments, the vectors contain double-D (DD) elements characteristic of AAV vectors. This allows target cells to be transduced with DNA vectors bearing heterologous genes that behave like AAV viral DNA (e.g., reduced transcriptional silencing and increased persistence), without the need for the virus itself.

[0075]

[0193] In some embodiments, the molecule 110 comprises a nucleic acid-based molecule, such as a small interfering RNA (siRNA), a short hairpin RNA (shRNA), an oligonucleotide, an antisense oligonucleotide (ASO), a microRNA (miRNA), a decoy DNA, a ribozyme, a morpholino, and a plasmid.

[0076]

[0194] RNA interference using small inhibitory RNAs (siRNAs) can be used to downregulate mRNA levels by cellular nucleases that are activated when sequence homology between the siRNA and respective mRNA molecules is detected. Thus, in some embodiments, siRNAs are used to silence genes involved in the pathogenesis of various diseases associated with known genetic backgrounds. In some embodiments, molecule 110 comprises patisiran, an siRNA-based drug approved by the FDA for the treatment of polyneuropathy in people with hereditary transthyretin-mediated amyloidosis. For siRNA to function, the siRNA must be located within the target cells of interest. This means that the siRNA must be transported to tissues within the body where the target cells reside and then cross the cell membrane. These requirements are commonly referred to as "delivery" of the siRNA to the desired location. Because siRNAs are negatively charged molecules that do not naturally cross extracellular membranes, delivery has proven difficult using conventional delivery methods. The devices, systems, and methods described herein overcome these delivery challenges and deliver siRNA into target cells.

[0077]

[0195] In some embodiments, molecule 110 comprises a microRNA (miRNA), a class of small, non-coding RNAs, approximately 22 nt in length, that are involved in regulating gene expression at the post-transcriptional level by degrading target mRNAs and / or inhibiting their translation.

[0078]

[0196] In some embodiments, molecule 110 comprises an antisense oligonucleotide (ASO). ASOs are synthetic DNA oligomers that hybridize to target RNA in a sequence-specific manner. In some embodiments, ASOs are delivered to inhibit gene expression, modulate precursor messenger RNA splicing, or inactivate microRNAs. Chemically modified nucleotides, such as phosphorothioates, 2'-O-methyl RNA, or locked nucleic acids, can be used to stabilize ASOs against nucleic acid degradation, as these confer nuclease resistance. In some embodiments, ASOs are delivered to optimize enhanced delivery, selectivity, affinity, and nuclease resistance while reducing toxicity.

[0079]

[0197] Exemplary ASOs include (1) fomivirsen, such as for the treatment of CMV retinitis in AIDS patients; (2) mipomersen, such as for the treatment of familial hypercholesterolemia; (3) defibrotide, such as for the treatment of hepatic veno-occlusive disease; (4) eteplirsen, such as for the treatment of Duchenne muscular dystrophy; (5) pegaptanib, such as for the treatment of neovascular age-related macular degeneration; and (6) nusinersen, such as for the management of spinal muscular atrophy.

[0080]

[0198] In some embodiments, the molecule 110 comprises an oligomeric molecule such as a phosphorodiamidate morpholino oligomer (PMO), also known as a morpholino, which is a type of oligomeric molecule used to alter gene expression and knock down gene function. Morpholinos are typically 25 bases in length and bind to complementary sequences of RNA or single-stranded DNA through standard nucleobase pairing. Morpholino oligos specifically bind to selected DNA or RNA target sites, preventing cellular components from accessing the site. This property can be used to block translation, splicing, microRNA (miRNA) or their targets, and ribozyme activity. The molecular structure includes DNA bases attached to a backbone of methylene morpholino rings linked via phosphorodiamidate groups. The uncharged backbone of morpholino oligos is not recognized by enzymes, making them completely stable against nucleases. In some embodiments, eteplirsen, a morpholino-based drug that can be used to treat some mutations that cause Duchenne muscular dystrophy (DMD), is delivered. In other embodiments, golodirsen, a morpholino-based drug, is delivered for the treatment of DMD.

[0081]

[0199] In some embodiments, molecule 110 comprises a ribozyme (ribonucleic acid enzyme), a naturally occurring RNA molecule that catalyzes specific biochemical reactions, including RNA splicing, in gene expression, similar to the action of enzyme proteins. In some embodiments, molecule 110 comprises a synthetic ribozyme, such as one designed to inhibit the production of proteins through the specific cleavage of disease-causing mRNA. Another application of ribozyme therapy includes the inhibition of RNA-based viruses, such as HIV, Hepatitis C virus, SARS coronavirus (SARS-CoV), adenovirus, and influenza A and B viruses.

[0082]

[0200] In some embodiments, molecule 110 comprises a ribonucleoprotein (RNP). RNPs are complexes formed between RNA and RNA-binding proteins. For example, purified Cas9 protein can be combined with a guide RNA to form an RNP complex that is delivered to cells for rapid and highly efficient genome editing. RNPs have a short intracellular residence time and minimal dose, resulting in lower toxicity and reduced off-target editing compared to other methods. Additionally, RNP complexes are DNA-free, thus eliminating the risk of insertional mutagenesis.

[0083]

[0201] In some embodiments, the molecules 110 delivered by the devices, systems, and methods described herein contain CRISPR (Clustered Regularly Interspaced Short Palindromic Repeats Repetitive) DNA sequences, also known as CRISPRs. These DNA sequences were initially observed in bacteria as "spacer" DNA sequences between repeats that matched exactly with viral sequences. It was subsequently discovered that upon viral infection, bacteria transcribe these DNA elements into RNA. The RNA guides nucleases (proteins that cut DNA) to the viral DNA, cleaving it and providing protection against the virus. The nucleases are named "Cas," for "CRISPR-associated."

[0084]

[0202] In 2012, researchers demonstrated that RNA can be engineered to guide Cas nucleases (Cas9 was the first to be used) to any DNA sequence. These so-called guide RNAs can be specific for just one sequence, increasing the likelihood that the DNA will be cut at that site in the genome but not at other sites. Further testing revealed that the system works remarkably well in all types of cells, including human cells.

[0085]

[0203] CRISPR / Cas can disrupt targeted genes or insert new sequences at desired precise locations when a DNA template is added to the mixture. This method has been used to develop animal models with specific genomic mutations. Also, for known mutation-driven human diseases, such as cystic fibrosis, it is theoretically possible to insert DNA that corrects the mutation. However, it is difficult to deliver CRISPR / Cas materials to large numbers of mature cells using traditional methods, such as viral vectors. However, the devices, systems, and methods described herein overcome these challenges and enable the delivery of molecules 110 containing CRISPR / Cas materials into cells.

[0086]

[0204] In some embodiments, molecule 110 comprises a recombinant protein. Using recombinant DNA technology, such therapeutic proteins have been developed to treat a wide variety of diseases, including cancer, autoimmune / inflammatory diseases, exposure to infectious agents, and genetic disorders.

[0087]

[0205] In some embodiments, molecule 110 comprises a proteolysis targeting chimera (PROTAC). PROTACs are small molecules that can remove specific undesirable proteins. PROTACs consist of two covalently linked protein-binding molecules: one capable of binding to an E3 ubiquitin ligase, and the other binding to a target protein for degradation. Recruitment of the E3 ligase to the target protein results in the ubiquitination of the target protein, followed by degradation by the proteasome. PROTACs can be used in the degradation of different types of target proteins related to various diseases, including cancer, viral infection, immune disorders, and neurodegenerative diseases.

[0088]

[0206] PROTACs offer various advantages in cancer therapy, including overcoming drug resistance and degrading previously "undruggable" protein targets. Currently, only 20-25% of known protein targets can be targeted using traditional drug discovery techniques. Proteins with non-catalytic and / or catalytically independent functions are still considered "undruggable" targets. Furthermore, a large number of cancer proteins, such as transcription factors, chromatin modulators, and small GTPases, are difficult to directly target pharmacologically. PROTACs are designed to target target proteins of interest (usually cancer proteins) for degradation by hijacking endogenous E3 ligases and / or the ubiquitin-proteasome system.

[0089]

[0207] In some embodiments, molecule 110 comprises an anti-tumor drug, such as a chemotherapy, including agents such as alkylating agents (e.g., cisplatin), nitrosoureas (e.g., carmustine), antimetabolites (e.g., fluorouracil), alkaloids (e.g., taxol), antibiotics (e.g., doxorubicin), corticosteroid and sex hormones (e.g., dexamethasone and tamoxifen), topoisomerase inhibitors (e.g., etoposide), and retinoids (e.g., all-trans retinoid acid (ATRA)).

[0090]

[0208] In some embodiments, molecule 110 comprises an immunotherapeutic agent, such as a checkpoint inhibitor. Immune checkpoint inhibitors work by blocking checkpoint proteins from binding to partner proteins, preventing the "off" signal from being sent, allowing T cells to kill cancer cells.

[0091]

[0209] In some embodiments, molecule 110 comprises an immunotherapy drug, such as T cell transplantation therapy, which enhances the body's T cells' ability to fight cancer. Immune cells are extracted from tumors, and those identified as most active against tumors are further modified to attack more cancer cells. Once enough cells have grown, they are infused back into the body to fight disease.

[0092]

[0210] In some embodiments, molecule 110 comprises an immunotherapeutic agent, such as a cancer vaccine. These vaccines are administered to trigger an immune response against a specific cancer, thereby enhancing the immune system's response to cancer cells. Exemplary cancer vaccines include the following vaccines approved by the U.S. Food and Drug Administration to prevent cancer: 1) the HPV vaccine, which protects against human papillomavirus (HPV), which predisposes to cervical cancer; and 2) the hepatitis B vaccine, which protects against hepatitis B virus (HBV), which causes liver cancer.

[0093]

[0211] In some embodiments, molecule 110 comprises an immune system modulator. Types of immunomodulatory agents include cytokines (e.g., interferons, interleukins) and immunomodulatory drugs (e.g., thalidomide).

[0094]

[0212] In some embodiments, molecule 110 comprises a monoclonal antibody. Monoclonal antibodies (mAbs) are laboratory-made immune system proteins (antibodies) designed to bind to specific proteins on cancer cells. These proteins bind to cancer cells, allowing them to be recognized and destroyed by the immune system. Many monoclonal antibodies are used to treat cancer (e.g., Avastin, Herceptin). Some monoclonal antibodies are also immunotherapeutics because they help transform the immune system against cancer (e.g., anti-PD-1, anti-PDL-1, anti-CTLA-4, anti-CD20, anti-CD19).

[0095]

[0213] The ability to deliver molecule 110 to tissues or cells can be altered using a variety of enhancements. For example, in some embodiments, additional / auxiliary substances are added to the body, such as by adding them to a solution carrying the molecule, which makes the cells more susceptible to uptake of small molecules or macromolecules. Exemplary auxiliary substances include polymeric nanoparticles, liposomes, PEGylated liposomes, lipofectamine, cell-penetrating peptides (CPC), dimethyl sulfoxide (DMSO), cholesterol, or other substances known to interact with the fluidity and dynamics of cell membranes. In some embodiments, the auxiliary substance is injected, and the injection pressure is selected or adjusted to enhance uptake of molecule 110 by the cells.

[0096]

[0214] In other embodiments, tissues or cells are heated or cooled to alter their ability to better accommodate molecules 110. For example, in some embodiments, cells are heated or cooled, such as by heating or cooling the solution carrying molecules 110, to improve transfer efficiency or increase the likelihood of cell survival after energy transfer. In some embodiments, warming cells can increase membrane fluidity, thus increasing acceptance of molecules 110. In other embodiments, cooling cells can increase stiffness, increasing the likelihood of "crack" formation, which increases acceptance of molecules 110.

[0097]

[0215] As previously described, processor 154, among other activities, modifies and / or switches energy delivery algorithms, monitors energy delivery and sensor data, and reacts to the monitored data via a feedback loop. In some embodiments, processor 154 is configured to execute one or more algorithms for implementing a feedback control loop based on one or more measured system parameters, one or more measured tissue parameters, and / or combinations thereof. In some embodiments, the parameter includes temperature, and the temperature can be maintained within a specific range by controlling the cadence of energy delivery. This can be useful for enhancing cellular uptake, immune response, overall safety, etc.

[0098]

[0216] It will be appreciated that enhancement may be performed before, during, or after delivery of molecules 110 and / or before, during, or after delivery of therapeutic energy. In some embodiments, an ancillary substance is administered to the patient at desired intervals during the multi-function waveform, for example, between the short high pulses and the long low pulses of the asymmetric waveform. This may help propel or push the ancillary substance into the cells.

[0099]

[0217] It will be appreciated that in some embodiments, isotonic or hypertonic saline solutions are delivered to the treatment site to adjust local tonicity.

[0100] IV. Example Waveforms

[0218] In some embodiments, the modulated PEF energy has a waveform that includes monophasic, long duration (greater than 500 μs) pulses. FIG. 14A shows an exemplary waveform of such PEF energy provided by the energy delivery algorithm 152 of the generator 104 used to induce extravasation. In this embodiment, the waveform is comprised of a series of pulses 400, each having a pulse width 402 and amplitude (determined by a set voltage 404), and each pulse 400 is separated by a delay 406. In this embodiment, the pulse width is considered long duration and is greater than 500 microseconds. In this embodiment, the delay 406 between pulses 400 is in the range of 10 μs to 10 s, including 10 μs to 100 μs, 1 ms to 100 ms, 100 ms to 500 ms, 500 ms to 1 s, 1 to 5 s, 5 to 10 s, 1 ms, 500 ms, 1 s, 2 s, and 5 s. While two pulses 400 are illustrated in FIG. 14A , modulation may be achieved with 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, or more than 10 pulses. In some embodiments, the PEF energy is not designed to induce uptake of molecules 110 by cells in the target tissue area, and therefore a range of pulse parameters (e.g., voltage, frequency, inter-pulse delay, etc.) may be utilized. However, it will be appreciated that in some embodiments, the treatment energy itself may be similar to that of FIG. 14A . In some embodiments, the waveform is biphasic, as shown in FIG. 14B . Here, each pulse 400 is biphasic and has a pulse width 402 separated by a delay 406. Even in this embodiment, the pulse width 402 is considered long, greater than 500 microseconds. In this embodiment, the delay 406 between pulses 400 is in the range of 1 μs to 1 second, with some examples being 1 μs to 10 μs, 10 μs, 1 μs to 100 μs, 100 μs, 1 μs to 250 μs, 250 μs, 1 μs to 500 μs, 500 μs, 1 ms, 2 ms, 5 ms, or 1 to 5 ms. In some embodiments, the pulses 400 are reversed in polarity, with some pulses 400 having positive amplitudes and some pulses 400 having negative amplitudes, and it will be appreciated that such polarity reversal can be symmetrical or asymmetrical.It will also be appreciated that in some embodiments, the pulses 400 are grouped by polarity. It will be appreciated that there can be any suitable number of pulses within each group, and that each group can have the same or a different number of pulses. For example, six positive pulses followed by two negative pulses, or four positive pulses followed by one negative pulse. In this manner, various combinations can be generated. Such groupings can be symmetrical or asymmetrical. Furthermore, while FIG. 13 illustrates unipolar delivery using a specialized energy delivery device 102 and return electrode 106, PEF energy may also be delivered by bipolar electrodes, such as a bipolar electrode array.

[0101]

[0219] FIG. 15A illustrates exemplary waveforms provided by the energy delivery algorithm 152 of the generator 104 used to perform a therapeutic treatment. Rather than longer pulses (greater than 500 μs) configured to induce extravasation, these waveforms have short pulses of 0.5-200 μs, which can be combined in multiple ways to achieve cumulative on-times of 1-200 μs comprising packets. Multiple packets configured for therapeutic use can then be delivered, for example, to ablate a targeted region of tissue. It will be appreciated that such PEF energy can also induce extravasation. In this embodiment, the waveform is comprised of a series of low-voltage, low-frequency pulses 800, each having a pulse width 802 and amplitude (determined by a set voltage 804), and each pulse 800 separated by a delay 806. Such waveforms may be suitable for transferring genetic material into cells. While three pulses 800 are illustrated in this embodiment, transfer may be achieved with 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, or more pulses. It will be appreciated that in some embodiments, the pulses 800 are reversed in polarity, with some pulses 800 having positive amplitudes and some pulses 800 having negative amplitudes. It will also be appreciated that in some embodiments, the pulses 800 are grouped by polarity. For example, FIG. 15B shows an example waveform provided by the energy delivery algorithm 152, with two pulses 800′ having positive polarity followed by two pulses 800″ having negative polarity. It will be appreciated that there can be any suitable number of pulses in each group, and that each group can have the same or a different number of pulses. For example, six positive pulses followed by two negative pulses, or four positive pulses followed by one negative pulse. In this manner, various combinations can be generated. Such groupings can be symmetrical or asymmetrical. Similarly, the pulses 800 can have different characteristics, such as different amplitudes (determined by the set voltages 804) and pulse widths 802.

[0102]

[0220] In some embodiments, the treatment energy is delivered monopolarly and the amplitude or set voltage 804 of each pulse is 1-500V, 1-250V, 1-100V, 10-100V, 10-70V, 10-50V, 10-40V, 10-30V, 10-20V, 10V, 20V, 30V, 40V, 50V, 60V, 70V, 80V, 90V, 100V, to name a few. The voltages used and considered can be the top of a square waveform, the peak of a sine or sawtooth waveform, or the RMS voltage of a sine or sawtooth waveform.

[0103]

[0221] It will be appreciated that the set voltage 804 may vary depending on whether the energy is delivered monopolarly or bipolarly. With bipolar delivery, lower voltages may be used because the electric field is smaller and more directed. While the bipolar voltage selected for use in treatment depends on the electrode separation distance, a monopolar electrode configuration using one or more separate dispersive pad electrodes may be delivered without much consideration for the precise placement of the catheter electrode and the dispersive electrode on the body. In monopolar electrode embodiments, the dispersive electrode may be a pad or any other receiving electrode. Typically, it functions as a dispersive electrode due to its size (large enough to prevent localized effects at the placement location) and / or its placement (sufficiently far away to avoid localized effects and not risk arcing). However, in some embodiments, the dispersive electrode is small and may have some effect at the placement site, but such effect may be a harmless side effect. For example, the delivery molecule 110 may not be present near the dispersive electrode to avoid delivery, or delivery in that area is minimal. In monopolar electrode embodiments, larger voltages are typically used due to the dispersive behavior of the delivered energy through the body to the dispersive electrodes at effective separation distances of about 10 cm to 100 cm. However, it will be appreciated that in some embodiments, the separation distance may be as short as 2 cm to 5 cm, with 5 cm being a typical minimum for moderately sized dispersive electrodes. In contrast, in bipolar electrode configurations, the relatively close active area of ​​the electrodes, about 0.5 mm to 10 cm, including 1 mm to 1 cm, has a greater effect on electrical energy concentration and increases the effective amount delivered to tissue from the separation distance.

[0104]

[0222] In some embodiments, the pulse width 802 is 1 ms, 2 ms, 5 ms, 10 ms, 20 ms, 30 ms, 40 ms, 50 ms, 60 ms, 70 ms, 80 ms, 90 ms, 100 ms, 1 ms to 100 ms, 2 ms to 100 ms, or 1 to 2 ms, to name a few examples. In some embodiments, the delay between pulses is 0.01 to 5 seconds, 0.01 to 0.1 seconds, 0.01 to 0.5 seconds, 0.01 to 1 second, 0.5 seconds, 0.5 to 1 second, 1 second, 1 to 1.5 seconds, 1 to 2 seconds, 0.5 to 2 seconds, 2 seconds, or 1 to 3 seconds, to name a few examples. In some embodiments, the number of pulses is 1 pulse, 2 pulses, 3 pulses, 4 pulses, 5 pulses, 6 pulses, 7 pulses, 8 pulses, 9 pulses, 10 pulses, or more than 10 pulses, to name a few examples.

[0105]

[0223] In some embodiments, the therapeutic energy comprises a series of high-voltage, high-frequency pulses followed by a series of low-voltage, low-frequency pulses, the combination of which has a specific effect on target cells. For example, as shown in FIG. 16A, a first pulse set 820 is delivered, comprising multiple high-voltage, high-frequency pulses, optionally in packets. Examples of such high-voltage, high-frequency pulses are provided in U.S. Patent No. 10,702,337, entitled "Methods, Apparatuses, and Systems for the Treatment of Pulmonary Disorders," and PCT Application No. PCT / US2020 / 028844, entitled "DEVICES, SYSTEMS AND METHODS FOR THE TREATMENT OF ABNORMAL TISSUE," to name a few, which are incorporated herein by reference. Such pulses can prepare cells for cellular uptake of molecules 110. In some embodiments, the first pulse set 820 is followed by a delay 822 (e.g., 100 microseconds to 2 seconds), followed by a second pulse set 824. In this embodiment, the second pulse set 824 is comprised of multiple low-voltage, low-frequency pulses. FIG. 16A shows that the first pulse 826 of the second pulse set 824 lasts for up to 10 microseconds, followed by a delay 806 (e.g., up to 1 ms), followed by a second pulse 828. In this embodiment, the second pulse 828 has the opposite polarity to the first pulse 826, and thus the delay 806 can be considered a switch time delay 807. It will be appreciated that in some embodiments, there is no delay 806 / 807 between the pulses 826, 828. In some instances, the first pulse set 820 prepares the cell for uptake of the molecule 110, e.g., making the cell receptive to a molecule reception or translocation process. Thus, the first pulse set 820 initiates the process. The second pulse set 824 then assists in uptake of the molecule into the cell, e.g., propelling or pushing the molecule into the cell. Optionally, these pulse sets 820, 824 may be repeated in a pattern.

[0106]

[0224] FIG. 16B shows another example waveform with modified segments. Here, a first pulse set 820 is delivered, optionally in packets, including multiple high-voltage, high-frequency pulses. Again, examples of such high-voltage, high-frequency pulses are provided in U.S. Pat. No. 10,702,337, entitled "Methods, Apparatuses, and Systems for the Treatment of Pulmonary Disorders," and PCT Application No. PCT / US2020 / 028844, entitled "DEVICES, SYSTEMS AND METHODS FOR THE TREATMENT OF ABNORMAL TISSUE," to name a few, which are incorporated herein by reference. In some embodiments, the first pulse set 820 is followed by a delay 822 (e.g., 100 microseconds to 2 seconds), followed by a second pulse set 824. In this embodiment, the second pulse set 824 is comprised of multiple low-voltage, low-frequency pulses. In this embodiment, the second pulse set 824 consists of a series of biphasic pulses with no switch time delay, lasting approximately 100 microseconds to 5 milliseconds. Again, in some examples, the first pulse set 820 prepares the cells for uptake of the molecules 110, e.g., making the cells receptive to a molecule reception or translocation process. Thus, the first pulse set 820 initiates the process. The second pulse set 824 then assists in uptake of the molecules into the cells, e.g., propelling or pushing the molecules into the cells. Optionally, these pulse sets 820, 824 may be repeated in a pattern.

[0107]

[0225] Thus, in some embodiments, the system 100 includes an algorithm 152 for generating waveforms having a first pulse set 400 designed to induce extravasation, followed (optionally after a large delay to allow time for the edema effect to maximally develop) by a second pulse set 800 designed to provide a therapeutic treatment. If the therapeutic treatment involves uptake of the molecule 110 by the target cells, the second pulse set 800 is typically configured to enhance uptake of the molecule 110. In some embodiments, the therapeutic treatment involves intracellular transfection of genetic material into cells. Considerations for this purpose include the need to move large, often charged genetic material to the cell surface of the cell membrane and to force that genetic material through the cell membrane, which may include temporary disruption to enhance membrane integrity. This can be achieved by a long-duration monophasic or biphasic sequence of PEF. In this manner, plasmids present in the interstitial fluid are introduced into the cells to perform downstream purposes.

[0108]

[0226] Optionally, second pulse set 800 may include multiple different types of pulses, such as pulse set 820 including multiple high-voltage, high-frequency pulses followed by pulse set 826 including multiple low-voltage, low-frequency pulses. In such an example, the overall waveform may include three pulse sets: 1) extravasation-inducing pulse set 400, 2) high-voltage, high-frequency pulse set 820, and 3) low-voltage, low-frequency pulse set 826. Such a pulse combination may maximize uptake of molecule 110 by target cells.

[0109]

[0227] It will be appreciated that PEF energy delivery for extravasation and therapeutic treatment can be supplemented by including secondary methods to promote either of these goals. For example, if molecule 110 includes a plasmid, an agent such as lipofectamine can be mixed with the plasmid to promote cellular uptake. This can enhance transfection in areas initially bathed in the plasmid and lipofectamine mixture via extravasation induction by capillary disruption PEF energy.

[0110]

[0228] Typically, modulated PEF energy disrupts capillaries with minimal or no destruction of target tissue cells. The extent and ratio of cells killed to disrupted capillaries varies depending on the target organ and the disease being treated. For example, when used in the liver, concomitant cell death of liver cells is generally well tolerated due to the regenerative nature of this organ. Thus, the first (or second) wave protocol of liver-targeted PEF may have a higher intensity (voltage, lower frequency, longer duration, or more) to generate a larger volume of local edema than in more sensitive organs. In contrast, targets such as the brain or heart may not have a high tolerance for concomitant cell death, and therefore, treatment in these target organs may involve using a weaker protocol to generate a smaller volume of edema to prevent excessive cell death in these sensitive organs.

[0111]

[0229] In some embodiments, the modified PEF energy is used in conjunction with therapeutic treatments, including ablation and / or immune response, either alone or in combination with molecules, including drugs or pharmaceuticals, such as chemotherapeutic agents. In such instances, extravasation is induced by the modified PEF to standardize the target tissue area prior to the therapeutic treatment (e.g., to create a stable impedance environment) and / or to expand the target treatment area by creating virtual or fluid electrodes. This may be particularly true when the modified PEF energy is utilized in conjunction with a treatment without including molecules for cellular uptake. Such therapeutic treatments may include microwave ablation, radiofrequency ablation, cryoablation, high-intensity focused ultrasound (HIFU), and / or pulsed electric field therapy. Examples of systems and waveforms providing this type of ablative pulsed electric field therapeutic treatment are described in International Patent Application No. PCT / US2017 / 039527, entitled "GENERATOR AND A CATHETER WITH AN ELECTRODE AND A METHOD FOR TREATING A LUNG PASSAGEWAY," which claims priority to U.S. Provisional Application Nos. 62 / 355,164 and 62 / 489,753; International Patent Application No. PCT / US2018 / 067501, entitled "METHODS, APPARATUSES, AND SYSTEMS FOR THE TREATMENT OF DISORDERS," which claims priority to U.S. Provisional Application Nos. 62 / 610,430, filed December 26, 2017, and 62 / 693,622, filed July 3, 2018, and entitled "OPTIMIZATION OF This invention also includes pulmonary tissue modification systems (e.g., energy delivery catheter systems) described in commonly assigned patent applications, including International Patent Application No. PCT / US2018 / 067504, entitled "ENERGY DELIVERY FOR VARIOUS APPLICATIONS," all of which are incorporated herein by reference for all purposes.

[0112]

[0230] In some embodiments, a local therapy is used in conjunction with a molecule 110, such as a drug or agent. Thus, modulating extravasation and edema can improve the local therapy, the uptake of the molecule 110 by cells, or both. When the molecule 110 is delivered in combination with the local therapy, the molecule 110 can act as a neoadjuvant therapy. Neoadjuvant therapy can be used in cancer treatment, delivered before primary therapy to help reduce tumor size or kill spread cancer cells.

[0113]

[0231] In some embodiments, molecule 110 comprises a chemotherapy drug. Chemotherapy is typically a systemic treatment introduced into the bloodstream, and therefore, in principle, can address cancer at any anatomical location within the body. Traditional chemotherapy drugs are cytotoxic by inhibiting cell division, but cancer cells vary widely in their sensitivity to these drugs. Chemotherapy can often be thought of as a way to injure or stress cells, which can lead to cell death if apoptosis is initiated. Many of the side effects of chemotherapy can be traced back to damage to normal cells, particularly cells in the bone marrow, gastrointestinal tract, and hair follicles, which rapidly divide and are therefore sensitive to cytostatic drugs. Chemotherapy can also be administered locally to tumor tissue.

[0114]

[0232] In some embodiments, modulated PEF energy is used to induce extravasation and edema, which increases the concentration of chemotherapy in the target tissue area. Additionally, the target tissue is treated with therapeutic PEF energy. Such treatment disrupts cellular homeostasis, initiating effects such as programmed cell death, which can result in permanent cell death or priming of cells for more effective damage by chemotherapy. Such priming provides a synergistic effect between therapeutic PEF treatment and chemotherapy, resulting in results superior to either treatment alone. Thus, such combined treatments may result in more effective treatments and significantly improved responses.

[0115]

[0233] In some embodiments, the PEF energy has waveforms and signal parameters configured for tumor treatment, particularly for the treatment of cancerous tumors. FIG. 17 illustrates one embodiment of such a waveform 900 defined by the energy delivery algorithm 152. Here, two packets are shown: a first packet 902 and a second packet 904, separated by a rest period 906. It will be appreciated that in tumor treatment, multiple packets are typically delivered to the target tissue. In this embodiment, each packet 902, 904 is comprised of a first biphasic pulse (comprising a first positive peak 908 and a first negative peak 910) and a second biphasic pulse (comprising a second positive peak 908′ and a second negative peak 910′). The first and second biphasic pulses are separated by a dead time or inter-cycle delay 912 (i.e., pause) between each cycle. In some embodiments, the inter-cycle delay 912 is between 250 μs and 5000 μs, and particularly 1000 μs. In other embodiments, the delay 912 is longer, for example, between 2000 μs and 5000 μs. In this embodiment, the biphasic pulse is symmetrical, with the positive and negative peak set voltages 916 being identical. Here, the biphasic symmetrical wave is a square wave, with the magnitude and duration of the positive voltage wave approximately equal to the magnitude and duration of the negative voltage wave. The positive voltage wave causes cell depolarization, where normally negatively charged cells become positive for a short period of time. The negative voltage wave causes hyperpolarization, where the cell potential is negative.

[0116]

[0234] In some embodiments, each high voltage pulse or set voltage 916 is between about 3000V and 6000V, such as between 3000V and 3300V, 3000V and 3500V, 3000V and 4000V, 3000V, 3100V, 3200V, 3300V, 3400V, 3500V, 3600V, 3700V, 3800V, 3900V, 4000V, 4100V, 4200V, 4300V, 4400V, 4500V, 4600V, 4700V, 4800V, 4900V, 5000V, 5100V, 5200V, 5300V, 5400V, 55 00V, 3900V, 4000V, 4100V, 4200V, 4300V, 4400V, 4500V, 4600V, 4700V, 4800V, 4900V, 5000V, 5100V, 5200V, 5300V, 5400V, 5500V, 5600V, 5700V, 5800V, 5900V, 6000V. It will be appreciated that the set voltage 916 may vary depending on whether energy is delivered unipolar or bipolar, and that such values ​​are specific to unipolar delivery.

[0117]

[0235] The number of pulses per unit time is the frequency. In some embodiments, the frequency of the signal is in the range of 100-600 kHz, e.g., 100-200 kHz, 100-300 kHz, 100-400 kHz, 100-500 kHz, 400-500 kHz, 100 kHz, 200 kHz, 300 kHz, 400 kHz, 500 kHz, or 600 kHz. Additionally, in some embodiments, cardiac synchronization is used to reduce or avoid undesired myocardial stimulation. In some embodiments, biphasic pulses are used to reduce undesired muscle stimulation, particularly myocardial stimulation. It will be appreciated that higher frequencies may be used with components that minimize signal artifacts.

[0118]

[0236] The cycle count 920 is the number of cycles in each packet. Referring to FIG. 17, the cycle count 920 for the first packet 902 is 2 (i.e., two biphasic pulses). In some embodiments, the cycle count 920 is set to 10-60 cycles per packet, including all values ​​and subranges therebetween. In some embodiments, the cycle count 920 is 10, 20, 30, 40, 50, 60, 10-20, 20-30, 30-40, 40-50, or 50-60, including all values ​​and subranges therebetween. In some embodiments, the on-time per packet is 70-100 μs, including 70 μs, 80 μs, 90 μs, and 100 μs. The period is the time it takes for a signal to complete an on and off cycle, so the on-time of a cycle is the time that the cycle is "on." Similarly, the on-time per packet is the sum of the on-times of the cycles within the packet, and the packet duration is the sum of the periods of the packet based on frequency.

[0119]

[0237] In some embodiments, the number of packets delivered during a treatment ranges from 1 to 1000 packets, typically 20 to 400 packets or 40 to 100 packets, including 50 packets, 100 packets, 150 packets, and 200 packets, including all values ​​and subranges therebetween. In some embodiments, the time between packets, referred to as the rest period or inter-packet delay 906, is approximately 3 to 6 seconds, e.g., 3 seconds, 4 seconds, 5 seconds, and 6 seconds, including all values ​​and subranges therebetween. In some embodiments, the signal is synchronized with the cardiac rhythm, such that each packet is delivered between heartbeats, thereby aligning the rest period with the heartbeat. Therefore, the rest period between packets may be affected by heartbeat synchronization, and therefore the rest period 906 may vary.

[0120]

[0238] It will be appreciated that the particular settings for desired target tissue modification will depend on each other and on the electrode design. Thus, while the embodiments provided herein illustrate specific example waveforms, it is within the scope of the present invention to use multiple waveforms and / or features in any combination to achieve a desired tissue effect.

[0121]

[0239] In some embodiments, the waveform of Figure 17 induces extravasation and can be used for this purpose in addition to therapeutic purposes. A specific example of such a waveform has a voltage of 1400 V, a frequency of 300 kHz, 30 cycles, an on-time of 100 μs, 100 packets, a cycle delay of 1000 μs, and a packet delay of 3 seconds. Thus, the total treatment time in this example is approximately 5 minutes (i.e., 100 packets * 3 seconds = 300 seconds or approximately 5 minutes). This example will be used to illustrate various timing examples described in later sections.

[0122] Sensor

[0240] In some embodiments, the energy delivery device 102 includes one or more sensors that can be used to determine pressure, temperature, impedance, resistance, capacitance, conductivity, pH, optical properties (coherence, echogenicity, fluorescence), electrical or optical permittivity, and / or conductance, to name a few. In some embodiments, one or more of the electrodes of the energy delivery portion 108 act as the one or more sensors. In other embodiments, the one or more sensors are separate from the electrodes. Sensor data can be used to plan the procedure, monitor the procedure, and / or provide direct feedback via the processor 154, which can then modify the energy delivery algorithm 152.

[0123] A. Pressure detection

[0241] It will be appreciated that cells typically respond to mechanical stimuli. One such type of mechanical stimulus is pressure. Generally, hydrostatic pressure is determined by the volume of interstitial fluid and the overall compliance of the target tissue interstitium. It should be noted that this varies by tissue type. Some organs are contained within stiffer / less compliant structures (e.g., brain, kidney, etc.), while others expand / contract more freely (e.g., lung, muscle, skin, etc.). Increased hydrostatic pressure can increase the permeability of local cell membranes. Therefore, it is often beneficial to be mindful of the pressure exerted on the target tissue, particularly during local injection of molecules 110. To this end, in some embodiments, the energy delivery device 102 includes a pressure sensor. Pressure sensor measurements can be used to monitor the level of edema resulting from extravasation before, during, and / or after injection of molecules 110 and therapeutic energy. Thus, the induction of extravasation can be tailored to achieve a desired level of edema at specific points during the overall treatment protocol.

[0124]

[0242] Various pressure sensors 200 can be used. In some embodiments, as shown in FIG. 18A , the pressure sensor 200 is positioned along the distal tip of the energy delivery device 102. Here, the energy delivery device 102 includes a needle-shaped energy delivery portion 108 that is at least partially covered by an insulating sleeve 202. As shown, the molecules 110 pass through the energy delivery portion 108 to a nearby target tissue area. Thus, the pressure sensor 200 can monitor pressure during injection of the molecules 110 and application of therapeutic energy. In other embodiments, as shown in FIG. 18B , the pressure sensor 200 is positioned along the distal end of the energy delivery device 102 but proximal to the tip. Here, the pressure sensor 200 is positioned along the insulating sleeve 202 that at least partially covers the energy delivery portion 108. Obtaining relative pressure measurements at the tissue level can provide a user with information about the distribution of the injected molecules 110 within the tissue. Given that the injection solution is at a known pressure and flow rate (values ​​that can be easily measured near the proximal end of the device 102), additional relative measurements at the distal end provide information about the spatial distribution of molecules along the target tissue and the temporal pressure profile.

[0125]

[0243] In some embodiments, pressure sensor 200 is a strain gauge transducer. Strain gauge transducers are typically characterized by exhibiting a change in output form in response to a measurand (i.e., strain, electrical resistance, or wavelength). Sensitivity is determined by the relative change in resistance with respect to length.

[0126]

[0244] In another embodiment, the pressure sensor 200 includes a diaphragm displacement sensor. Diaphragm displacement sensors are based on macroelectromechanical systems technology, where the sensor has a flat surface (diaphragm) that is bent over a sealed cavity. The diaphragm bends or deforms in response to pressure changes. The resulting output form can be capacitance-based or piezoelectric-based. In some embodiments, the sensor 200 is located at the distal tip of the energy delivery device 102, and a corresponding diaphragm is located proximal to the sensor 200, allowing measurement of the pressure drop across the distance between them. In instances where placement of such a sensor is difficult, for example due to size constraints, a pressure-sensing optical fiber may be preferred.

[0127]

[0245] In some embodiments, as shown in FIG. 18C , the energy delivery device 102 includes an expandable member 204 disposed along its distal tip. Here, the expandable member 204 is mounted on an insulating sleeve 202 that at least partially covers the needle-shaped energy delivery portion 108. Positioning the expandable member 204 in this manner can help prevent reflow of the molecule 110 solution back through the passageway created by inserting the energy delivery device 102. This can improve pressure distribution within the target tissue and, therefore, overall delivery of the molecules 110. The expandable member 204 can also prevent movement of the needle-shaped energy delivery portion 108 during PEF energy delivery. In some embodiments, a pressure sensor 200 mounted on the expandable member 204 monitors the pressure within the expandable member 204, thereby ensuring proper expansion of the expandable member 204. Additionally, in some embodiments, the pressure sensor 200 monitors tissue pressure during injection of the molecules 110 and / or delivery of PEF energy.

[0128] Timing Embodiments

[0246] It will be appreciated that the timing of PEF energy delivery and molecule 110 delivery can be optimized for improved results, e.g., improved treatment of abnormal tissue such as tumors. FIG. 19 illustrates three exemplary timing embodiments of molecule 110 delivery relative to treatment delivery, where the x-axis indicates the timing of PEF energy delivery. Each segment includes a start 950 of the PEF energy delivery protocol and an end 952 of the PEF energy delivery protocol. Such a protocol may be sufficient to treat a target tissue area, e.g., treat a tumor by killing all or a desired amount of the tumor. For illustrative purposes, the waveform described above (i.e., 1400 V voltage, 300 kHz frequency, 30 cycles, 100 μs on-time, 100 packets, 1000 μs cycle delay, and 3-second packet delay) is used. In this example, the time between the start and end of treatment is approximately 5 minutes. Additional boundaries are provided, such as section 954, which represents approximately one-third (33%) of the treatment process, and section 956, which represents approximately two-thirds (66%) of the treatment process.

[0129]

[0247] In a first example, molecule 110A is delivered near the start of PEF energy delivery 950 and continues delivery through a first portion of PEF energy delivery, e.g., the first 25-33% of PEF energy delivery. In this example, molecule 110A is delivered for approximately 1.25-1.67 minutes. It will be appreciated that in some examples, molecule 110A may be delivered additionally prior to the start of PEF energy delivery 950 (as indicated by dashed line 960A) to ensure that molecule 110A reaches the target tissue by the time PEF energy delivery begins. In some embodiments, molecule 110A is delivered 10 seconds to 10 minutes prior to PEF energy delivery, typically 1 minute to 10 minutes prior to PEF energy delivery. It will be appreciated that molecule 110A may be delivered by various methods described herein, including local injection, regional delivery, and systemic delivery, e.g., intravenous delivery. Delivery methods such as systemic delivery may benefit from earlier initiation than local delivery due to dynamics considerations. It will be appreciated that the majority of the therapeutic effect (e.g., extravasation and ablation) typically occurs in the first 25-33% of the treatment time, but the remaining PEF energy delivery helps to reinforce the effect. Thus, by aligning this period with the delivery of molecules 110A, molecules 110A are available during this valuable time, maximizing their effect.

[0130]

[0248] In a second example, molecule 110B' is delivered near PEF energy delivery start 950 and continuously delivered throughout a first portion of PEF energy delivery, e.g., the first 25% of PEF energy delivery. An additional delivery of molecule 110B'' occurs prior to PEF energy delivery end 950, e.g., during the last 25% of the PEF energy delivery period. Thus, in this example, molecule 110B' is delivered for approximately 1.25 minutes near PEF energy delivery start, no delivery occurs for 2.50 minutes, and then molecule 110B'' is delivered for approximately 1.25 minutes until PEF energy delivery end 952. Again, it will be appreciated that in some examples, molecule 110B' may be additionally delivered prior to PEF energy delivery start 950 (as indicated by dashed line 960B) to ensure that molecule 110B' reaches the target tissue by the time PEF energy delivery begins. It will be appreciated that molecules 110B′, 110B″ can be delivered by a variety of methods described herein, including local injection, local delivery, and systemic delivery, e.g., intravenous delivery. Delivery methods such as systemic delivery may benefit from earlier initiation than local delivery due to dynamic considerations. Again, it will be appreciated that while the majority of the therapeutic effect (e.g., extravasation and ablation) typically occurs in the first 25–33% of the treatment time, the remaining delivery helps to reinforce the effect. Therefore, aligning molecule delivery with this period ensures that molecules are available during this valuable time, maximizing their effect. Furthermore, delivering molecules 110B″ later in the PEF energy delivery period increases the reinforcement effect, such that the final molecular extrusion after extravasation settles many molecules 110B″ within the treatment area.

[0131]

[0249] In a third example, molecule 110C is delivered near PEF energy delivery start 950 and continuously delivered throughout the PEF energy delivery period until PEF energy delivery end 952. Thus, in this example, molecule 110C is delivered for approximately 5 minutes throughout the PEF energy delivery period. Again, it will be appreciated that in some examples, molecule 110C may be additionally delivered prior to PEF energy delivery start 950 (as indicated by dashed line 960C) to ensure that molecule 110C reaches the target tissue by the time PEF energy delivery begins. It will be appreciated that molecule 110C may be delivered by various methods described herein, including local injection, regional delivery, and systemic delivery, e.g., intravenous delivery. Delivery methods such as systemic delivery may benefit from an earlier initiation than local delivery due to dynamics considerations. Such continuous delivery of molecule 110C, e.g., at a constant infusion rate, maximizes the coordinated interaction of molecule, extravasation, and ablation throughout the treatment. In some examples, this combination produces the most powerful results. The slow, constant delivery of molecules 110C over the 5 minutes of PEF energy delivery allows more molecules 110C to diffuse slowly into the tissue, with the added benefit of a shockwave-like mechanical force being released from the energy delivery device with the delivery of each packet of PEF energy.

[0132]

[0250] Figure 20 shows the results of a laboratory study illustrating this phenomenon. In this study, pigs were anesthetized and then subjected to laparotomy to expose their livers. Cisplatin (0.1 mg) was injected into the pig livers and combined with PEF energy delivery using three modalities: 1) localized injection of cisplatin without PEF energy delivery (CIS-only group); 2) cisplatin was injected into different areas of the pig liver, and PEF was delivered to the same location 2 minutes after the drug bolus (bolus and PEF group); and 3) cisplatin was delivered over 5 minutes simultaneously with PEF delivery (injection and PEF group). Two hours after PEF delivery, the livers were harvested, and the treated area was divided into central, peripheral, and outer regions. A 6 mm punch biopsy was used to select the central treatment area. A 10 mm punch biopsy was used to collect the peripheral region. A 15 mm punch biopsy was used to isolate the outer region. Liver samples were analyzed by mass spectrometry (ICP-MS) to quantify cisplatin concentrations. As shown in Figure 20, the highest cisplatin concentrations in both the central and peripheral regions were achieved when drug and PEF energy were delivered simultaneously (infusion and PEF group), especially when drug was delivered throughout the entire treatment with PEF energy.

[0133]

[0251] While the timing example in FIG. 19 above is provided with respect to treatment time, it will be appreciated that the relative timing of molecule and PEF energy delivery can be controlled based on other factors, such as the volume of molecules 110 delivered and / or the delivery rate / flow rate. For example, in some embodiments, a predetermined volume of molecules 110 is delivered to the target tissue area throughout the entire PEF energy delivery during a treatment protocol. Thus, the delivery rate is based on the total volume of molecules delivered and a predetermined treatment time. In other embodiments, a predetermined volume of molecules is delivered during a first portion of energy delivery, e.g., the first 25-33% of the energy delivery, and then no molecules are delivered for the remainder of the treatment. In other embodiments, half of a predetermined volume of molecules is delivered during a first portion of energy delivery, e.g., 25% of the energy delivery, and half of the predetermined volume is delivered during a second portion of energy delivery, e.g., the last 25% of the energy delivery. In each of these situations, the delivery rate is based on a specific volume of molecules and a specific amount of treatment time. In examples where molecules are delivered throughout the entire treatment protocol, it can be assumed that the molecules are delivered at a minimum flow rate. Similarly, the highest flux occurs in instances where molecules are delivered in the first 25-33% of energy delivery and then not delivered for the remainder of the procedure.

[0134]

[0252] In some embodiments, a user manually delivers molecules (e.g., by local injection, regional injection, systemic injection, etc.) and activates a generator to deliver PEF energy (e.g., by a foot switch). In such embodiments, timing and coordination is accomplished solely by the user or with the assistance of various components such as timers, sensors, alerts, data feedback, etc.

[0135]

[0253] In other embodiments, the PEF energy is delivered in response to one or more components, such as one or more sensors, one or more timers, one or more monitors, or a combination thereof. In some embodiments, a controller configured to control the delivery of pulsed electric field energy in response to one or more components is provided. Exemplary controllers include a switch box, a delivery control panel, a relay system, a dispatch unit, a microcontroller, a molecule distribution control panel, a molecule control system, a fluid control system, a fluid control valve, and a molecule fluid servo system, to name a few. The controller can be included in the generator or separate from the generator and functions in conjunction with the generator to control the PEF energy delivery. In some embodiments, the controller utilizes one or more components, including a sensor, to detect the flow rate of molecules being delivered to the patient. In other embodiments, the controller utilizes one or more components, including a sensor, to detect the pressure of a syringe pump configured to deliver molecules to the patient. In other embodiments, the controller utilizes one or more components, including a timer, and the controller executes the delivery of pulsed electric field energy at a predetermined time after the initiation of molecule delivery to the target tissue area.

[0136]

[0254] With respect to the examples described above, in some embodiments, the controller may execute the delivery of pulsed electric field energy throughout the entire molecule delivery to the target tissue area. In embodiments in which a predetermined volume of molecules is delivered during a first portion of energy delivery, e.g., the first 25-33% of energy delivery, and then no molecules are delivered for the remainder of the treatment, the controller may execute the delivery of pulsed electric field energy throughout the entire molecule delivery to the target tissue area, and then continue delivering pulsed electric field energy for a period that is 200-300% longer than the molecule delivery. In embodiments in which half of a predetermined volume of molecules is delivered during a first portion of energy delivery, e.g., 25% of energy delivery, and half of the predetermined volume is delivered during a later portion, e.g., the last 25% of energy delivery, the controller may execute the delivery of pulsed electric field energy throughout the additional molecule delivery that occurs during the time period following the initial delivery of molecules.

[0137]

[0255] It will be appreciated that in some embodiments, the PEF energy and the molecules 110 are delivered by separate devices, while in other embodiments, the PEF energy and the molecules 110 are delivered by the same device. Thus, in some embodiments, the energy delivery device 102 is configured to deliver energy to a target tissue area and to deliver multiple molecules to the target tissue area. In such embodiments, the energy is delivered via the energy delivery portion 108, and the molecules 110 can be delivered via a lumen and a port near the distal end of the device 102. In some embodiments, the molecules 110 are stored in a container, pump, or syringe separate from the device 102 and connectable to the lumen. In other embodiments, the molecules 110 are stored in a container within the device 102 that is connected to the lumen or directly to the port.

[0138] Alternative Device Designs

[0256] The energy can be delivered by a variety of energy delivery devices 102. Typically, the energy delivery device 102 includes a flexible, elongated shaft having a distal end that can be advanced to the target tissue within the body, and an energy delivery portion 108 disposed near the distal end. The energy delivery portion 108 includes one or more electrodes that deliver energy to the target tissue.

[0139]

[0257] In some embodiments, the molecules 110 and energy are delivered by the energy delivery device 102. This is in contrast to the system delivery of molecules 110 described and illustrated with respect to Figures 5A-5C. In this example, induced extravasation can produce improved (e.g., more uniform) molecular distribution throughout the target treatment area and / or trap the molecules 110 within the target tissue area so that the molecules are at least temporarily not diluted.

[0140]

[0258] 21A-21B show an energy delivery device 102 having a needle-shaped energy delivery portion 108. The needle-shaped tip can be pierced like a needle to deliver molecules 110 through a lumen. Furthermore, the energy delivery portion 108 is electrically insulated with an insulating layer 504, except for the needle-shaped tip, which acts as an electrode. FIG. 21A shows direct injection of molecules 110 into target tissue via the energy delivery portion 108. Again, the target tissue is shown as cell C (not to scale). The tip is inserted into or near the target tissue so that the injected molecules 110 can bathe the target tissue and, optionally, reside therein for biodistribution. Referring to FIG. 21B, PEF energy is then delivered from the energy delivery portion 108 to the target tissue, as indicated by the wavy line 502. If the PEF energy is a modulated PEF, local edema results. When the PEF energy is a therapeutic PEF, the energy promotes uptake of molecule 110 into cell C or affects the effect of molecule 110 on the cell.

[0141]

[0259] 22 illustrates an energy delivery device 102 including a shaft 106 having an energy delivery portion 108 near its distal end. The energy delivery portion 108 includes a plurality of teeth 600. Typically, the teeth 600 have a pointed shape to pierce tissue. Similarly, the teeth 600 typically extend laterally outward from the shaft 106, and in some embodiments, the teeth 600 are circumferentially disposed around the shaft 106. It will be appreciated that in some embodiments, the teeth 600 are disposed on one side of the shaft 106, e.g., in a row. In some embodiments, the teeth 600 extend the same distance from the shaft 106, and in other embodiments, the teeth 600 extend a varying distance. It will be appreciated that in some embodiments, the extension distance of at least some of the teeth 600 from the shaft 106 is adjustable.

[0142]

[0260] Typically, each tooth 600 delivers molecules 110 and / or energy from it. In some embodiments, molecules 110 are delivered from the tip 601 of the tooth 600, while in other embodiments, molecules 110 are delivered from delivery ports 602 along the tooth 600. In some embodiments, the teeth 600 are excitable together (to act as a single electrode) or at least some of the teeth 600 are excitable individually (to act as a bipolar pair).

[0143]

[0261] In this embodiment, the shaft 106 has three sections: a first section 106a, a second section 106b, and a third section 106c. As shown in FIG. 22 , the first section 106a is distal to the second section 106b, which is distal to the third section 106c. Each section 106a, 106b, 106c can be insulated or non-insulated to generate a variety of different electrode combinations, thereby enabling a variety of electric field shapes and / or directing the electric field in a desired direction. It will also be appreciated that in some embodiments, at least a portion of at least one tine 600 is insulated to direct the energy emanating therefrom. Generally, the tine 600 often enables a single positioning of the energy delivery device 102 to deliver molecules 110 and / or energy to a larger volume of target tissue than a device 102 having an energy delivery portion 108 that includes a single needle.

[0144]

[0262] FIG. 23 illustrates an energy delivery device 102 including an energy delivery portion 108 having a basket shape configured for treating target tissue intraluminally. Here, the target tissue includes cells C disposed near a wall W of a body cavity, specifically at least partially circumferentially enveloping the body cavity. In this embodiment, the energy delivery portion 108 is comprised of multiple wires or ribbons 120 forming a helical basket that functions as an electrode. In some embodiments, the energy delivery portion 108 is self-expandable and is delivered to the target area in a collapsed configuration. This collapsed configuration can be achieved, for example, by placing a sheath over the energy delivery portion 108. Retracting the sheath or advancing the energy delivery portion 108 from the sheath allows the energy delivery portion 108 to self-expand. In other embodiments, the energy delivery device 102 includes a handle with an energy delivery portion manipulation knob, which, when moved, expands or retracts / collapses the basket-shaped electrode. The basket-shaped electrode is expandable within a body cavity or passageway (whether naturally occurring or created within the body) and adapted to contact at least a portion of the wall W of the body cavity. 23, molecules 110, for example, within a basket-shaped electrode, are delivered from the energy delivery device 102, for example, via a distal end port 510 and / or various side ports 512 along the shaft 106 of the device 102. The molecules 110 can bathe the target tissue and optionally reside for biodistribution. Modulated PEF energy, as indicated by the wavy line 502, is delivered from the energy delivery portion 108 to the target tissue, thereby inducing extravasation in a localized area surrounding the lumen. The therapeutic PEF energy promotes uptake of the molecules 110 into cells C or affects the effect of the molecules 110 on the cells.

[0145]

[0263] FIG. 24 illustrates another embodiment of an energy delivery device 102 including an energy delivery portion 108 having a shape configured for treating target tissue intraluminally. In this embodiment, the energy delivery portion 108 includes at least two protrusions 514, each extending radially outward to contact the lumen wall W. It will be appreciated that while a single protrusion may be present, typically two protrusions are present to apply a substantially opposing force against the lumen wall. In the embodiment of FIG. 24, there are three protrusions 514. In some embodiments, each protrusion 514 is formed of a wire or ribbon that acts as an electrode, bending or flexing radially outward from the longitudinal axis or shaft 106 of the delivery device 102. In this embodiment, the protrusions 514 together act as a single electrode. However, in other embodiments, one or more protrusions 514 are individually excitable to act as multiple electrodes (e.g., one or more bipolar pairs). The protrusions 514 can be constructed of various suitable materials that act as electrodes, such as stainless steel, spring steel, or other alloys, and may be, for example, round wire or ribbon. In some embodiments, portions of the protrusions 514 are insulated by insulating segments of a polymer (e.g., PET, polyether block amide, polyimide), or the like. For example, in some embodiments, at least a portion of the proximal and distal ends of the energy delivery portion 108 are insulated to direct energy laterally toward the wall W.

[0146]

[0264] In some embodiments, the energy delivery portion 108 of FIG. 24 is self-expandable and is delivered to the target area in a collapsed configuration. During expansion within a body cavity or passageway (naturally occurring or created within the body), the protrusions deflect outward to contact at least a portion of the wall W of the body cavity. As shown in FIG. 24 , molecules 110 are delivered from the energy delivery device 102, for example, through ports 516 in the energy delivery portion 108. The molecules 110 can bathe the target tissue and optionally reside for biodistribution. PEF energy is then delivered from the energy delivery portion 108 to the target tissue, as indicated by the wavy line 502. The PEF energy delivers the molecules 110 to the cells C.

[0147]

[0265] FIG. 25 illustrates another embodiment of an energy delivery device 102 including an energy delivery portion 108 having a shape configured for intraluminal treatment of target tissue. In this embodiment, the energy delivery portion 108 includes an expandable member 518, such as an inflatable balloon, on which electrodes 520 are mounted or incorporated. The energy delivery portion 108 is delivered to the target area in a collapsed configuration. In this embodiment, the electrodes 520 are in the form of pads having a relatively large surface area and a thin cross-section. The pad shape provides a larger surface area than other shapes, such as wire shapes. Each electrode 520 is connected to a conductive wire 522 that electrically connects the electrode 520 to a generator. While three electrodes 520 are shown in this embodiment, it will be appreciated that additional electrodes may be present around the expandable member 518. It will be appreciated that any number of electrodes 520 may be present and may act as a single electrode or may act separately or in combination. The placement of the electrodes 520 and / or selective excitation of the electrodes 520 may direct energy to specific target locations. In some embodiments, the electrodes 520 are comprised of flexible circuit pads or other material attached to or formed within the expandable member 518. In some embodiments, the electrodes 520 are dispersed radially around the circumference of the expandable member 518 and / or longitudinally along the length of the expandable member 518. Such a design promotes improved deployment and retraction quality, eases user movement, and improves fit with introducer lumens.

[0148]

[0266] Upon expansion of the expandable member, one or more of the electrodes 520 are positioned to contact at least a portion of the lumen wall W. As shown in FIG. 25 , molecules 110 are delivered from the energy delivery device 102, for example, via the distal end port 510. The molecules 110 can bathe the target tissue and optionally reside for biodistribution. As shown by the wavy line 502, modulated PEF energy is delivered from the energy delivery portion 108 to the target tissue, thereby inducing edema in the localized area surrounding the lumen. The therapeutic PEF energy promotes uptake of the molecules 110 into cells C or affects the effect of the molecules 110 on the cells.

[0149]

[0267] FIG. 26 illustrates another embodiment of the energy delivery device 102. Here, the energy delivery portion 108 has a fingertip shape configured to contact the lumen wall W. In this embodiment, the energy delivery device 102 has an elongate shaft 106 and a fingertip electrode 530 disposed at its distal tip. The fingertip electrode 530 is positionable relative to a portion of the lumen wall W near the target tissue cells C. The molecules 110 may be delivered in any suitable manner, e.g., systemically, locally, or locally, e.g., by injection with a separate device or by the energy delivery device 102. FIG. 26 illustrates delivery of the molecules 110 via the fingertip electrode 530. As indicated by the wavy line 502, modulated PEF energy is delivered from the fingertip electrode 530 to the target tissue, inducing extravasation in a localized area surrounding the lumen. The therapeutic PEF energy promotes uptake of the molecules 110 into the cells C or influences the effect of the molecules 110 on the cells.

[0150]

[0268] It will be appreciated that in some embodiments, PEF energy is delivered to a conductive fluid (e.g., blood, saline, etc.) in contact with the target tissue, thereby allowing the energy to pass through the conductive fluid to the target tissue for delivery. In other embodiments, energy delivery to the conductive fluid facilitates molecular delivery to cells in the fluid itself, such as, for example, delivery to white blood cells in blood.

[0151]

[0269] It will be appreciated that the various embodiments described herein include multiple steps or methodologies, such as extravasation, molecular delivery, transfection, and ablation, each of which can be used alone or in any combination with any other method. For example, extravasation can be induced for various purposes, with or without a subsequent therapy. It will be appreciated that PEF energy can be used to improve the diffusion and distribution of molecules between tissues in various therapies, many of which do not involve ablation or another therapy. For example, when delivering a drug by inhalation, PEF energy can be delivered before, during, or after inhalation to allow the drug to reach cells deeper within the pulmonary anatomical structures, such as smooth muscle cells and cartilage. Similarly, when delivering anti-epileptic drugs via IV, local infusion, or via cerebrospinal fluid, PEF energy can be delivered to better distribute the drug between centers where seizures begin. These are just a few examples of improved delivery of drugs to treat diseases or disorders.

[0152]

[0270] Similarly, various therapies and combinations of therapies may be provided to a patient without inducing extravasation. Additionally, some effects of portions of a therapy may occur independently of the presence of specific steps in the therapy. Similarly, various therapeutic aspects described herein may occur without including all of the steps of the methodology. For example, steps occurring after the generation of the debris field DF (FIGS. 8A-8B) occur independently of the use of extravasation induction in the procedure. Thus, removal of the debris field DF and the resulting immune response, including its effects on metastasis, occur independently of the use of extravasation induction. However, extravasation induction may affect the extent of these effects, for example, by modifying the size, depth, composition, etc. of the debris field.

[0153]

[0271] The above detailed description includes references to the accompanying drawings, which form a part of the detailed description. The drawings show, by way of illustration, specific embodiments in which the invention may be practiced. These embodiments are also referred to herein as "examples." Such examples may include elements in addition to those shown or described. However, the present invention also contemplates examples in which only the elements shown or described are provided. Furthermore, the inventors also contemplate examples (or one or more aspects thereof) using any combination or permutation of the elements shown or described, with respect to the specific example (or one or more aspects thereof) shown or described herein, or with respect to other examples (or one or more aspects thereof).

[0154]

[0272] In the event of a conflicting usage between this document and any document incorporated by reference in this application, the usage in this document controls.

[0155]

[0273] The terms "a" or "an" are used herein, as is common in patent documents, to include one or more, regardless of any other instance or use of "at least one" or "one or more." The term "or" is used herein to indicate a non-exclusive or, so that "A or B" includes "including A but not B," "including B but not A," and "including A and B," unless otherwise indicated. The terms "including" and "in which" are used herein as the plain-English equivalents of the terms "comprising" and "wherein," respectively. Also, in the following claims, the terms "including" and "comprising" are open-ended; that is, systems, devices, articles, compositions, formulations, or processes that include elements in addition to those recited after such terms in a claim are deemed to fall within the scope of that claim. Furthermore, in the following claims, terms such as "first," "second," and "third" are used merely as identifiers and are not intended to impose numerical requirements on their objects.

[0156]

[0274] The above description is intended to be illustrative, not limiting. For example, the above examples (or one or more aspects thereof) may be used in combination with each other. Other embodiments may be employed, for example, by one of ordinary skill in the art upon reviewing the above description. An Abstract is provided in accordance with 37 CFR §1.72(b) to allow the reader to quickly ascertain the nature of the technical disclosure. It is submitted with the understanding that it will not be used to interpret or limit the scope or meaning of the claims. Additionally, various features may be grouped together in the above Detailed Description to streamline the disclosure. This should not be construed as intending that any unclaimed disclosed feature is essential to any claim. Inventive subject matter may not reside in all features of a particular disclosed embodiment. Thus, the following claims are incorporated into the Detailed Description as examples or embodiments, with each claim standing on its own as a separate embodiment, and it is contemplated that such embodiments can be combined with each other in various combinations or permutations. The scope of the invention should be determined with reference to the appended claims, along with the full range of equivalents to which such claims are entitled. The present invention provides, for example, the following. (Item 1) 1. A system for treating a target tissue area of ​​a patient, comprising: an energy delivery device having at least one energy delivery portion configured to be positioned near the target tissue area within the patient; a generator in electrical communication with the at least one energy delivery unit, the generator including at least one energy delivery algorithm configured to provide an electrical signal of deliverable pulsed electric field energy to the at least one energy delivery unit to induce extravasation within the target tissue area; A system comprising: (Item 2) 2. The system of claim 1, wherein the induced extravasation is sufficient to force molecules delivered to the target tissue area to enter cells of the target tissue area. (Item 3) 3. The system of claim 2, wherein the molecule comprises a drug, a chemotherapeutic agent, an immunotherapeutic agent, and / or a monoclonal antibody. (Item 4) 3. The system of claim 2, wherein the molecule comprises an auxiliary substance including a polymer nanoparticle, a liposome, a PEG-modified liposome, lipofectamine, a cell-penetrating peptide (CPC), dimethyl sulfoxide (DMSO), cholesterol, or other substance known to interact with the fluidity and dynamics of cell membranes. (Item 5) 5. The system of any one of items 2 to 4, wherein the energy delivery device is configured to deliver the molecules to the target tissue area of ​​the patient. (Item 6) 6. The system of any one of items 1 to 5, wherein the extravasation delivers molecules from the vasculature in the target tissue area to the interstitial space around cells in the target tissue area. (Item 7) 7. The system of any one of items 1 to 6, further comprising a controller configured to control delivery of the pulsed electric field energy in response to at least one component. (Item 8) 8. The system of claim 7, wherein the at least one component includes a sensor that detects the flux of a molecule being delivered to the patient. (Item 9) 8. The system of claim 7, wherein the at least one component includes a sensor that detects pressure of a syringe pump configured to deliver molecules to the patient. (Item 10) the at least one component includes a timer; 8. The system of claim 7, wherein the controller executes delivery of the pulsed electric field energy at a predetermined time after initiation of molecule delivery to the target tissue area. (Item 11) 11. The system of any one of items 7 to 10, wherein the controller executes delivery of the pulsed electric field energy throughout molecule delivery to the target tissue area. (Item 12) 12. The system of any one of claims 7 to 11, wherein the controller executes delivery of the pulsed electric field energy throughout molecule delivery to the target tissue area and lasts 200-300% longer than the molecule delivery. (Item 13) 12. The system of any one of claims 7 to 11, wherein the controller executes the delivery of the pulsed electric field energy throughout an additional molecule delivery that occurs during a time period after the molecule delivery. (Item 14) 14. The system of any one of items 1 to 13, wherein the electrical signal of pulsed electric field energy deliverable to the at least one energy delivery unit to induce extravasation within the target tissue area also causes cell death within the target tissue area. (Item 15) Item 15. The system of item 14, wherein the signal includes at least two packets of biphasic pulses separated by an inter-packet delay. (Item 16) 14. The system of any one of claims 1 to 13, wherein the generator further comprises at least one additional energy delivery algorithm configured to provide an additional electrical signal of deliverable pulsed electric field energy to the at least one energy delivery portion to cause cell death within the target tissue area. (Item 17) 17. The system of any one of items 1 to 16, wherein the target tissue area comprises cells of the digestive system, including the liver, pancreas, stomach, intestine, and / or colon. (Item 18) 17. The system of any one of items 1 to 16, wherein the target tissue area comprises tissue of the respiratory system, including the lungs, airways, bronchial passages, and / or alveolar sacs. (Item 19) 17. The system of any one of paragraphs 1 to 16, wherein the target tissue area comprises cells of the reproductive system, including the vagina, uterus, cervix, fallopian tubes, ovaries, testes, penis, epididymis, vas deferens, urethra, prostate, seminal vesicles, and / or bulbourethral glands. (Item 20) 20. The system of any one of items 1 to 19, wherein the target tissue area comprises at least a portion of a tumor or abnormal growth. (Item 21) 21. The system of any one of items 1 to 20, wherein the energy delivery unit is configured to function monopolarly. (Item 22) 1. A system for treating a target tissue area of ​​a patient, comprising: an energy delivery device configured to deliver energy to the target tissue area and configured to deliver a plurality of molecules to the target tissue area; a generator in electrical communication with the energy delivery device, the generator including at least one energy delivery algorithm configured to provide an electrical signal of deliverable pulsed electric field energy to the at least one energy delivery portion that induces extravasation in the target tissue area, the extravasation being sufficient to urge molecules delivered to the target tissue area into cells of the target tissue area; A system comprising: (Item 23) 23. The system of claim 22, further comprising a controller that coordinates the delivery of the pulsed electric field energy and the delivery of the plurality of molecules. (Item 24) 24. The system of claim 23, wherein the controller initiates the delivery of the pulsed electric field energy at a predetermined time after the start of delivery of the plurality of molecules. (Item 25) 25. The system of claim 23 or 24, wherein the controller effects simultaneous delivery of the pulsed electric field energy and molecules to the target tissue area throughout treatment of the target tissue area. (Item 26) the electrical signal of pulsed electric field energy deliverable to the at least one energy delivery portion to induce extravasation in the target tissue area also causes cell death in the target tissue area; 26. The system of claim 25, wherein the treatment of the target tissue area includes cell death within at least a portion of the target tissue area. (Item 27) 27. The system of any one of claims 23 to 26, wherein the controller executes delivery of the pulsed electric field energy throughout molecule delivery to the target tissue area and lasts 200-300% longer than the molecule delivery. (Item 28) 28. The system of any one of claims 23 to 27, wherein the controller executes the delivery of the pulsed electric field energy throughout an additional molecule delivery that occurs during a time period after the molecule delivery. (Item 29) 29. The system of any one of items 1 to 28, wherein the electrical signal of pulsed electric field energy deliverable to the at least one energy delivery unit to induce extravasation within the target tissue area also causes cell death within the target tissue area. (Item 30) 30. The system of claim 29, wherein the signal includes at least two packets of biphasic pulses separated by an inter-packet delay. (Item 31) 23. The system of claim 22, wherein the generator further comprises at least one additional energy delivery algorithm configured to provide an additional electrical signal of deliverable pulsed electric field energy to the at least one energy delivery portion to cause cell death within the target tissue area. (Item 32) the additional electrical signal is comprised of a plurality of pulses forming a packet; each of the plurality of pulses has a duration of 0.5 to 200 μs; Item 32. The system of item 31, wherein the packets have a cumulative on time of 1 to 200 μs. (Item 33) 33. The system according to item 31 or 32, wherein the additional electrical signal includes 40 to 100 packets. (Item 34) 1. A system for killing cells in a target tissue area of ​​a patient, comprising: an energy delivery device having at least one energy delivery portion configured to be positioned near the target tissue area within the patient; a generator in electrical communication with the at least one energy delivery unit, the generator including at least one energy delivery algorithm configured to provide an electrical signal of deliverable pulsed electric field energy to the at least one energy delivery unit to induce extravasation in the target tissue area and kill cells in the target tissue area; A system comprising: (Item 35) 35. The system of claim 34, wherein the induced extravasation is sufficient to urge molecules delivered to the target tissue area into cells of the target tissue area. (Item 36) the molecule comprises a drug, a chemotherapeutic agent, an immunotherapeutic agent, and / or a monoclonal antibody; 36. The system of claim 35, wherein at least some of the cells are killed by the entry of the molecule. (Item 37) 37. The system of any one of items 34 to 36, wherein the energy delivery device includes at least one sensor. (Item 38) Item 38. The system of item 37, wherein the at least one sensor is configured to monitor the effects of the extravasation and provide sensor feedback data. (Item 39) Item 39. The system of item 38, wherein the system includes a mechanism for providing the sensor feedback data or information based on the sensor feedback data to a user. (Item 40) 40. The system of claim 39, wherein the generator includes a processor configured to modify or switch to a different energy delivery algorithm based on the sensor feedback data to transmit energy that regulates the induction of extravasation. (Item 41) 37. The system of any one of items 34 to 36, wherein the system includes at least one sensor. (Item 42) Item 42. The system of item 41, wherein the at least one sensor comprises a sensor that monitors pressure, temperature, impedance, resistance, capacitance, conductivity, pH, optical properties, coherence, echogenicity, fluorescence, electric permittivity, optical permittivity, and / or conductance.

Claims

[Claim 1] The invention described in this specification.

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