Invasive and non-invasive tumor-treating electric field (TTF) therapy: An exciting advance in oncologic neuromodulation.

Tumor-treating fields (TTF) have been shown to slow glioblastoma (GBM) cell growth through mitotic arrest, increased membrane and blood-brain barrier permeability, and other cellular mechanisms. TTF as currently used prolongs GBM survival by 5 months, but there are areas of possible improvement. One of the interesting problems is optimization of TTF delivery to tumor cells, which is attenuated by intervening anatomy and shunting. Current research involving invasive approaches including cranial remodeling, intracortical TTF and intratumoral modulation therapy (IMT) may improve outcomes. Present the history of TTF and discuss current areas of research with a focus on invasive TTF. We obtained and analyzed studies referencing TTF, invasive TTF, and any of transcranial electrical stimulation (tES), transcranial direct current stimulation (tDCS), deep brain stimulation (DBS), vagus nerve stimulation (VNS), peripheral nervous system (PNS), focused ultrasound (FUS), and transcranial magnetic stimulation (TMS) with respect to mechanism of action or anti-cancer-related effects. Invasive strategies including cranial remodeling and IMT, through stereotaxis like DBS, would help alleviate the current limitations of TTF. In addition, FUS and VNS induce similar blood brain barrier effects and immune modulation as TTF that may enhance and promote an insurmountable host immune response against the immunosuppressive tumor microenvironment. TTF as currently practiced is a remarkable advance in cancer treatment. Improvements which exploit the effects of TTF in combination with other neuromodulatory modalities or in immunotherapy promise to improve this even further.