Clinical and preclinical photodynamic therapy

Recalcitrant hand and foot warts successfully treated with photodynamic therapy with topical 5-aminolaevulinic acid: a pilot study

The purpose of this pilot study was to determine if photodynamic therapy with topical application of 5-aminolaevulinic acid followed by irradiation with incoherent filtered and unfiltered light (ALA-PDT) is an effective therapy for recalcitrant hand and foot warts. In 30 patients with recalcitrant warts, 49 regions with a total of 250 warts were randomized to one of the following five treatments: (i) ALA-PDT with white light applied three times within 10 days (W3); (ii) ALA-PDT with white light applied once (W1); (iii) ALA-PDT with red light applied three times within 10 days (R3); (iv) ALA-PDT with blue light applied three times within 10 days (B3), and (v) cryotherapy applied up to four times within 2 months (CRYO). The ALA-PDT treatment modality was repeated in case of partially responding warts. Significantly more warts were completely healed after W3 and W1 than after R3, B3 and CRYO (P < 0.01): 73% of the warts treated with W3 were completely healed, 71% after W1, 42% after R3, 23% after B3 and 20% after CRYO. No scars were observed in the ALA-PDT treated areas and patients treated for foot warts were all able to walk after the treatment. No recurrences in completely responding ALA-PDT treated warts were observed after 12 months of follow-up. In conclusion, photodynamic therapy with topical 5-aminolaevulinic acid followed by irradiation with white light is a promising treatment for recalcitrant hand and foot warts.

The role of photodynamic therapy in dermatology

Photodynamic therapy (PDT) involves selective photosensitization of a target tissue by means of a topically or systemically administered agent which is then activated by light to effect an oxygen dependent cytotoxic reaction. The production of reactive oxygen intermediates, including singlet oxygen, is localized to where the photosensitizer accumulates and induces apoptosis and vascular endothelial damage. First-generation photosensitizers are haematoporphyrin derivatives and are effective in treating certain nonmelanoma skin cancers. However, they induce cutaneous photosensitization for at least 4-6 weeks and have a limited role in dermatology. Many second-generation photosensitizers, such as 5-aminolaevulinic acid, are associated with less prolonged photosensitization. Although PDT remains largely experimental, it has potential applications in both benign and malignant skin disease.

Evaluation of the effects of photodynamic therapy with phosphorus 31 magnetic resonance spectroscopy

Magnetic resonance spectroscopy in situ was used to study changes in phosphorus 31 metabolism after photodynamic therapy (PDT) of transplanted HeLa cell tumours. Tumours were irradiated 2 h after administration of ATX-S10 (8-formyloximethylidene-7-hydroxy-3-ethenyl-2,7,12,18, tetramethyl-porphyrin-13,17-bispropionil aspartate), a new photosensitizer and chlorin derivative. Nuclear magnetic resonance spectra were measured prior to illumination and 1, 3, 7, 14, 21 and 28 days after PDT on each mouse. A drastic decrease in adenosine triphosphate (ATP) and a concomitant increase in inorganic phosphate (Pi) were evident on the first day after PDT in all cases. The beta-ATP/total phosphate (P) ratio was 0.64 +/- 0.29% (average +/- s.d.) in complete response, 0.67 +/- 0.30% in recurrence and 2.45 +/- 0.93% in partial response. Comparison of this ratio to the histological findings revealed that the beta-ATP/total P ratio reflects the HeLa cell tumours which survived PDT. In other words, partial response on the one hand was distinguished from complete response and recurrence on the other with this ratio 1 day after PDT (P < 0.05). In addition, the ratio of phosphomonoester (PME) to Pi rose beyond 1.0 when macroscopic recurrence occurred, while it stayed under 1.0 in complete response. This finding suggests that the recurrence of HeLa cell tumours can be detected by the PME/Pi ratio.

Ultrastructural changes in PAM cells after photodynamic treatment with delta-aminolevulinic acid-induced porphyrins or photosan

Photodynamic therapy (PDT) is the combination of a photosensitizing drug (Ps) with light in the presence of oxygen leading to the generation of reactive molecular species and destruction of cancer cells. In this study we compared PDT with two Ps, the hematoporphyrin derivative Photosan (Ph) and delta-aminolevulinic acid (ALA)-induced endogenous protoporphyrin IX, with respect to mitochondrial function and ultrastructural alterations. The effects of PDT were investigated in PAM 212 cells after different Ps incubation times, light doses, and post-treatment periods. Both Ps induced a light dose-dependent impairment of the mitochondrial function with the dose-response curve being steep for ALA and flat for Ph. The prolongation of the incubation time from 4 to 20 h resulted in an increased reduction of mitochondrial activity after ALA PDT but not after Ph PDT. Treatment with an irradiation dose that decreased mitochondrial activity by 50% (IC50) led to early and profound changes of mitochondrial morphology in ALA photosensitized cells, whereas photosensitization with Ph resulted in more pronounced alterations of lysosomes. We conclude that at bioequivalent sublethal PDT exposures of PAM 212 cells, ALA-induced damage is primarily restricted to mitochondria, whereas Ph-induced cytotoxicity is mediated by damage of the lysosomal system.

Systemic application of photosensitizers in the chick chorioallantoic membrane (CAM) model: photodynamic response of CAM vessels and 5-aminolevulinic acid uptake kinetics by transplantable tumors

The aim of this study is to modify the chick chorioallantoic membrane (CAM) model into a whole-animal tumor model for photodynamic therapy (PDT). By using intraperitoneal (i.p.) photosensitizer injection of the chick embryo, use of the CAM for PDT has been extended to include systemic delivery as well as topical application of photosensitizers. The model has been tested for its capability to mimic an animal tumor model and to serve for PDT studies by measuring drug fluorescence and PDT-induced effects. Three second-generation photosensitizers have been tested for their ability to produce photodynamic response in the chick embryo/CAM system when delivered by i.p. injection: 5-aminolevulinic acid (ALA), benzoporphyrin derivative monoacid ring A (BPD-MA), and Lutetium-texaphyrin (Lu-Tex). Exposure of the CAM vasculature to the appropriate laser light results in light-dose-dependent vascular damage with all three compounds. Localization of ALA following i.p. injections in embryos, whose CAMs have been implanted with rat ovarian cancer cells to produce nodules, is determined in real time by fluorescence of the photoactive metabolite protoporphyrin IX (PpIX). Dose-dependent fluorescence in the normal CAM vasculature and the tumor implants confirms the uptake of ALA from the peritoneum, systemic circulation of the drug, and its conversion to PpIX.

Pyropheophorbide-a methyl ester-mediated photosensitization activates transcription factor NF-kappaB through the interleukin-1 receptor-dependent signaling pathway

Pyropheophorbide-a methyl ester (PPME) is a second generation of photosensitizers used in photodynamic therapy. We demonstrated that PPME photosensitization activated NF-kappaB transcription factor in colon cancer cells. Unexpectedly, this activation occurred in two separate waves, i.e. a rapid and transient one and a second slower but sustained phase. The former was due to photosensitization by PPME localized in the cytoplasmic membrane which triggered interleukin-1 receptor internalization and the transduction pathways controlled by the interleukin-1 type I receptor. Indeed, TRAF6 dominant negative mutant abolished NF-kappaB activation by PPME photosensitization, and TRAF2 dominant negative mutant was without any effect, and overexpression of IkappaB kinases increased gene transcription controlled by NF-kappaB. Oxidative stress was not likely involved in the activation. On the other hand, the slower and sustained wave could be the product of the release of ceramide through activation of the acidic sphingomyelinase. PPME localization within the lysosomal membrane could explain why ceramide acted as second messenger in NF-kappaB activation by PPME photosensitization. These data will allow a better understanding of the molecular basis of tumor eradication by photodynamic therapy, in particular the importance of the host cell response in the treatment.

Photosensitization of human skin cell lines by ATMPn (9-acetoxy-2,7,12,17-tetrakis-(beta-methoxyethyl)-porphycene) in vitro: mechanism of action

9-Acetoxy-2,7,12,17-tetrakis-(beta-methoxyethyl)-porphycene (ATMPn) is a promising new photosensitizer characterized by high absorption around 640 nm and high singlet oxygen yield. To study the mechanism of action in vitro we have investigated uptake, intracellular localization, cell survival and ultrastructural changes following photodynamic treatment in human cell lines derived from the skin (SCL1 and SCL2, squamous cell carcinoma; HaCaT keratinocytes; N1 fibroblasts). Using flow cytometry we have determined the cellular fluorescence as a marker for the uptake of ATMPn after incubation for 60 min. Co-staining with ATMPn and fluorescent dyes specific for cell organelles reveals an intracellular localization of ATMPn in lysosomes. Following irradiation using an incoherent light source (580-740 nm) and a light fluence of 24 J cm-2, phototoxicity is determined by means of the 3-4.5 dimethylthiazol-2,5 diphenyl tetrazolium bromide (MTT) assay. For all cell lines ATMPn concentrations above 15 nM yield a significant phototoxic effect. The 50% effective concentration, EC50, for SCL1 cells is 11.2 +/- 2.9 nM ATMPn. ATMPn uptake and phototoxicity are more effective for HaCaT and SCL1 as compared to SCL2 and N1 cells. Growth curves confirmed the results of the MTT assay. Because of the high lysosomal accumulation of ATMPn, already low photosensitizer concentrations without dark toxicity yield a high photodynamic effect. Immunofluorescence and electron microscopy reveal damage to tonofilaments, plasma membrane and mitochondria, indicating a mechanism unrelated to apoptosis. A dose yielding complete cell killing, as needed for oncological indications, might lead to necrosis, whereas lower sub-lethal doses result in induction of apoptosis.

Cationic photoimmunoconjugates between monoclonal antibodies and hematoporphyrin: selective photodestruction of ovarian cancer cells

The photosensitizer hematoporphyrin (HP) was site specifically attached to a murine monoclonal antibody (MAb) fragment OC125F(ab?)(2) directed against ovarian cancer cells and to nonspecific rabbit immunoglobulin G. The photoimmunoconjugates were positively charged and were purified by column chromatography. The OC125F(ab?)(2) conjugate retained immunoreactivity with human ovarian cancer cells, and the binding was competed with unmodified MAb. Phototoxicity paralleled the cellular uptake with the OC125F(ab?)(2) conjugate and the light showing selective killing of target cells compared with nontarget cells. Nontargeted conjugates and free HP produced lower levels of phototoxicity and showed no selectivity.

What does photodynamic therapy have to offer radiation oncologists (or their cancer patients)?

Major advances have recently been made in photodynamic therapy (PDT) for clinical application, including the development of more powerful photosensitizers and light sources and suitable light applicators. PDT is emerging as an attractive new form of cancer therapy, suitable for treating superficial lesions (less than 1 cm in depth) and carcinoma in situ, or as an adjuvant to surgery for more bulky disease. PDT is therefore complementary to radiotherapy which is better suited to treating larger tumours. There are some qualitative similarities between light distribution in tissue during superficial illumination and ionizing radiation dose distributions during external beam irradiation, or between interstitial PDT and brachytherapy, although the geometric scale is very different (visible light penetrates a maximum of 5-10 mm in tissue). The contribution of scattered light to tissue irradiance is much greater than for ionizing radiation and in situ light dosimetry is very important (although rather complicated) to ensure adequate illumination without over-treating. Dosimetry and treatment planning are highly advanced for ionizing radiation and are routine in all radiotherapy departments. Proper in situ light dosimetry and dose distribution calculation for PDT is in its infancy. Physicists have an important role to play in the further optimization of clinical PDT and much of the infrastructure and expertise present in the radiotherapy department is ideally suited to accommodate PDT. In this review, parallels and contrasts are made between PDT and ionizing radiation for both mechanistic and dosimetric aspects of the therapies. A summary of the most interesting clinical applications is also given.

Delta-aminolevulinic acid-mediated photosensitization of prostate cell lines: implication for photodynamic therapy of prostate cancer

BACKGROUND

Delta-aminolevulinic acid (ALA)-mediated photodynamic therapy (PDT) is currently being investigated for the treatment of prostate diseases. In this study, we evaluate 1) the in vitro production of protoporphyrin IX (PPIX) (the active photosensitizing agent of ALA-mediated PDT) by two different prostate cancer cell lines (LNCaP and PC-3) and a benign, modified, prostatic cell line (TP-2), and 2) the extent of PDT-induced cell injury, as determined by electron microscopy (EM) and cell survival.

METHODS

The cell lines were assigned into four treatment groups: group 1, control, no ALA and no light irradiation; group 2, dark control, ALA only; group 3, light control, radiation only; and group 4, PDT, ALA followed by irradiation (630 nm, 3 joules/cm2). The experiments were performed in triplicate. ALA concentration was 50 microg/ml of media in all instances.

RESULTS

Following incubation with ALA, PPIX production was significantly increased in the three cell lines studied, and more notably in the PC-3 cell line. Compared to controls, EM and cell survival studies demonstrated significant mitochondrial damage and decreased survival, respectively, in the cells treated with PDT. This was also more evident in the PC-3 cell line.

CONCLUSIONS

Our results demonstrate that prostate cells differ in their response to ALA-mediated PDT. This response appears to depend on the intracellular production of PPIX and the cell type, i.e., on the functional and structural characteristics of the cell mitochondria. In addition, our results suggest that PDT might be effective at killing prostate cancer cells.

Modification of tumor blood flow: current status and future directions

Suboptimal drug distribution and hypoxia, which can contribute to treatment failure, are a direct consequence of the spatial and temporal heterogeneity in perfusion that occurs in solid tumors. Therefore, improvements in tumor blood flow have wide-ranging therapeutic importance. Paradoxically, controlled decreases in tumor blood flow can also be exploited and, if permanent, induce extensive tumor cell death on their own. We review the current knowledge of the factors controlling tumor blood flow with emphasis on the roles of the endogeneous vasodilator nitric oxide and the endogenous vasoconstrictor endothelin-1. The potential importance and application of approaches that irreversibly damage vascular function, so-called vascular targeting, are also discussed. Emphasis is given to the drug-based approaches to vascular targeting that are now entering clinical evaluation. There is no doubt that increased understanding of the processes that determine blood flow in tumors, coupled with the availability of techniques to monitor blood flow noninvasively in the clinic, will enable strategies for selectively modifying tumor blood flow to be transferred from the laboratory to the clinical setting.

Photodynamic therapy results in induction of WAF1/CIP1/P21 leading to cell cycle arrest and apoptosis

Photodynamic therapy (PDT) is a promising new modality that utilizes a combination of a photosensitizing chemical and visible light for the management of a variety of solid malignancies. The mechanism of PDT-mediated cell killing is not well defined. We investigated the involvement of cell cycle regulatory events during silicon phthalocyanine (Pc4)-PDT-mediated apoptosis in human epidermoid carcinoma cells A431. PDT resulted in apoptosis, inhibition of cell growth, and G0-G1 phase arrest of the cell cycle, in a time-dependent fashion. Western blot analysis revealed that PDT results in an induction of the cyclin kinase inhibitor WAF1/CIP1/p21, and a down-regulation of cyclin D1 and cyclin E, and their catalytic subunits cyclin-dependent kinase (cdk) 2 and cdk6. The treatment also resulted in a decrease in kinase activities associated with all the cdks and cyclins examined. PDT also resulted in (i) an increase in the binding of cyclin D1 and cdk6 toward WAF1/CIP1/p21, and (ii) a decrease in the binding of cyclin D1 toward cdk2 and cdk6. The binding of cyclin E and cdk2 toward WAF1/CIP1/p21, and of cyclin E toward cdk2 did not change by the treatment. These data suggest that PDT-mediated induction of WAF1/CIP1/p21 results in an imposition of artificial checkpoint at G1 --> S transition thereby resulting in an arrest of cells in G0-G1 phase of the cell cycle through inhibition in the cdk2, cdk6, cyclin D1, and cyclin E. We suggest that this arrest is an irreversible process and the cells, unable to repair the damages, ultimately undergo apoptosis.

Two-photon photodynamic therapy

OBJECTIVE

We demonstrate the use of infrared excitation in conjunction with an efficient two-photon absorbing dye and a photosensitizer in photodynamic therapy.

SUMMARY BACKGROUND DATA

An efficient two-photon absorbing dye is excited by short infrared (800 nm) laser pulses, which transfer its energy to the photosensitizer and the photosensitizer, in turn, generates the singlet oxygen.

METHODS

A new approach to photodynamic cancer therapy based on the strong two-photon absorption of certain newly developed organic molecules. Near infrared pulsed laser light efficiently excites these molecules which, in turn, transfer the energy to the photosensitizer used in photodynamic therapy.

RESULTS

A newly synthesized two-photon absorbing dye 4-[N-(2-hydroxyethyl)-N-(methyl) amino phenyl]-4'-(6-hydroxyhexyl sulfonyl)stilbene (APSS), which exhibits a strong two-photon absorption at 800 nm, and upconverted fluorescence at 520 nm, in solution in the presence of a photosensitizer was found to generate singlet oxygen under infrared excitation (800 nm). The generation of singlet oxygen in a reaction system containing two-photon absorbing dye and photosensitizer under infrared excitation has been chemically detected by using ADPA (9,10-anthracenedipropionic acid) as singlet oxygen detector.

CONCLUSIONS

The efficient two-photon absorption of certain chromophores can be used to extend photodynamic therapy to the near infrared spectral region. Whereas the photosensitizer itself may not exhibit two-photon absorption, it could be used in conjunction with one of these new chromophores. The chromophores can act as "photon harvesters" whereby they absorb two photons of near infrared light and transfer the energy to the photosensitizer, which can generate singlet oxygen in the presence of atmospheric oxygen.

Photosensitization of skin-derived cell lines by Dimegin [2,4-di-(alpha-methoxyethyl)-deuteroporphyrin IX] in vitro

The deuteroporphyrin-IX derivative Dimegin [2,4-di-(alpha-methoxyethyl)-deuteroporphyrin IX] was investigated with respect to cellular uptake, intracellular localization and cell survival following photodynamic treatment in human cell lines derived from the skin (SCL1 and SCL2, squamous cell carcinoma; HaCaT keratinocytes; N1 fibroblasts). Using flow cytometry, we determined the cellular fluorescence as a marker of the uptake of Dimegin after incubation for 24 h. The intracellular localization of Dimegin was analysed using fluorescence microscopy and co-staining with fluorescent dyes specific for cell organelles. Following irradiation with an incoherent light source (580-740 nm) using a light dose of 24 J/cm2, phototoxicity was determined by means of trypan blue dye exclusion, MTT assays and growth curves. The relative Dimegin fluorescence of the different cell lines declined as follows: SCL1 > HaCaT > N1 > SCL2. Intracellular localization of Dimegin was found in the mitochondria. For all cell lines Dimegin concentrations above 15 microM yielded a significant phototoxic effect. The EC50 for SCL1 cells was 8.9 +/- 2.0 microM Dimegin. The EC50 for the cell lines increased as follows: SCL1 < HaCaT < N1 < SCL2, thus correlating with the cellular fluorescence of Dimegin. The results of the MTT assay were confirmed by trypan blue dye exclusion assay and growth curves. In conclusion, the study shows that Dimegin is an effective photosensitizer with a rapid mechanism of action in vitro, resulting in an immediate loss of plasma membrane integrity following irradiation.

Interstitial photodynamic therapy with the second-generation photosensitizer bacteriochlorin a in a rat model for liver metastases

Bacteriochlorin a (BCA) is a second-generation photosensitizer that is effective in tumour destruction upon illumination with light of a wavelength of 760 nm. Tissue penetration by light at this wavelength is greater compared with wavelengths at which commonly used photosensitizers are illuminated, making it possible to treat larger tumours. In a model of experimental liver metastases in rats, we measured lesion sizes after interstitial illumination of tumours at different times after intravenous administration of BCA (10 mg kg(-1) bodyweight), as well as BCA concentrations in liver and tumour tissue. In both, BCA concentrations showed a rapid decline within the first 4 h, followed by a slow decrease over the next 20 h, suggesting biphasic pharmacokinetics. No selective uptake in tumour tissue was observed. A near-linear relationship was found between lesion sizes and liver and tumour BCA concentrations, suggesting that optimal results with photodynamic therapy (PDT) could be obtained by illumination within a short time interval after administration, when tissue concentrations are highest. No severe liver toxicity was observed as indicated by serum ALAT levels. However, in all tumours evaluated, islands of vital-looking cells were present leading to tumour regrowth within 35 days. In view of the obtained lesion diameters of approximately 13 mm after BCA-PDT and the rapid clearance rate of BCA, the concept of a near-infrared absorbing photosensitizer for PDT of liver tumours is a potential interesting strategy.

Differentiation-specific increase in ALA-induced protoporphyrin IX accumulation in primary mouse keratinocytes

A treatment regimen that takes advantage of the induction of intracellular porphyrins such as protoporphyrin IX (PPIX) by exposure to exogenous 5-amino-laevulinic acid (ALA) followed by localized exposure to visible light represents a promising new approach to photodynamic therapy (PDT). Acting upon the suggestion that the effectiveness of ALA-dependent PDT may depend upon the state of cellular differentiation, we investigated the effect of terminal differentiation upon ALA-induced synthesis of and the subsequent phototoxicity attributable to PPIX in primary mouse keratinocytes. Induction of keratinocyte differentiation augmented intracellular PPIX accumulation in cells treated with ALA. These elevated PPIX levels resulted in an enhanced lethal photodynamic sensitization of differentiated cells. The differentiation-dependent increase in cellular PPIX levels resulted from several factors including: (a) increased ALA uptake, (b) enhanced PPIX production and (c) decreased PPIX export into the culture media. Simultaneously, steady-state levels of coproporphyrinogen oxidase mRNA increased but aminolaevulinic acid dehydratase mRNA levels remained unchanged. From experiments using 12-o-tetradecanoylphorbol-13-acetate, transforming growth factor beta 1 and calcimycin we demonstrated that the increase in PPIX concentration in terminally differentiating keratinocytes is calcium- and differentiation specific. Stimulation of the haem synthetic capacity is seen in primary keratinocytes, but not in PAM 212 cells that fail to undergo differentiation. Interestingly, increased PPIX formation and elevated coproporphyrinogen oxidase mRNA levels are not limited to differentiating keratinocytes; these were also elevated in the C2C12 myoblast and the PC12 adrenal cell lines upon induction of differentiation. Overall, the therapeutic implications of these results are that the effectiveness of ALA-dependent PDT depends on the differentiation status of the cell and that this may enable selective targeting of several tissue types.

Hydroxyphthalocyanines as potential photodynamic agents for cancer therapy

A series of benzyl-substituted phthalonitriles, substituted at the 3-, 4-, and 4,5-positions, underwent varied condensations with phthalonitrile to give a series of protected (monohydroxy- and polyhydroxyphthalocyaninato)zinc(II) derivatives which were readily cleaved to give several hydroxyphthalocyanines (ZnPc) (phthalocyanine phenol analogues). Their efficacy as sensitizers for the photodynamic therapy (PDT) of cancer was evaluated on the EMT-6 mammary tumor cell line. In vitro, the 2-hydroxy ZnPc (32) was the most active, followed by the 2,3- and 2,9-dihydroxy ZnPc (39 and 45), with the 2,9,16-trihydroxy ZnPc (33) exhibiting the least activity. In vivo, the monohydroxy derivative 32 and the 2,3-dihydroxy derivative 39 were both efficient in inducing tumor necrosis at 1 micromol kg-1, but complete tumor regression was poor, even at 2 micromol/kg. In contrast, the 2,9-dihydroxy isomer 45, at 2 micromol kg-1, induced tumor necrosis in all animals treated, with 75% complete regression. These results underline the importance of the position of the substituents on the Pc macrocycle to optimize tumor response and confirm the PDT potential of the unsymmetrical Pcs bearing functional groups on adjacent benzene rings.

Photodynamic therapy as a tool for suppressing the haematogenous dissemination of tumour cells

The chance of most cancer patients surviving their disease is to a high degree dependent on the status of the metastatic processes. One general route of cancer-cell dissemination is passive transport in the blood stream, i.e., haematogenous dissemination. In this study we try to find an answer to the following question: is it possible to use photodynamic therapy for suppressing the haematogenous dissemination of cancer cells? In first in vitro experiments we incubated CX1 cells (colon carcinoma cells) with two photosensitizers, Photofrin II and mesotetra(hydroxyphenyl)chlorin (mTHPC). We added the cells to fresh whole blood and irradiated the blood with suitable laser light in a flow-through irradiation system. The tumour-cell survival fraction (SF) was determined with plating efficiency. Using Photofrin II we observed a minimal tumour-cell survival in blood of SF = 3.5% and using mTHPC we measured SF = 0.02%. These results encourage further investigations concerning the use of photodynamic therapy for suppressing haematogenous dissemination.

Antitumor efficacy of the combination of photodynamic therapy and chemotherapy in murine tumors

Photodynamic therapy (PDT) is based on the administration of tumor-localizing photosensitizers followed by light exposure of the tumor mass. The photocytotoxic effects are mainly caused by the generation of singlet oxygen. Recently, PDT has been proposed for use in combination with anticancer chemotherapy with a view to exploiting any additive antitumor effect. We investigated the effect of PDT with photoactivated aluminum disulfonated phthalocyanine (AlS2Pc) combined with the antiblastic drugs Adriamycin (ADR) and cisplatinum (CDDP) on murine tumors. Mice bearing L1210 leukemia and P388 lymphoma were treated with ADR or CDDP and subsequently treated with PDT. Low chemotherapy doses were ineffective, but the combination of antiblastic drugs + PDT had a significantly additive antitumor effect. In conclusion, with this combined therapy we were able to greatly reduce the effective doses of antiblastic drugs, thus lowering their toxic effects on normal host tissues.

Photodynamic ablation of high-grade dysplasia and early cancer in Barrett's esophagus by means of 5-aminolevulinic acid

BACKGROUND & AIMS

The first therapeutic experiences with the conventional photosensitizer dihematoporphyrinester in the treatment of Barrett's esophagus show the curative potential of photodynamic therapy (PDT). The aim of this study was to test 5-aminolevulinic acid (5-ALA)-induced protoporphyrin IX, a photosensitizer with a high mucosa specificity without phototoxic side effects on the skin, as a new form of PDT.

METHODS

Thirty-two patients (mean age, 68.5 years) with histologically proven high-grade dysplasia (n = 10) and mucosal cancer (n = 22) in Barrett's esophagus were treated. Four to 6 hours after oral ingestion of 5-ALA (dose, 60 mg/kg body wt), irradiation was conducted with a dye laser system (635 nm) with a light dose of 150 J/cm2. The patients received 20-80 mg omeprazole daily after PDT.

RESULTS

High-grade dysplasia was eradicated in all patients (10 of 10), and mucosal cancer was eliminated in 17 of 22 patients (77%) at a mean follow-up of 9.9 months (range, 1-30 months). All tumors < or = 2 mm in thickness were completely ablated (17 of 17). The method-related mortality and morbidity was 0%.

CONCLUSIONS

Severe dysplasia and thin (< or = 2 mm) mucosal cancer of Barrett's esophagus can be completely ablated. PDT might offer a minimally invasive treatment modality as an alternative to esophagectomy.

Anthrapyrazoles and interstitial laser phototherapy for experimental treatment of squamous cell carcinoma

Interstitial laser therapy (ILT) is an effective palliative treatment for advanced head and neck cancer, but recurrence often is seen at the margin. The objective of the current study was to test combined drug and laser therapy as an experimental approach for improved treatment of human squamous cell carcinoma (SCCA). Human SCCA tumor transplants were grown in nude mice and injected with the photosensitive anthrapyrazole CI-941 before ILT. Intralesional drug injections alone at levels ranging from 60 to 1200 microg/gm of tumor induced a growth delay at the higher doses, but recurrence was seen in all 35 tumors tested. SCCA tumor transplants injected with 240 microg/gm CI-941 followed after 4 hours by ILT with the KTP532 laser led to a complete response rate of 72% (21/29) compared with 45% (13/29) for ILT alone. Laser chemotherapy was a significant improvement compared with ILT when partial and complete responses were combined (P < 0.03). The results provide preclinical evidence that laser chemotherapy may become a useful minimally invasive treatment for advanced squamous cell carcinoma of the head and neck.

Differential photosensitivity in wild-type and mutant p53 human colon carcinoma cell lines

Tumor sensitivity to cancer therapies may be modulated by the p53 status of the malignant cells. Generally, tumors retaining wild-type p53 are more sensitive to radiotherapy and some chemotherapeutic agents than are tumors with either a mutated or deleted p53 phenotype. The role of p53 in the responsiveness to PDT as a cancer treatment is clinically unknown. In the current study, we evaluated the photosensitivity of two human colon carcinoma cell lines, one expressing wild-type p53 protein and the other expressing mutant p53. Wild-type p53 cells were found to be significantly more sensitive to Photofrin-mediated photodynamic treatment measured by clonogenic assay. Uptake of the photosensitizer was equivalent for both cell lines. Interestingly, sensitivity of the colon carcinoma cell lines to ionizing radiation was similar. These two cell lines represent a useful model for examining p53 involvement in the cellular response to PDT-mediated oxidative stress.

A regulatory role for porphobilinogen deaminase (PBGD) in delta-aminolaevulinic acid (delta-ALA)-induced photosensitization?

As an initial approach to optimize delta-aminolaevulinic acid (delta-ALA)-induced photosensitization of tumours, we examined the response of three enzymes of the haem biosynthetic pathway: delta-ALA dehydratase, porphobilinogen deaminase (PBGD) and ferrochelatase. Only PBGD activity displayed a time- and dose-related increase in tumours after intravenous administration of 300 mg kg(-1) delta-ALA. The time course for porphyrin fluorescence changes, reflecting increased production of the penultimate porphyrin, protoporphyrin IX (PPIX), showed a similar pattern to PBGD. This apparent correlation between PBGD activity and porphyrin fluorescence was also observed in four cultured tumour cell lines exposed to 0.1-2.0 mM delta-ALA in vitro. The increase in PBGD activity and PPIX fluorescence was prevented by the protein synthesis inhibitor cycloheximide. As the apparent Km for PBGD was similar before and after delta-ALA, the increase in PBGD activity was attributed to induction of enzyme de novo. These observations of an associated response of PBGD and PPIX imply that PBGD may be a rate-limiting determinant for the efficacy of delta-ALA-induced photosensitization when used in photodynamic therapy.

Photosensitization of isolated rat liver mitochondria by tetra(m-hydroxyphenyl)chlorin

Tetra(m-hydroxyphenyl)chlorin (mTHPC) is used as a photosensitizer in photodynamic therapy (PDT), a novel modality for cancer treatment. Since little is known about mTHPC-mediated damage in vitro, we chose isolated rat liver mitochondria as a model system to study its photodynamic effects. Incubation of isolated mitochondria with mTHPC plus irradiation with light of a wavelength of 652 nm resulted in protein oxidation and lipid peroxidation, as measured by the mitochondrial content of carbonyl groups and thiobarbituric acid-reactive substances, respectively. Type I and type II photochemical reactions contribute to this oxidative damage as shown by the use of scavengers. Photodynamically treated mitochondria had a reduced membrane potential, and their Ca2+ uptake was impaired. Oxygen consumption of complex I of the respiratory chain was stimulated at a low concentration of mTHPC plus irradiation, but decreased at higher concentrations, whereas oxygen consumption at complex II and IV decreased with all mTHPC concentrations offered. No mitochondrial changes were seen with mTHPC in the absence of irradiation. Our results confirm the sensitivity of mitochondria to PDT and may help to understand the mechanisms by which PDT using mTHPC kills cells.

Nonlinear Dynamics of Intracellular Methylene Blue During Light Activation of Cell Cultures

Methylene blue (MB+) is a well-known dye in medicine and has been discussed as an easily applicable drug for topical treatment in photodynamic therapy (PDT). Methylene blue can potentially be used as a redox indicator to detect the important redox reactions that are induced during PDT. The kinetics of this process was analyzed on a subcellular level with confocal laser scanning microscopy. BKEz-7 endothelial cells were incubated 4 h with 1 microM MB+. The fluorescence dynamics of MB+ during irradiation with 633 nm light was observed with subcellular resolution. Images were acquired at 0.5 s intervals (frame rate 1 image/0.5 s). Fluorescence was observed in the red channel of the laser scanning microscope. Synchronously, the phase-contrast image was visualized with the green channel. Morphological changes could therefore be correlated with the dynamics of MB+. In addition, the light-dose-dependent phototoxicity at 633 nm irradiation was determined by viable cell counting. After an induction period (phase I), fast fluorescent spikes could be observed in the whole cytoplasm, which decayed with a time constant of about 20 s (phase II), followed by a period of nearly constant fluorescence intensity (phase III) and exponential photobleaching (phase IV). Phase II exhibits highly nonlinear kinetics, which is hypothesized to correlate probably with a nonlinear quantal production of reactive oxygen species (ROS). Morphological cell changes were not observed during phase II. During phase III, a pycnotic cell nucleus developed. From the determination of viable cells we can conclude that a light dose applied within phase II was only sublethal in correlation with morphological observations. Overproduction of ROS leading finally to cell killing during phases III and IV is discussed.

Syntheses and photodynamic activities of novel trisulfonated zinc phthalocyanine derivatives

The synthesis of water-soluble, unsymmetrical, trisulfonated zinc phthalocyanines (ZnPcS3) as single products of the ring expansion of boron tri(4-sulfo)subphthalocyanine (SubPc) is reported. The novel, water-soluble trisulfo-SubPcB(OH) was prepared via hydrolysis of the tris(4-chlorosulfonyl)SubPcB(Br) which in turn was obtained from the condensation of 4-(chlorosulfonyl)phthalonitrile with BBr3 in 1-chlorobenzene. A number of ZnPcS3 analogues were prepared via the reaction of S3SubPcB (OH) with different diiminoisoindoline derivatives of increasing hydrophobicity. The reaction proceeds at relative low temperature with acceptable yields. Metalation of free base Pc's with zinc acetate dihydrate afforded the corresponding zinc complexes. Photodynamic activities were measured against the EMT-6 mouse mammary tumor cell line and compared to those of the known ZnPcS3 and ZnPcS4. Added (t-Bu)benzo and (t-Bu)naphtho groups increased the in vitro cell photoinactivation efficacy of the ZnPcS3, whereas addition of a fourth sulfobenzo or bulky diphenylpyrazino group decreased the activity of the parent molecule. The (t-Bu)naphthotrisulfobenzoporphyrazine induced the best in vivo photodynamic tumor control which, combined with its good solubility and broad absorption spectrum, renders this compound an interesting dye for photodynamic applications in medicine.

A hydroxypyridinone (CP94) enhances protoporphyrin IX formation in 5-aminolaevulinic acid treated cells

Different cell lines were given photodynamic treatment with 5-aminolaevulinic acid (ALA) and light. In addition, the iron chelator 1,2-diethyl-3-hydroxypyridin-4-one (CP94) was used. The porphyrin species produced was spectrofluorimetrically identified as protoporphyrin IX. All the cell lines responded to treatment, including a multidrug resistance gene expressing bladder cancer line and, to a lesser degree, cells derived from untransformed human skin fibroblasts. CP94 enhanced both porphyrin fluorescence, total porphyrin content and photosensitivity of the cells. CCD fluorescence microscopy showed a granular extranuclear porphyrin fluorescence distribution for all the cell lines involved, but the untransformed cells showed a distribution pattern different from the ones seen in the other cells.

Differences in in vitro photodynamic sensitivity among head and neck cancers

This study was conducted to address the question of how cancers of different histologies of the head and neck region responded to photodynamic therapy (PDT). Five human cancer cell lines were investigated: two squamous cell carcinoma lines (pharynx and tongue), mucoepidermoid carcinoma (submaxillary gland), rhabdomyosarcoma (embryonic) and adenocarcinoma (colon). The cell lines were treated with haematoporphyrin derivative (HpD) at doses of 0.78-25Mug ml(-1), with excitation of the absorbed drug by a 'black light' source (340-380 nm). An MTT assay demonstrated different PDT responses among the various cell types. On the basis of LD(50), the sensitivity of the different cell lines was ranked as follows: adenocarcinoma> squamous cell carcinoma> rhabdomyosarcoma> mucoepidermoid carcinoma. The magnitude of the LD(50) was suggested by a drug uptake study to be governed in part by cellular levels of sensitizer and in part by intrinsic cell sensitivity. This study provided information that may help to identify the histological types of head and neck cancers that would respond favourably to PDT.

Photodynamic destruction of Haemophilus parainfluenzae by endogenously produced porphyrins

Bacterial resistance against antibiotic treatment is becoming an increasing problem in medicine. Therefore methods to destroy microorganisms by other means are being investigated, one of which is photodynamic therapy (PDT). It has already been shown that a variety of Gram-positive and Gram-negative bacteria can be killed in vitro by PDT using exogenous sensitizers. An alternative method of photosensitizing cells is to stimulate the production of endogenous sensitizers. The purpose of this study was to investigate the bactericidal efficacy of PDT for Haemophilus parainfluenzae with endogenously produced porphyrins, synthesized in the presence of delta-aminolaevulinic acid (delta-ALA). H. parainfluenzae incubated with increasing amounts of delta-ALA showed decreased survival after illumination with 630 nm light. No photodynamic effect on the bacterial viability was found when H. parainfluenzae was grown without added delta-ALA. H. influenzae, grown in the presence of delta-ALA, but not capable of synthesizing porphyrins from delta-ALA, was not affected by PDT. Of the range of incident wavelengths, 617 nm appeared to be the most efficient in killing the bacteria. Spectrophotometry of the bacterial porphyrins demonstrated that the maximum fluorescence occurred at approximately 617 nm, with a much lower peak around 680 nm. We conclude that a substantial killing of H. parainfluenzae by PDT in vitro after endogenous sensitization with delta-ALA can be achieved.

Implicit and explicit dosimetry in photodynamic therapy: a New paradigm

Dosimetry for photodynamic therapy (PDT) is becoming increasingly complex as more factors are identified which may influence the effectiveness of a given treatment. The simple prescription of a PDT treatment in terms of the administered photosensitizer dose, the incident light and the drug-light time interval does not account for patient-to-patient variability in either the photosensitizer uptake, tissue optical properties or tissue oxygenation, nor for the interdependence of the photosensitizer-light-tissue factors. This interdependence is examined and the implications for developing adequate dosimetry for PDT are considered. The traditional dosimetric approach, measuring each dose factor independently, and termed here 'explicit dosimetry', may be contrasted with the recent trend to use photosensitizer photobleaching as an index of the effective delivered dose, termed here 'implicit dosimetry'. The advantages and limitations of each approach are discussed, and the need to understand the degree to which the photobleaching mechanism is linked, or 'coupled', to the photosensitizing mechanism is analysed. Finally, the influence of the tissue-response endpoints on the optimal dosimetry methods is considered.

Fluorescence lifetime imaging of experimental tumors in hematoporphyrin derivative-sensitized mice

Tumor detection has been carried out in mice sensitized with hematoporphyrin derivative (HpD) by measuring the spatial distribution of the fluorescence lifetime of the exogenous compound. This result has been achieved using a time-gated video camera and a suitable mathematical processing that led to the so-called "lifetime images." Extensive experimental tests have been performed on mice bearing the MS-2 fibrosarcoma or the L1210 leukemia. Lifetime images of mice show that the fluorescence decay of HpD is appreciably slower in the tumor than in healthy tissues nearby, allowing a reliable detection of the neoplasia. The lengthening of the lifetime in tumors depends little on the drug dose, which in our experiments could be lowered down to 0.1 mg/kg body weight, still allowing a definite tumor detection. In order to ascertain the results achieved with the imaging apparatus, high-resolution spectroscopy, based on a time-correlated single photon counting system, has also been performed to measure the fluorescence lifetime of the drug inside the tumor and outside. The outcomes obtained with two techniques are in good agreement.

Increased photosensitivity in HL60 cells expressing wild-type p53

Loss of p53 function has been correlated with decreased sensitivity to chemotherapy and radiation therapy in a variety of human tumors. Comparable analysis of p53 status with sensitivity to oxidative stress induced by photodynamic therapy has not been reported. In the current study we examined photosensitivity in human promyelocytic leukemia HL60 cells exhibiting either wild-type p53, mutated p53 or deleted p53 expression. Experiments were performed using a purpurin, tin ethyl etiopurpurin (SnET2)-, or a porphyrin, Photofrin (PH)-based photosensitizer. Total SnET2 accumulation was comparable in all three cell lines. Uptake of PH was highest in cells expressing wild-type p53 but incubation conditions could be adjusted to achieve equivalent cellular PH levels during experiments that analyzed photosensitivity. Survival measurements demonstrated that HL60 cells expressing wild-type p53 were more sensitive to PH- and SnET2-mediated photosensitization, as well as to UVC irradiation, when compared to HL60 cells exhibiting deleted or mutated p53 phenotypes. A rapid apoptotic response was observed following purpurin- and porphyrin-induced photosensitization in all cell lines. Results of this study indicate that photosensitivity is increased in HL60 cells expressing wild-type p53 and that photosensitizer-mediated oxidative stress can induce apoptosis through a p53-independent mechanism in HL60 cells.

Simultaneous two-photon activation of type-I photodynamic therapy agents

The excitation and emission properties of several psoralen derivatives are compared using conventional single-photon excitation and simultaneous two-photon excitation (TPE). Two-photon excitation is effected using the output of a mode-locked titanium: sapphire laser, the near infrared output of which is used to promote nonresonant TPE directly. Specifically, the excitation spectra and excited-state properties of 8-methoxypsoralen and 4'-aminomethyl-4,5,8-trimethylpsoralen are shown to be equivalent using both modes of excitation. Further, in vitro feasibility of two-photon photodynamic therapy (PDT) is demonstrated using Salmonella typhimurium. Two-photon excitation may be beneficial in the practice of PDT because it would allow replacement of visible or UV excitation light with highly penetrating, nondamaging near infrared light and could provide a means for improving localization of therapy. Comparison of possible laser excitation sources for PDT reveals the titanium: sapphire laser to be exceptionally well suited for nonlinear excitation of PDT agents in biological systems due to its extremely short pulse width and high repetition rate that together provide efficient PDT activation and greatly reduced potential for biological damage.

H-dependent formation of 5-aminolaevulinic acid-induced protoporphyrin IX in fibrosarcoma cells

pH-Dependent variations in the fluorescence intensity of 5-aminolaevulinic acid-induced 5-aminolaevulinic acid protoporphyrin IX (PP IX) were compared with the cell viability following light irradiation. The fluorescence intensity was determined by flow cytometry and the cell activity was investigated by a colorimetric 3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide (MTT) assay 24 h after photodynamic treatment. The results obtained by fluorescence measurements clearly showed that pH values of the incubation medium containing (5-ALA) below and above pH 7.4 led to a significant decrease in the fluorescence intensity. The viability of cells incubated with 0.6 mM 5-ALA in a medium at pH 6.0 was unaffected on exposure to light at lambda = 635 nm up to 15 J cm-2. However, cells incubated at pH 7.4 (with the other treatment parameters the same) were nearly completely destroyed. In addition, depletion of intracellular PPIX was faster in physiological medium than in acid medium.

A solubilization technique for photosensitizer quantification in ex vivo tissue samples

The determination of the photosensitizer concentration in ex vivo tissue samples is commonly used for pharmacokinetic and dosimetric studies of photodynamic therapy, both clinically and pre-clinically. In this report, a new method is presented based on tissue solubilization and subsequent fluorometry. This method has the advantages of good sensitivity, accuracy and reproducibility, as well as low cost and ease of handling of the tissue samples. The method was tested for six different photosensitizers in a variety of tissues. The accuracy and concentration detection limits are compared with those of other published extraction methods.

An optical phantom with tissue-like properties in the visible for use in PDT and fluorescence spectroscopy

The design and characterization of optical phantoms which have the same absorption and scattering characteristics as biological tissues in a broad spectral window (between 400 and 650 nm) are presented. These low-cost phantoms use agarose dissolved in water as the transparent matrix. The latter is loaded with various amounts of silicon dioxide, Intralipid, ink, blood, azide, penicillin, bovine serum, and fluorochromes. The silicon dioxide and Intralipid particles are responsible for the light scattering whereas the ink and blood are the absorbers. The penicillin and the azide are used to ensure the conservation of such phantoms when stored at 4 degrees C. The serum and fluorochromes, such as Coumarin 30, produce an autofluorescence similar to human tissues. Various fluorochromes or photosensitizers can be added to these phantoms to simulate a cancer photodetection procedure. The absorption and fluorescence spectroscopy of the porphyrin-type fluorescent markers used clinically for such photodetection procedures is similar in these phantoms and in live tissues. The mechanical properties of these gelatinous phantoms are also of interest as they can easily be moulded and reshaped with a conventional cutter, so that complex structures and shapes, with different optical properties, can be designed. The optical properties of these phantoms were determined between 400 and 650 nm by measuring their effective attenuation coefficient (mu eff) and total reflectance (Rd). The microscopic absorption and reduced scattering coefficients (mu a, mu s') were deduced from mu eff and Rd using a Monte Carlo simulation.

In vivo fluorescence detection of ovarian cancer in the NuTu-19 epithelial ovarian cancer animal model using 5-aminolevulinic acid (ALA)

The purpose of this study was to determine whether in vivo fluorescence detection of protoporphyrin IX (PpIX) could be used to identify intraperitoneal micrometastases of epithelial ovarian carcinoma after application of 5-aminolevulinic acid (ALA). ALA was applied intraperitoneal at different concentrations (25, 50, and 100 mg/kg) and iv (100 mg/kg) to immunocompetent Fischer 344 rats bearing a syngeneic epithelial ovarian carcinoma. At different time intervals after ALA administration (1.5, 3, and 6 hr) the peritoneal cavity was illuminated with ultraviolet (uv) light. In vivo fluorescence of PpIX initially was determined by direct visualization. Subsequently ex vivo measurements were made with a slow-scan, thermoelectrically cooled CCD camera. Red in vivo fluorescence was observed in ovarian micrometastases smaller than 0.5 mm in 100% of the ALA-administered animals independent of time interval, drug concentration, or route of administration. The intensity of the fluorescence was concentration dependent as strong fluorescence was consistently found only above 25 mg/kg ALA. Ex vivo tumor to peritoneum fluorescence yield peaked 3 hr after administration of a 100 mg/kg intraperitoneal dose. Direct visualization of in vivo fluorescence after ALA application may improve the detection of intraperitoneal ovarian cancer micrometastases.

Ex vivo application of delta-aminolevulinic acid induces high and specific porphyrin levels in human skin tumors: possible basis for selective photodynamic therapy

In photodynamic therapy with topically applied delta-aminolevulinic acid porphyrins are acting as photosensitizers. The profile of porphyrin metabolites in normal or in neoplastic skin after administration of delta-aminolevulinic acid has not been determined in detail yet. Thus, to study porphyrin biosynthesis in human skin an organ culture model was developed. Explant pieces of normal skin, keratoacanthoma, and basal cell carcinoma were incubated with 1 mM delta-aminolevulinic acid for 36 h. Levels of delta-aminolevulinic acid, porphyrins and porphyrin metabolites were measured in tissues and supernatants. After incubation with delta-aminolevulinic acid, higher porphyrin levels were demonstrated in tumors as compared to normal skin. In supernatants, most of formed porphyrins, preferentially highly carboxylated porphyrin metabolites, were measured. The pattern of synthesized porphyrins differed between normal and neoplastic skin explants. In tissues of basal cell carcinomas protoporphyrin was preferentially shown and tissues of keratoacanthomas were characterized by a predominance of coproporphyrin as compared to normal skin. The results show that explant cultures offer an easy approach to examine the porphyrin biosynthesis of various tissues. The tumor-specific delta-aminolevulinic acid metabolism indicates additional porphyrin metabolites such as coproporphyrin apart from protoporphyrin as effective photosensitizers and may offer a novel approach to tumor-selective photodynamic damage.

Current status of photodynamic therapy in dermatology

The accessibility of skin to light treatment, as well as the expertise developed by dermatologists in laser surgery and phototherapy, creates an exciting opportunity for dermatologic PDT to become part of our standard therapeutic armamentarium. PDT appears to be viable alternative to conventional therapy for superficial BCC and Bowen's disease, although definitive controlled studies are lacking. The introduction of ongoing research developments, new photosensitizers, and better light sources into clinical PDT trials in the coming years will undoubtedly expand the range of indications for this novel form of therapy, particularly for nononcologic conditions.

5-Aminolevulinic acid-based photodynamic therapy. Clinical research and future challenges

BACKGROUND

Photodynamic therapy (PDT) for cancer patients has developed into an important new clinical treatment modality in the past 25-years. PDT involves administration of a tumor-localizing photosensitizer or photosensitizer prodrug (5-aminolevulinic acid [ALA], a precursor in the heme biosynthetic pathway) and the subsequent activation of the photosensitizer by light. Although several photosensitizers other than ALA-derived protoprophyrin IX (PpIX) have been used in clinical PDT, ALA-based PDT has been the most active area of clinical PDT research during the past 5 years. Studies have shown that a higher accumulation of ALA-derived PpIX in rapidly proliferating cells may provide a biologic rationale for clinical use of ALA-based PDT and diagnosis. However, no review updating the clinical data has appeared so far.

METHODS

A review of recently published data on clinical ALA-based PDT and diagnosis was conducted.

RESULTS

Several individual studies in which patients with primary nonmelanoma cutaneous tumors received topical ALA-based PDT have reported promising results, including outstanding cosmetic results. However, the modality with present protocols does not in general, appear to be superior to conventional therapies with respect to initial complete response rates and long term recurrence rates, particularly in the treatment of nodular skin tumors. Topical ALA-PDT does have the following advantages over conventional treatments: it is noninvasive; it produces excellent cosmetic results; it is well tolerated by patients; it can be used to treat multiple superficial lesions in short treatment sessions; it can be applied to patients who refuse surgery or have pacemakers and bleeding tendency; it can be used to treat lesions in specific locations, such as the oral mucosa or the genital area; it can be used as a palliative treatment; and it can be applied repeatedly without cumulative toxicity. Topical ALA-PDT also has potential as a treatment for nonneoplastic skin diseases. Systemic administration of ALA does not seem to be severely toxic, but the advantage of using this approach for PDT of superficial lesions of internal hollow organs is still uncertain. The ALA-derived porphyrin fluorescence technique would be useful in the diagnosis of superficial lesions of internal hollow organs.

CONCLUSIONS

Promising results of ALA-based clinical PDT and diagnosis have been obtained. The modality has advantages over conventional treatments. However, some improvements need to be made, such as optimization of parameters of ALA-based PDT and diagnosis; increased tumor selectivity of ALA-derived PpIX; better understanding of light distribution in tissue: improvement of light dosimetry procedure; and development of simpler, cheaper, and more efficient light delivery systems.

Laser light delivery systems for medical applications

For medical applications, the choice of a delivery system will be governed by the characteristics of the laser system on the one hand and the tissue application on the other. The most important parts are the beam guide and the target optics. Most lasers have wavelengths in the visible and near-infrared and can be transported by silica fibres. For the mid- and far-IR other fibre materials or hollow waveguides are used. At the end of the waveguide or fibre, an optically active component is present to direct the beam and to control the power density on the target tissue. The laser beam can be delivered either by focusing handpieces and scanning devices to treat superficial areas or through microscopes, endoscopes and flexible fibres to treat areas almost anywhere inside the human body. The characteristics of the delivery systems can be determined looking at beam properties, transmission and thermal properties. The delivery of continuous wave or pulsed laser energy, contact or non-contact, will determine the contribution of optical, thermal and mechanical effects to the tissue. The practical use of laser delivery systems is illustrated by various clinical applications.

Photophysical and photobiological processes in the photodynamic therapy of tumours

Photodynamic therapy (PDT) is an innovative and attractive modality for the treatment of small and superficial tumours. PDT, as a multimodality treatment procedure, requires both a selective photosensitizer and a powerful light source which matches the absorption spectrum of the photosensitizer. Quadra Logic's Photofrin, a purified haematoporphyrin derivative, is so far the only sensitizer approved for phase III and IV clinical trials. The major drawbacks of this product are the lack of chemical homogeneity and stability, skin phototoxicity, unfavourable physicochemical properties and low selectivity with regard to uptake and retention by tumour vs. normal cells. Second-generation photosensitizers, including the phthalocyanines, show an increased photodynamic efficiency in the treatment of animal tumours and reduced phototoxic side effects. At the time of writing of this article, there were more than half a dozen new sensitizers in or about to start clinical trials. Most available data suggest a common mechanism of action. Following excitation of photosensitizers to long-lived excited singlet and/ or triplet states, the tumour is destroyed either by reactive singlet oxygen species (type II mechanism) and/or radical products (type I mechanism) generated in an energy transfer reaction. The major biological targets of the radicals produced and of singlet oxygen are well known today. Nucleic acids, enzymes and cellular membranes are rapidly attacked and cause the release of a wide variety of pathophysiologically highly reactive products, such as prostaglandins, thromboxanes and leukotrienes. Activation of the complement system and infiltration of immunologically active blood cells into the tumorous region enhance the damaging effect of these aggressive intermediates and ultimately initiate tumour necrosis. The purpose of this review article is to summarize the up-to-date knowledge on the mechanisms responsible for the induction of tumour necrotic reactions.

Production of the free radicals O2.- and .OH by irradiation of the photosensitizer zinc(II) phthalocyanine

Zinc(II) phthalocyanine (ZnPC) is a new photosensitizer currently undergoing phase I and II clinical trials at Lausanne's CHUV hospital for the photodynamic therapy (PDT) of early cancer in the upper aerodigestive tract. Activated oxygen species other than singlet oxygen produced during the photosensitization of ZnPC in liposomes have been examined by electron paramagnetic resonance (EPR) spin trapping and by the cytochrome c reduction method. Visible light irradiation of ZnPC associated with liposomes in the presence of the spin trap 5,5-dimethyl-1-pyrroline-1-oxide (DMPO) gives an EPR spectrum characteristic of the DMPO-hydroperoxyl radical spin adduct (DMPO-.OOH). Superoxide anion attains a level of 1 microM min-1 20 min after the start of irradiation as determined by the superoxide dismutase (SOD)-inhibitable reduction of cytochrome c. The yield of O2.- is strongly enhanced by physiological electron donors. An EPR spectrum characteristic of the DMPO-hydroxyl radical spin adduct (DMPO-.OH) is also observed. The addition of dimethyl sulphoxide or ethanol produces additional hyperfine splittings due to the respective hydroxyalkyl radical products, indicating the presence of free .OH. DMPO-.OH is significantly inhibited by desferrioxamine or catalase. Conversely, this adduct is enhanced by hydrogen peroxide. These data demonstrate the ability of ZnPC in liposomes to photoreact effectively by an electron transfer mechanism. Such type I processes may add to the effects of singlet oxygen in ZnPC-mediated PDT.

In vivo fluorescence kinetics of porphyrins following intravesical instillation of 5-aminolaevulinic acid in normal and tumour-bearing rat bladders

The fluorescence kinetics of protoporphyrin IX (PPIX) following intravesical instillation of 5-aminolaevulinic acid (5-ALA) have been studied in vivo in a rat bladder tumour model. 5-ALA dissolved in NaHCO3 was intravesically instilled for 60 min in tumour-bearing and normal bladders of Wistar rats. The fluorescence was excited with the violet lines of a Kr(+)-laser and recorded in vivo by means of a fibre coupled optical multichannel analyser. The fluorescence emission bands of PPIX at lambda = 636 nm and lambda = 708 nm were detected in normal and tumorous urothelium after only 30 min. The maximum fluorescence intensity was obtained in tumorous and normal urothelium 3-4 h after instillation. The ratio of the fluorescence intensity in tumorous to normal urothelium decreased continuously from four to about two during the time range of 6 h. PPIX fluorescence following 5-ALA instillation could also be observed in kidney and liver. Fluorescence from further porphyrin species with emission bands at lambda = 617 nm and lambda = 682 nm was detected in the bladder, indicating an efflux of hydrophilic porphyrins from the hepatic pathway.