On the pharmacokinetics of topically applied 5-aminolevulinic acid and two of its esters

Superficial hemangioma is better treated by topical 5-aminolevulinic followed by 595-nm pulsed dye laser therapy rather than 595-nm laser therapy alone

The aim of this study was to compare the efficacy and adverse effects of a 595-nm pulsed dye laser therapy alone (PDL alone) with a 5-aminolevulinic (5-ALA) local application followed by a 595-nm PDL (5-ALA PDL) in the treatment of superficial hemangioma (SH). A prospectively randomized study in 181 patients with SH was carried out over a period of 24 months. One hundred and ninety-three patients were seen. One hundred and eighty-one patients with SH were enrolled, of which 165 completed final follow-up. One hundred and nineteen patients received PDL alone and 46 received 5-ALA PDL. The patients were assessed clinically and the patient's parents were given a satisfaction questionnaire. Baseline patient data (gender, lesion size, lesion site, treatment times, cure rate, and adverse reactions) were recorded and the results of the treatment of the two groups were analyzed and compared. Complete clearing of the lesion (recovery grade 4) was achieved in 44/119 (37.0%) of the PDL alone group and 31/46 (67.4%) of the 5-ALA PDL group (X ² = 10.30, p < 0.001). Atrophic scars, hyper- and hypopigmentation occurred in both groups (X ² = 3.32, p = 0.564). The patients' parents' satisfaction was greater in the 5-ALA PDL group. The clinical outcome of 5-ALA PDL was superior to that of PDL alone in the treatment of SH and only minor adverse events occurred in each group.

Photodynamic therapy of the surface form of basalioma and actinic keratosis with the topical administration of methyl aminolevulinate

Goal. To assess the efficacy of the photodynamic therapy with the external use of methyl aminolevulinate as a photosensitizer with further irradiation with visible red light with the wavelength of 630 nm in the treatment of patients suffering from a surface form of basalioma and actinic keratosis. Materials and methods. The study involved 28 patients diagnosed with the surface form of basalioma and 34 patients diagnosed with actinic keratosis. They underwent treatment by the photodynamic therapy method using a LED lamp radiating visible red light with the wavelength of 630 nm, with the total dose of irradiation equal to 37 J/cm2. All patients also underwent a confocal in vivo laser scanning microscopy of lesions at the baseline and after 7, 30, 90 and 180 days of treatment. Results. Absolute regression of abnormal lesions was observed in 25 (91%) patients diagnosed with the surface form of basalioma and 30 (88.9%) patients diagnosed with actinic keratosis after 30 days of treatment. No signs of the diseases were revealed in these patients after examination by the method of confocal in vivo laser scanning microscopy. Conclusion. The photodynamic therapy with the local administration of methyl aminolevulinate with further irradiation with visible red light with the wavelength of 630 nm is an efficient method of treatment of the surface form of basalioma and actinic keratosis.

Photodynamic therapy with methyl aminolevulinate in the treatment of basal cell carcinoma

The article presents the results of the studies on the effectiveness of treatment basal cell carcinoma of the skin with photodynamic therapy with 5-aminolevulinic acid and methyl aminolevulinate. The results of the comparing trials between photodynamic therapy with methyl aminolevulinate and different other treatment modalities are presented.

Photodynamic therapy in dermatology: Dundee clinical and research experience

Topical photodynamic therapy (PDT) is increasingly accepted and used as a highly effective treatment for superficial non-melanoma skin cancer and dysplasia. We describe the developments in topical PDT for the treatment of skin diseases in our own PDT Centre in Dundee, both clinically and from a research base. Improvements in PDT could be achieved by optimisation of photosensitiser and light delivery, and these goals underpin the aims of our centre. We hope to facilitate the dissemination of use of PDT in dermatology throughout Scotland and outline some of the progress in these areas.

Percutaneous absorption in diseased skin: an overview

The stratum corneum's (SC) functions include protection from external hazardous environments, prevention of water loss and regulation of body temperature. While intact skin absorption studies are abundant, studies on compromised skin permeability are less common, although products are often used to treat affected skin. We reviewed literature on percutaneous absorption through abnormal skin models. Tape stripping is used to disrupt water barrier function. Studies demonstrated that physicochemical properties influence the stripping effect: water-soluble drugs are more affected. Abrasion did not affect absorption as much. Freezing is commonly used to preserve skin. It does not seem to modify water absorption, but still increases the penetration of compounds. Comparatively, heating the skin consistently increased percutaneous absorption. Removing SC lipids may increase percutaneous absorption of drugs. Many organic solvents are employed to delipidize. Delipidization with chloroform-methanol increased hydrophilic compound permeability, but not lipophilic. Acetone pre-treatment enhanced hydrophilic compound penetration. More data is needed to determine influence on highly lipophilic compound penetration. Sodium lauryl sulfate (SLS) induces irritant dermatitis and is frequently used as a model. Studies revealed that SLS increases hydrophilic compound absorption, but not lipophilic. However, skin irritation with other chemicals increases lipophilic penetration as much as hydrophilic. Animal studies show that UV exposure increases percutaneous absorption whereas human studies do not. Human studies show increased penetration in psoriatic and atopic dermatitis skin. The data summarized here begin to characterize flux alteration associated with damaged skin. Understanding the degree of alteration requires interpretation of involved conditions and the enlarging of our database to a more complete physicochemical spectrum.

Intracutaneous ALA photodynamic therapy: dose-dependent targeting of skin structures

BACKGROUND

Photodynamic therapy (PDT) using topical aminolevulinic acid (ALA) depends on local drug uptake, metabolism to porphyrins, and depth of light penetration using different wavelengths. Topical ALA-PDT has limited depth of drug penetration. We studied induced porphyrin distribution and PDT after intradermal ALA administration using different drug concentrations followed by high-fluence red light irradiation.

MATERIALS AND METHODS

Intradermal injections (∼2 mm deep) of ALA concentrations from 0.0005% to 1% were studied in swine to evaluated porphyrin fluorescence before PDT and clinical and histological damage 24 hours after PDT. Porphyrin accumulation was measured by fluorescence microscopy of frozen section. PDT was performed 3 hours after intradermal injections using a 635 nm LED array at a fluence of 200 J/cm2 . Skin responses to PDT were observed grossly and by histology (blind evaluation).

RESULTS

Intradermal ALA caused porphyrin accumulation in epidermis, hair follicles (HF), sebaceous glands (SG), sweat glands (eccrine glands, EG and apocrine glands, AG), and subcutaneous fat. Significant differences of fluorescence intensity were observed between different skin structures (P < 0.05), but there was no significant difference comparing HF to SG; epidermis with either HF or SG; and dermis with fat (P > 0.05). Intradermal ALA is potent. ALA concentrations ≥0.25% followed by red light exposures caused a very intense vascular PDT reaction. Moderate doses of injected ALA concentration (∼0.06%), selectively targeted EG. Low doses (≤0.016%) targeted fat; producing fat necrosis with minimal inflammation, manifested both clinically and histologically. In contrast to topical ALA-PDT, intradermal ALA-PDT can effectively photosensitize deep skin structures.

CONCLUSION

Potentially, intradermal ALA-PDT using various ALA concentrations may be useful for treating vascular lesions (malformations, hemangiomas, tumors), EG/AG disorders, fat or deep targets in skin.

Fluorescence diagnostics as a guide for demarcation and biopsy of suspected anal cancer

BACKGROUND

Malignant epithelial tumors of the perianal skin are relatively rare however show high recurrence rates. A preoperative precise diagnosis and demarcation of the involved cancerous skin remains challenging but is worthwhile to minimize tissue defects and possible limitations of quality of life.

OBJECTIVES

To show the use of fluorescence diagnostics (FD) in the management of chronic perianal disease.

METHODS

FD was performed using methylaminolevulinate (MAL) for three hours topically followed by visualization with blue light (405 nm).

RESULTS

We report on two patients in whom FD helped to demarcate the involved tissue or to direct biopsy to ascertain the final diagnosis. In one patient with a history of Bowen's disease and recurrent anal carcinoma, biopsy showed extramammary Paget's disease and thus was treated by surgical anoplasty. The other patient had a history of chronic anal eczema, and FD-directed biopsy could exclude suspected malignancy so that the anal eczema was treated by local therapy.

CONCLUSIONS

FD is a non-invasive technique which can be used in the perianal region in order to delineate pathologic processes which may reduce the number of surgical interventions.

Long wavelength absorbing cationic Zn(II)-phthalocyanines as fluorescent contrast agents for B16 pigmented melanoma

Three cationic zinc phthalocyanines ( ZnPcs ), tetrakis-(3-methylpyridyloxy)-, tetrakis-(3-hexyl-pyridyloxy)-, and tetrakis-(3-dodecylpyridyloxy)phthalocyaninezinc ( ZnPc Me, ZnPc He and ZnPc Do) have been studied as advanced fluorescent contrast agents for pigmented melanoma tumor. UV-vis spectroscopic properties of the monomers were investigated. Their photophysical behavior as a substantial part of dye-induced fluorescence was evaluated. The selective accumulation and labeling capacity towards B16F0 pigmented melanoma tumor were determined. Melanin containing cells were isolated and incubated with ZnPcs at several time intervals (1, 1.5 and 6 h) following the kinetics of cellular uptake. The highest accumulation was found for ZnPcHe . A lower uptake was detected for the more lipophilic ZnPcDo and more hydrophilic ZnPcMe . The fluorescence diagnostic potential of ZnPcs towards pigmented melanoma by using an argon-dye laser detection set-up was demonstrated.

Fluorescence diagnosis in actinic keratosis and squamous cell carcinoma

BACKGROUND

As different tissue types have distinct capabilities to accumulate protoporphyrin IX, fluorescence diagnosis with aminolevulinic acid-induced porphyrins (FDAP) could be used to discriminate between different types of tissue. Previous results demonstrated higher fluorescence ratios in squamous cell carcinoma (SCC) compared with actinic keratoses (AKs).

OBJECTIVES

The lesional : non-lesional fluorescence ratio of AKs was compared with the ratio of SCC. Other factors influencing macroscopic fluorescence were also assessed, including stratum corneum thickness, which has been demonstrated to account for heterogeneous fluorescence in psoriasis and in AKs.

METHODS

After 1 week of keratolytic pretreatment, FDAP was performed in 13 patients with 36 lesions suspected for AK or SCC. Biopsies were taken for histopathological diagnosis and measurement of stratum corneum thickness.

RESULTS

No significant differences were found in the fluorescence ratio (lesional : non-lesional skin) between AKs and SCCs, although macroscopic fluorescence was significantly higher in Bowen's disease and micro-invasive SCCs.

CONCLUSIONS

There could be a potential applicability of FDAP to differentiate premalignant lesions with a tendency to progress into SCC and squamous cutaneous lesions already progressing into early invasive cancer from other squamous cutaneous (pre)malignancies. The amount of hyperkeratosis, invasiveness and degree of differentiation seem to be responsible for variations in fluorescence intensity.

Intracellular ZnO Nanorods Conjugated with Protoporphyrin for Local Mediated Photochemistry and Efficient Treatment of Single Cancer Cell

ZnO nanorods (NRs) with high surface area to volume ratio and biocompatibility is used as an efficient photosensitizer carrier system and at the same time providing intrinsic white light needed to achieve cancer cell necrosis. In this letter, ZnO nanorods used for the treatment of breast cancer cell (T47D) are presented. To adjust the sample for intracellular experiments, we have grown the ZnO nanorods on the tip of borosilicate glass capillaries (0.5 μm diameter) by aqueous chemical growth technique. The grown ZnO nanorods were conjugated using protoporphyrin dimethyl ester (PPDME), which absorbs the light emitted by the ZnO nanorods. Mechanism of cytotoxicity appears to involve the generation of singlet oxygen inside the cell. The novel findings of cell-localized toxicity indicate a potential application of PPDME-conjugated ZnO NRs in the necrosis of breast cancer cell within few minutes.

Novel patch-based systems for the localised delivery of ALA-esters

In photodynamic therapy (PDT) a combination of visible light and a sensitising drug causes the destruction of selected cells. Aminolaevulinic acid (ALA) has been widely used in topical PDT for over 15 years. However, ALA does not possess favourable physicochemical properties for skin penetration. Consequently, the clearance rates for difficult to treat lesions, such as nodular basal cell carcinomas are relatively low. For the first time, equimolar concentrations of ALA, methyl-ALA (m-ALA) and hexyl-ALA (h-ALA) have been incorporated into a bioadhesive patch-based system. In vitro penetration studies into excised porcine skin revealed that ALA patches containing relatively high loadings (226.7 micromol cm(-2)) were associated with significantly greater tissue concentrations (70.7 micromol cm(-3)) than patches containing m-ALA (16.3 micromol cm(-3)) or h-ALA (17.4 micromol cm(-3)). ALA was also found to be the most efficient inducer of protoporphyrin (PpIX) fluorescence in mice, in vivo (maximum mean fluorescence: ALA=236.2 a.u., m-ALA=175.1 a.u., h-ALA=193.5 a.u.). However, when the lipophilic hexylester was formulated in a pressure sensitive adhesive (PSA) patch, significantly higher PpIX levels were achieved compared to all bioadhesive systems tested. Of major importance, PSA patches containing relatively low h-ALA loadings induced high PpIX levels, which were localised to the application area. This study has highlighted the importance of rational selection of both the active agent and the delivery system. Bioadhesive preparations containing ALA are ideal for delivery to moist environments; whereas h-ALA-loaded PSA systems may facilitate enhanced delivery to dry areas of skin. In addition, owing to the relatively low loadings of h-ALA required in PSA patches, the costs of clinical PDT may potentially be reduced.

Fluorescence detection and diagnosis of non-melanoma skin cancer at an early stage

BACKGROUND

The occurrence of non-melanoma skin cancer (NMSC), including actinic keratosis (AK) is increasing all over the world. The detection and diagnosis of NMSC is not optimal in clinical practice. Complementary methods for detection and accurate demarcation of NMSC at an early stage are needed in order to limit the damage caused by tumours.

OBJECTIVE

The purpose of the present study was to use a large area skin fluorescence detection system to detect early NMSCs (clinical visible as well as non-visible lesions) in the face, neck, chest, back and hands of patients treated with UV and outdoor workers.

METHODS

Fluorescence detection with a purpose-made digital camera and software (Dyaderm combined with 5-aminolevulinic acid (5-ALA) encapsulated in liposomes.

RESULTS

In 93 consecutively referred patients positive skin fluorescence was detected in 61 patients. After histological examination the positive fluorescence appeared to be correlated to benign lesions in 28 patients (sebaceous gland hyperplasia in 22 patients) and to (pre-) malignant lesions in 33 patients (actinic keratosis in 29, BCC in 3 and SCC in 1 patient). False negative fluorescence was found in only one lesion. In five patients the FD technique used in this study appeared to be more sensitive for the identification of (pre-) malignant lesions than the clinical examination. This is in contrast with FD techniques used in previous studies.

CONCLUSION

Diagnostic skin fluorescence using liposomal encapsulated 5-ALA and a specialised computerised detection and visualisation system offers the possibility for detection of NMSC at an early, pre-clinical stage. The technique is well suited to examine large areas of skin. It also identifies areas of most interest for performing confirmatory skin biopsies, as well as pre-operative assessment of boundaries of skin malignancies, and finally, the technique is applicable in the control and follow-up of skin cancer treatment.

Sufficient PpIX production for PDT even with short contact time of topically applied 5-ALA in rabbit tongues

Although effectiveness of photodynamic therapy (PDT) after application of 5-aminolevulinic acid ointment to oral mucosal lesions has been reported, a consensus regarding recontact time of ALA applied to a lesion has been unreached. Hence, we determined the contact time of ALA required for protoporphyrin IX (PpIX) production efficient for full-blown PDT reaction. ALA ointment was topically applied to healthy rabbits' tongues for different periods and then washed out. On the surface of the tongue, 10-min contact of ALA maximized the PpIX-derived fluorescence. PpIX yield in a tissue specimen with 10-min contact of ALA reached 73% of that in a tissue specimen with 240-min contact. Histological observation showed that PpIX accumulation predominated in the basal layer, and the PDT effects were confined in the mucosal epithelium regardless of contact time. These results suggest that 5-aminolevulinic-acid-ointment-mediated PDT with short contact of ALA is potentially applicable for treating tongue epithelial lesions.

Fluorescence diagnosis in keratinocytic intraepidermal neoplasias

BACKGROUND

As different tissue types have distinct capabilities to accumulate protoporphyrin-IX, fluorescence diagnosis with aminolevulinic acid-induced porphyrin (FDAP) could be used to discriminate between different tissue types.

OBJECTIVE

Protoporphyrin-IX accumulation and proliferation were studied in cutaneous squamous (pre)malignancies to see whether FDAP could be used to discriminate between different stages of keratinocytic intraepidermal neoplasia or proliferative status.

METHODS

FDAP was performed in 14 patients (86 lesions) and biopsy specimens were taken, on which (immuno)histochemistry was performed for histopathologic classification and assessment of Ki67-antigen expression. Stratum corneum thickness was also measured.

RESULTS

The fluorescence ratio (lesional:nonlesional skin) showed neither significant differences between the different keratinocytic intraepidermal neoplasia stages, nor between different levels of Ki67-antigen expression. Macroscopic fluorescence intensity and stratum corneum thickness were negatively correlated.

LIMITATIONS

Relatively few malignancies were biopsied.

CONCLUSIONS

With FDAP we were not able to discriminate between keratinocytic intraepidermal neoplasia lesions or proliferative activity. However, hyperkeratosis appeared to be an important determinant in variations in macroscopic fluorescence intensity.

Photodynamic therapy: update 2006. Part 2: Clinical results

In several randomized, controlled studies, the application of a standard preparation containing methyl-aminolevulinate (MAL; Metvix, Galderma, F), followed by red light irradiation proved effective and well tolerated in the treatment of actinic keratosis and basal cell carcinoma, and has now been approved for clinical use in European countries. A brand name aminolevulinic acid (ALA) solution (Levulan Kerastick, Dusa Pharmaceuticals Inc., Wilmington, MA) plus blue light exposure has been approved for the treatment of actinic keratosis in the USA. Randomized and controlled studies have shown that MAL as well as ALA are also effective in the treatment of Bowen's disease. In addition, a large and growing number of open studies or case reports have evaluated its use in the treatment of a broad range of other neoplastic, inflammatory and infectious skin diseases. However, efficacy and definite advantages over standard therapies remain to be clarified because the experimental design of these studies was often poor, the number of enrolled patients was generally low, and the follow-up was shorter than 12 months. However, these studies have suggested a few possible clinical applications worthy of further investigation. A growing number of laboratory and clinical findings suggest that several new synthetic sensitizers, besides ALA and MAL, may be helpful in the treatment of non-melanoma skin cancers, melanoma metastasis, and selected inflammatory and infective skin diseases. These compounds are deliverable intravenously, have short half-lives both in the blood and skin, and are highly efficient. However, they are as of yet not approved for clinical use.

Response to ALA-based PDT in an immortalised normal breast cell line and its counterpart transformed with the Ras oncogene

Aminolevulinic acid (ALA)-based photodynamic therapy (PDT) has been successfully employed in the treatment of certain tumours. Porphyrins endogenously generated from ALA induce tumour regression after illumination with light of an appropriate wavelength. The aim of this work was to compare porphyrin production from ALA and sensitivity to photodynamic treatment in a tumour/normal cell line pair. We employed the HB4a cell line from normal mammary luminal epithelium and its counterpart transfected with the oncogen H-Ras (VAL/12 Ras). After 3 h of exposure to ALA, HB4a-Ras cells produce a maximum of 150 ng porphyrins per 10(5) cells whereas HB4a produce 95 ng porphyrins per 10(5) cells. In addition, HB4a-Ras cells show a plateau of porphyrin synthesis at 1 mM whereas HB4a porphyrins peak at the same concentration, and then decrease quickly. This higher porphyrin synthesis in the tumorigenic cell line does not lead to a higher response to the photodynamic treatment upon illumination. Lethal doses 50, LD(50), determined by MTT assay were 0.015 J cm(-2) and 0.039 J cm(-2) for HB4a and HB4a-Ras respectively after 3 h exposure to 1 mM ALA. The conclusion of this work is that a tumour cell line obtained by transfection of the Ras oncogene, although producing higher porphyrin synthesis from ALA, is more resistant to ALA-PDT than the parental non-tumour line, however the mechanism is not related to photosensitiser accumulation, but very likely to cell survival responses.

Topical application of 5-aminolaevulinic acid, methyl 5-aminolaevulinate and hexyl 5-aminolaevulinate on normal human skin

BACKGROUND

5-Aminolaevulinic acid (ALA) and its ester derivatives are used in photodynamic therapy. Despite extensive investigations, the differences in biodistribution and pharmacokinetics of protoporphyrin IX (PpIX) induced by ALA and its derivatives are still not well understood, notably for humans.

OBJECTIVES

To study porphyrin accumulation after topical application of ALA and two of its ester derivatives in normal human skin.

METHODS

Creams containing 0.2%, 2% and 20% (w/w) of ALA, methyl 5-aminolaevulinate (MAL) and hexyl 5-aminolaevulinate (HAL) were applied on normal human skin of six volunteers. The amount and distribution of porphyrins formed in the skin was investigated noninvasively by means of fluorescence spectroscopy.

RESULTS

Fluorescence emission and excitation spectra exhibited similar spectral shapes for the all drugs, indicating that mainly PpIX was formed. Low concentrations (0.2% and 2%) of MAL induced considerably less PpIX in normal human skin than similar concentrations of ALA and HAL. A high concentration (20%) of ALA gave higher PpIX fluorescence in normal human skin than was found for MAL and HAL.

CONCLUSIONS

The concentrations inducing half of the maximal PpIX fluorescence are around 2% for ALA, 8% for MAL and 1% for HAL.

Topical bioadhesive patch systems enhance selectivity of protoporphyrin IX accumulation

In clinical 5-aminolevulinic acid (ALA)-based photodynamic therapy (PDT) of skin tumors it is desirable to develop vehicles that minimize the penetration of ALA through normal stratum corneum and maximize it through the compromised stratum corneum of the tumors to improve tumor selectivity. We have designed a bioadhesive patch, which may be able to achieve this aim. It induces levels of protoporphyrin IX (PpIX) in skin overlying tumors similar to those induced by the proprietary cream (Porphin) but at the same time induces less PpIX to form in normal skin and at distant sites. The mechanisms of action of the patch, as compared with that of the cream, were studied by means of Cuprophan barriers that mimic compromised tumor stratum corneum and in a mouse model with transplanted tumors.

In vitro phototoxicity of 5-aminolevulinic acid and its methyl ester and the influence of barrier properties on their release from a bioadhesive patch

Topical administration of excess exogenous 5-aminolevulinic acid (ALA) leads to selective accumulation of the potent photosensitiser protoporphyrin IX (PpIX) in neoplastic cells, which can then be destroyed by irradiation with visible light. Due to its hydrophilicity, ALA penetrates deep lesions, such as nodular basal cell carcinomas (BCCs) poorly. As a result, more lipophilic esters of ALA have been employed to improve tissue penetration. In this study, the in vitro release of ALA and M-ALA from proprietary creams and novel patch-based systems across normal stratum corneum and a model membrane designed to mimic the abnormal stratum corneum overlying neoplastic skin lesions were investigated. Receiver compartment drug concentrations were compared with the concentrations of each drug producing high levels of PpIX production and subsequent light-induced kill in a model neoplastic cell line (LOX). LOX cells were found to be quite resistant to ALA- and M-ALA-induced phototoxicity. However, drug concentrations achieved in receiver compartments were comparable to those required to induce high levels of cell death upon irradiation in cell lines reported in the literature. Patches released significantly less drug across normal stratum corneum and significantly more across the model membrane. This is of major significance since the selectivity of PDT for neoplastic lesions will be further enhanced by the delivery system. ALA/M-ALA will only be delivered in significant amounts to the abnormal tissue. PpIX will only then accumulate in the neoplastic cells and the normal surrounding tissue will be unharmed upon irradiation.

Influence of formulation factors on methyl-ALA-induced protoporphyrin IX accumulation in vivo

Photodynamic therapy (PDT) is a medical treatment by which a combination of a photosensitising drug and visible light cause the destruction of selected cells. Thick lesions, such as nodular basal cell carcinomas (BCCs), or lesions with overlying keratinous debris, are reported as being difficult to eradicate using 5-aminolevulinic acid-based photodynamic therapy (ALA-PDT). Such treatment failures have been attributed to the shallow penetration of water-soluble drugs like ALA. In addition, the current scarcity of sophisticated drug delivery research centered on PDT applications has meant that accurate comparison of similar clinical studies is difficult. This paper investigates, for the first time, novel drug delivery systems for controlled drug delivery of methyl-ALA (M-ALA). Pressure sensitive adhesive (PSA) and bioadhesive patches containing defined M-ALA loadings and a standard cream containing equivalent amounts of drug were applied to the skin of mice for defined periods of time and the fluorescence of the protoporphyrin IX (PpIX) induced measured over 24h. Of major importance, the PSA patches containing low drug loadings induced high PpIX levels, which were limited to the site of application, after only 1h applications. Such systems have the potential to improve selectivity of PpIX accumulation, increase simplicity of treatment and, due to the low drug loadings required, reduce costs of clinical PDT. PSA patches would be most suitable for application to areas of dry skin, while bioadhesive patches would be suitable for moist areas, such as the mouth or lower female reproductive tract and have been shown here to induce significant PpIX production at the site of application after 4h applications of patches containing high drug loadings.

Fluorescence Detection of Pleural Malignancies Using 5-Aminolaevulinic Acid

STUDY OBJECTIVE

Although the use of video-assisted thoracoscopy has improved the diagnostic accuracy in patients presenting with pleural diseases, not all biopsies performed are conclusive and staging of the disease is not always optimal. Fluorescence diagnosis (FD) with 5-aminolaevulinic acid (5-ALA) has been used in the diagnostic workup for various malignancies. The impact of 5-ALA-mediated FD on diagnosis and staging during video-assisted thoracoscopy was examined.

DESIGN

Prospective, single-center study.

SETTING

National cancer center.

PATIENTS

Twenty-six patients with nonconclusive pleural effusions who were scheduled for video-assisted thoracoscopy.

INTERVENTION

Eligible patients were administered 1,500 to 2,500 mg po of 5-ALA before video-assisted thoracoscopy. After conventional inspection with white light, fluorescence inspection of the pleural cavity was performed (D-LIGHT Auto Fluorescent System; Karl Storz; Tuttlingen, Germany). Biopsy specimens of both normal and abnormal sites, as determined from white light and FD inspection, were obtained for histologic examination.

RESULTS

One patient was ineligible, and two patients were not evaluable because of equipment failure. One postoperative death occurred due to preexisting myocardial disease. In another patient, an empyema developed; in another patient, a postoperative infection of the lung developed. Other toxicities were minimal. A definitive diagnosis was obtained in 24 of 25 cases, with malignant mesothelioma in 15 cases, other malignancies in 5 cases, one infection, and three benign diseases. Upstaging occurred in four patients (unsuspected tumor deposits) due to FD examination. In 23 patients, a total of 111 biopsy specimens could be analyzed. When correct findings of white light and FD were compared, FD had an additional value in 21 of 111 biopsies, compared to white light with 16 of 111 biopsies.

CONCLUSIONS

FD using 5-ALA in the pleural cavity is feasible with limited side effects when used in addition to white light inspection. It improved visualization of abnormal lesions and led to upstaging in 4 of 15 mesothelioma patients.

Distribution of 5-aminolevulinic acid derivatives and induced porphyrin kinetics in mice tissues

PURPOSE

Porphyrins synthesised from 5-aminolevulinic acid (ALA) have been successfully used for the photodiagnosis and photodynamic treatment of cancer. To find a more efficient pro-photosensitiser, we synthesised two ALA esters: R,S-ALA-2-(hydroxymethyl)tetrahydropyranyl ester (THP-ALA) and ALA-Undecanoyl ester (Und-ALA).

METHODS

In mice bearing a subcutaneous mammary adenocarcinoma, we studied the distribution of the porphyrins formed from these esters in tissues after systemic administration, to establish if these esters are retained in any specific tissue, which could potentially be targeted for photodynamic treatment with ALA derivatives. We also investigated the topical use of these esters.

RESULTS

After systemic administration, tumour and skin overlying tumour porphyrin levels were lower from the ALA esters than from ALA. Other tissues such as liver, colon, kidney, skin and spleen also accumulated less porphyrins from the esters, showing that there is no specific retention of the esters in these tissues. However, the brain was the only organ that synthesised more porphyrins from THP-ALA than from ALA. The kinetics of porphyrin synthesis from ALA esters is comparable to those from ALA in almost all tissues, showing that esterases activities are not limiting the availability of the hydrolysed ALA. Both THP-ALA and Und-ALA, applied topically on the skin over the tumour, exhibited higher selectivity than ALA for the site of application, whereas the amount of tumour porphyrin was the same from ALA and THP-ALA but lower from Und-ALA.

CONCLUSIONS

THP-ALA may be useful for the treatment of brain tumours after systemic administration, whereas THP-ALA and Und-ALA may be used more suitable for the treatment of superficial tumours due to their higher selectivity.

Porphyrin Formation in Actinic Keratosis and Basal Cell Carcinoma after Topical Application of Methyl 5-Aminolevulinate

Photodynamic therapy using topical methyl 5-aminolevulinate (MAL) is a new treatment modality for basal cell carcinoma (BCC) and actinic keratosis (AK). MAL induces endogenous porphyrins, which act as photosensitizers. Pharmacokinetic studies of the porphyrin-inducing effect of MAL creams (Metvix) applied in different concentrations (16-160 mg/g) and application times are presented. Surface fluorescence measurements were used to monitor porphyrin accumulation in 18 superficial BCCs and 32 AKs. For both lesion types, the fluorescence increased during the first 13 of 28 hours of continuous MAL application. A 20-fold site-to-site variation was observed, and there were no significant MAL concentration dependencies. The selectivity between lesions and normal skin was 10-fold during the first hours and decreased throughout the application time. Fluorescence microscopy images of tissue sections from 32 nodular BCCs were analyzed to calculate the porphyrin content in tumor tissue as a function of depth. Significant correlation to MAL concentration was seen within the tumors treated for 3 hours. Increase to 18-hour MAL application enhanced the fluorescence levels in superficial tumor layers, but not in deep layers. In conclusion, application of the 160 mg/g cream for 3 hours gave advantageous porphyrin distributions for all types of lesions.

Design and evaluation of a water-soluble bioadhesive patch formulation for cutaneous delivery of 5-aminolevulinic acid to superficial neoplastic lesions

Photodynamic therapy of superficial neoplastic lesions generally uses high aminolevulinic acid (ALA) loadings (20%, w/w) in emulsion-type systems under occlusion. This approach makes ALA dosing difficult and delivery to demanding areas, such as the vulval, perineal and perianal skin, are seldom possible. This work evaluated a water-soluble bioadhesive patch, loaded with ALA, which can adhere to both intact skin and mucous surfaces. ALA loading in the patch (38 mg cm(-2)) was chosen using a simple comparative procedure. Tensile measurements showed that large ALA loadings did not adversely affect adhesion to porcine skin, achieving a mean strength of 1.7 N cm(-2). Increasing the loading was, however, shown to lower break strength and enhance percentage elongation at break. Water uptake studies showed an initial, rapid weight gain followed by gradual patch dissolution over 60 min. Drug release studies demonstrated that 57% of ALA was released across an aqueous semi-permeable membrane within 6 h, compared to 42% released from a proprietary cream formulation. The patch designed in this work is suited to definable ALA delivery to diverse regions, such as the lower female reproductive tract and lesions on exposed skin. Adhesion is sufficiently tenacious to allow photodynamic therapy (PDT), without the need to immobilise patients for up to 6 h, as was common with the cream-under-occlusion approach.

Skin permeation and stability studies of 5-aminolevulinic acid in a new gel and patch preparation

A new cubic gel as well as a patch system containing additional carrageenan as matrix were used as vehicles for 5-aminolevulinic acid (5-ALA). Standard diffusion experiments of 5-ALA using Franz-type diffusion cells and porcine skin were performed. Drug stability was monitored by analysing the 5-ALA content in the formulations. The analysis of 5-ALA as non-fluorescent probe was performed after chemical reaction leading to a fluorescent derivative. The 5-ALA permeation through porcine skin after 48 h was the highest from the patch formulation with 80.3% and the second highest from the cubic gel with 66.4%, however only about 40% of 5-ALA were chemical stable after 14 days storage in the patch formulation, whereas no degradation of 5-ALA was measured in the cubic gel over 90 days of observation.

The influence of light and darkness on cutaneous fluorescence in mice

The present work was carried out to investigate the role of light and darkness on the endogenous biosynthesis of porphyrins in mammalian skin (hairless BALB/c mouse) in vivo. In the skin of mice that were constantly kept in darkness (DD), increased endogenous porphyrin fluorescence was observed, which mainly originated from protoporphyrin IX (PpIX). No significant increase in the porphyrin levels was observed in mice that were kept under a normal day-night cycle (LD 12:12 h). The presence of cutaneous PpIX together with ambient light may comprise a photosensitizing mechanism by which PpIX may be a photomessenger between ambient light and internal rhythms.

5-Aminolevulinic Acid Derivatives in Photomedicine: Characteristics, Application and Perspectives

The introduction of lipophilic derivatives of the naturally occurring heme precursor 5-aminolevulinic acid (5-ALA) into photomedicine has led to a true revival of this research area. 5-ALA-mediated photodynamic therapy (PDT) and fluorescence photodetection (FD) of neoplastic disease is probably one of the most selective cancer treatments currently known in oncology. To date, this method has been assessed experimentally for the treatment of various medical indications. However, the limited local bioavailability of 5-ALA has widely prevented its use in daily clinical practice. Although researchers were already aware of this drawback early during the development of 5-ALA-mediated PDT, only recently have well-established concepts in pharmaceutical science been adapted to investigate ways to overcome this drawback. Recently, two derivatives of 5-ALA, methylaminolevulinate (MAL) and hexylaminolevulinate (HAL), gained marketing authorization from the regulatory offices in Europe and Australia. MAL is marketed under the trade name Metvix for the treatment of actinic keratosis and difficult-to-treat basal cell carcinoma. HAL has recently been launched under the trade name Hexvix to improve the detection of superficial bladder cancer in Europe. This review will first present the fundamental concepts underlying the use of 5-ALA derivatives in PDT and FD from a chemical, biochemical and pharmaceutical point of view. Experimental evidences from preclinical data on the improvements and limits observed with 5-ALA derivatives will then be introduced. The state-of-the-art from clinical studies with 5-ALA esters will be discussed, with special emphasis placed on the process that led to the development of MAL in dermatology and to HAL in urology. Finally, we will discuss promising medical fields in which use of 5-ALA derivatives might potentially lead to further use of this methodology in photomedicine.

Lipid cubic phases for improved topical drug delivery in photodynamic therapy

We have evaluated the efficacy of lipid cubic phases, highly ordered self-assembly systems on the nanometer level, as drug delivery vehicles for in vivo topical administration of delta-aminolevulinic acid (ALA) and its methyl ester (m-ALA) on nude mice skin. ALA, a precursor of heme, induces the production of the photosensitizer protoporphyrin IX (PpIX) in living tissue. Measuring the PpIX fluorescence at the skin surface, after topical administration, makes indirect quantification of the penetration of ALA into the tissue possible. Cubic phases were formed of lipid (monoolein or phytantriol), water and drug. In some cases, propylene glycol was included in the cubic phase as well. The drug concentration was 3% (w/w, based on the total sample weight) in all investigated vehicles. When the formulations were applied for 1 h, the monoolein cubic systems and the three-component phytantriol sample showed higher fluorescence compared to the standard ointment during the 10 h of measurement. Both ALA and m-ALA yielded similar results, although the differences between the investigated vehicles were more pronounced when using m-ALA. For the 24-h applications, the monoolein cubic systems with m-ALA showed faster PpIX formation than the standard ointment, implying higher PpIX levels at short application times (less than 4 h). The systemic PpIX fluorescence of ALA was elevated by using the lipid cubic formulations. Notably, a small systemic effect was also observed for the monoolein cubic sample with m-ALA. These results imply improved PpIX formation when using the lipid cubic systems, most probably due to enhanced drug penetration.

Bispectral fluorescence imaging combined with texture analysis and linear discrimination for correlation with histopathologic extent of basal cell carcinoma

Fluorescence imaging has been shown to be a potential complement to visual inspection for demarcation of basal cell carcinoma (BCC), which is the most common type of skin cancer. Earlier studies have shown promising results when combining autofluorescence with protoporphyrin IX (Pp IX) fluorescence, induced by application of delta-5-aminolaevulinic acid (ALA). In this work, we have tried to further improve the ability of this technique to discriminate between areas of tumor and normal skin by implementing texture analysis and Fisher linear discrimination (FLD) on bispectral fluorescence data of BCCs located on the face. Classification maps of the lesions have been obtained from histopathologic mapping of the excised tumors. The contrast feature obtained from co-occurrence matrices was found to provide useful information, particularly for the ALA-induced Pp IX fluorescence data. Moreover, the neighborhood average features of both autofluorescence and Pp IX fluorescence were preferentially included in the analysis. The algorithm was trained by using a training set of images with good agreement with histopathology, which improved the discriminability of the validation set. In addition, cross validation of the training set showed good discriminability. Our results imply that FLD and texture analysis are preferential for correlation between bispectral fluorescence images and the histopathologic extension of the tumors.

Spectroscopic study of ALA-induced endogenous porphyrins in arthritic knee tissues: targeting rheumatoid arthritis PDT

The inflamed synovium of rheumatoid arthritis exhibits many features typical for neoplastic tissue implying that the photodynamic therapy might be an efficient modality for chronic poliarthritis. The accumulation of endogenously produced porphyrins after administration of exogenous 5-aminolevulinic acid (ALA) in a rabbit model of rheumatoid arthritis was evaluated by fluorescence spectroscopy. Independent of the way, intravenously or intra-articularly, in which ALA was administered to the experimental animals, the highest fluorescence intensity of endogenously produced porphyrins was detected in the tissues of the inflamed joints. Besides, the application of ALA had a systemic sensitising effect on the whole organism of rabbits. The highest amount of endogenously produced porphyrins in the inflamed joints measured from the surface of the skin above the synovium tissues was detected 1-3 h after the administration of ALA. Fluorescence measurements performed on the tissue specimens ex vivo showed the predominant accumulation of porphyrins in the synovium of the inflamed joints. The fluorescence of porphyrins was also observed in the cartilage tissues taken from knee joints. However, the fluorescence spectra features indicated that the composition of porphyrins detected in the cartilage tissues was different than that in the synovial tissues. The selective accumulation of porphyrins in the inflamed synovial tissues stands up for the application of photodynamic therapy in the treatment of rheumatoid arthritis and implies the possibility to use optical non-invasive methods based on fluorescence detection of endogenously produced porphyrins for diagnostics of inflamed tissues.