Ischaemia-reperfusion injury in photodynamic therapy-treated mouse tumours

Photodynamic treatment for multidrug-resistant Gram-negative bacteria: Perspectives for the treatment of Klebsiella pneumoniae infections

The emergence of multi-drug resistance for pathogenic bacteria is one of the most pressing global threats to human health in the 21st century. Hence, the availability of new treatment becomes indispensable to prevent morbidity and mortality caused by infectious agents. This article reviews the antimicrobial properties of photodynamic therapy (PDT), which is based on the use of photosensitizers compounds (PSs). The PSs are non-toxic small molecules, which induce oxidative stress only under excitation with light. Then, the PDT has the advantage to be locally activated using phototherapy devices. We focus on PDT for the Klebsiella pneumoniae, as an example of Gram-negative bacteria, due to its relevance as an agent of health-associated infections (HAI) and a multi-drug resistant bacteria. K. pneumoniae is a fermentative bacillus, member of the Enterobacteriaceae family, which is most commonly associated with producing infection of the urinary tract (UTI) and pneumonia. K. pneumoniae infections may occur in deep organs such as bladder or lungs tissues; therefore, activating light must get access or penetrate tissues with sufficient power to produce effective PDT. Consequently, the rationale for selecting the most appropriate PSs, as well as photodynamic devices and photon fluence doses, were reviewed. Also, the mechanisms by which PDT activates the immune system and its importance to eradicate the infection successfully, are discussed.

Animal models for photodynamic therapy (PDT)

Photodynamic therapy (PDT) combines visible light and photosensitizing dyes. Different animal models have been used to test PDT for cancer, infectious disease and cardiovascular disease. Mouse models of tumours include subcutaneous, orthotopic, syngeneic, xenograft, autochthonous and genetically modified.

Photodynamic therapy (PDT) employs non-toxic dyes called photosensitizers (PSs), which absorb visible light to give the excited singlet state, followed by the long-lived triplet state that can undergo photochemistry. In the presence of ambient oxygen, reactive oxygen species (ROS), such as singlet oxygen and hydroxyl radicals are formed that are able to kill cancer cells, inactivate microbial pathogens and destroy unwanted tissue. Although there are already several clinically approved PSs for various disease indications, many studies around the world are using animal models to investigate the further utility of PDT. The present review will cover the main groups of animal models that have been described in the literature. Cancer comprises the single biggest group of models including syngeneic mouse/rat tumours that can either be subcutaneous or orthotopic and allow the study of anti-tumour immune response; human tumours that need to be implanted in immunosuppressed hosts; carcinogen-induced tumours; and mice that have been genetically engineered to develop cancer (often by pathways similar to those in patients). Infections are the second biggest class of animal models and the anatomical sites include wounds, burns, oral cavity, ears, eyes, nose etc. Responsible pathogens can include Gram-positive and Gram-negative bacteria, fungi, viruses and parasites. A smaller and diverse group of miscellaneous animal models have been reported that allow PDT to be tested in ophthalmology, atherosclerosis, atrial fibrillation, dermatology and wound healing. Successful studies using animal models of PDT are blazing the trail for tomorrow's clinical approvals.

Increasing the efficiency of photodynamic therapy by improved light delivery and oxygen supply using an anticoagulant in a solid tumor model

BACKGROUND AND OBJECTIVE

The main factors in photodynamic therapy (PDT) are: photosensitizer retention, photon absorption, and oxygen supply. Each factor has its unique set of problems that poses limitation to the treatment. Both light delivery and oxygen supply are significant bottlenecks in PDT. Vascular closure during PDT reduces oxygen supply to the targeted tissue. On the other hand, with the changes in blood perfusion, the tissue optical properties change, and result in variation in irradiation light transmission. For these reasons, it becomes very important to avoid blood coagulation and vascular closure during PDT.

STUDY DESIGN/MATERIALS AND METHODS

The efficiency of PDT combined with the anticoagulant heparin was studied in a BALB/c mouse model with subcutaneous EMT6 mammary carcinomas. Mice were randomized into three groups: control, PDT-only, and PDT with heparin. The photosensitizer Photofrin was used in our experiments. Light transmission, blood perfusion, and local production of reactive oxygen species (ROS) were monitored during the treatment. The corresponding histological examinations were performed to determine the thrombosis immediately after irradiation and to evaluate tumor necrosis 48 hours after the treatment.

RESULTS

The results clearly demonstrated that PDT combined with pre-administered heparin can significantly reduce thrombosis during light irradiation. The blood perfusion, oxygen supply, and light delivery are all improved. Improved tumor responses in the combined therapy, as shown with the histological examination and tumor growth assay, are clearly demonstrated and related to an increased local ROS production.

CONCLUSION

Transitory anticoagulation treatment significantly enhances the antitumor effect of PDT. It is mainly due to the improvement of the light delivery and oxygen supply in tumor, and ultimately the amount of ROS produced during PDT.

Active oxygen intermediates in the degradation of hematoporphyrin derivative in tumor cells subjected to photodynamic therapy

Hematoporphyrin derivative (HPD), a sensitizer used in photodynamic therapy (PDT) of malignancies, is progressively destroyed during the treatment. Prior studies suggested that upon PDT the photobleaching of HPD in tumor tissues is largely mediated by self-sensitized singlet oxygen. However, little is known about the role of other reactive oxygen species (ROS). The main aim of this work was to clarify the significance of H2O2, superoxide (O2.(-)) and hydroxyl (OH.) radicals in bleaching of HPD in tumor cells subjected to PDT. Experiments were performed on Ehrlich ascites carcinoma (EAC) cells, which were loaded with HPD in PBS and then irradiated with red light at 630 nm in the same buffer. Studies showed that photosensitization of EAC cells by HPD led to the formation of significant amounts of H2O2, O2.(-) and OH., and that these ROS could be involved in the photobleaching of HPD during PDT. In fact, we found that addition of catalase (CAT, a scavenger H2O2), Cu/Zn-superoxide dismutase (Cu/Zn-SOD) and Tiron (scavengers of O2.(-)), Na-benzoate, mannitol and deferoxamine (scavengers of OH.) caused a substantial decrease in the rate of HPD photobleaching in EAC cells. In these cells, the inhibitory effects of Na-benzoate, mannitol and deferoxamine on the photodegradation of HPD correlated well with suppression of the OH. generation, a highly active oxidizer. In EAC cells, the glutathione redox cycle and CAT (scavengers of H2O2) as well as Cu/Zn-SOD was found to suppress the photoinduced degradation of HPD. It was also established that HPD can directly scavenge H2O2 and oxygen free radicals; in a phosphate buffer its second-order rate constants were measured as 5.51+/-0.32 x 10(3)M(-1)s(-1) (for the reaction with O2.(-)), 5.08+/-0.31 x 10(4)M(-1)s(-1) (for H2O2), and 3.44+/-0.08 x 10(10)M(-1)s(-1) (for OH.). Thus, our data suggest that OH. could be one of the main oxidants mediating the photobleaching behavior of HPD in malignancies. Studies showed that photoexcited moieties of HPD can oxidize cell proteins with the formation of protein peroxides (PPO), which currently are regarded as a new form of ROS. Model experiments suggest that PPO could also participate in bleaching of HPD in tumors treated with PDT. It was found that HPD may destroy in tumor cells after cessation of photoirradiation and that this event is largely mediated by the presence of H2O2, a precursor of OH(.).

The role of oxygen monitoring during photodynamic therapy and its potential for treatment dosimetry

Understanding of the biology of photodynamic therapy (PDT) has expanded tremendously over the past few years. However, in the clinical situation, it is still a challenge to match the extent of PDT effects to the extent of the disease process being treated. PDT requires drug, light and oxygen, any of which can be the limiting factor in determining efficacy at each point in a target organ. This article reviews techniques available for monitoring tissue oxygenation during PDT. Point measurements can be made using oxygen electrodes or luminescence-based optodes for direct measurements of tissue pO2, or using optical spectroscopy for measuring the oxygen saturation of haemoglobin. Imaging is considerably more complex, but may become feasible with techniques like BOLD MRI. Pre-clinical studies have shown dramatic changes in oxygenation during PDT, which vary with the photosensitizer used and the light delivery regimen. Better oxygenation throughout treatment is achieved if the light fluence rate is kept low as this reduces the rate of oxygen consumption. The relationship between tissue oxygenation and PDT effect is complex and remarkably few studies have directly correlated oxygenation changes during PDT with the final biological effect, although those that have confirm the value of maintaining good oxygenation. Real time monitoring to ensure adequate oxygenation at strategic points in target tissues during PDT is likely to be important, particularly in the image guided treatment of tumours of solid organs.

PDT-associated host response and its role in the therapy outcome

BACKGROUND AND OBJECTIVES

The outcome of the treatment of solid tumors by photodynamic therapy (PDT) is critically dependent on the contribution from the host. This host response is provoked by the rapidly induced massive tumor tissue injury delivered by PDT that is experienced as a local trauma threatening the integrity and homeostasis at the affected site.

STUDY DESIGN/MATERIALS AND METHODS

Mouse tumor models were extensively employed in pre-clinical studies investigating various aspects of host-tumor interaction following PDT, but important input was also derived from clinical data.

RESULTS

The recognition of this PDT-inflicted insult by innate immune sensors detecting danger signals from the distressed/altered tumor tissue, triggers host-protecting responses dominantly manifested as acute inflammation that are elicited and orchestrated by the innate immune system. To secure the affected PDT-targeted site, the inflammatory reaction attacks tumor vasculature and then neutralizes the focal source of danger signals by eliminating the injured tumor cells.

CONCLUSION

The provoked highly intensified phagocytosis of dead tumor cells occurring in the context of a vigorous innate immune reaction emerges as a key factor responsible for the development of tumor antigen-specific adaptive immune response that contributes to the eradication of PDT-treated cancers.

Evidence for a bystander role of neutrophils in the response to systemic 5-aminolevulinic acid-based photodynamic therapy

BACKGROUND/PURPOSE

A significant increase in the number of circulating and tumour neutrophils immediately after therapy was observed while investigating the increase in response of tissues to aminolevulinic acid-based photodynamic therapy (ALA-PDT) using a twofold illumination scheme with a prolonged dark interval. The action of (tumour) neutrophils is an important therapeutic adjunct to the deposition of singlet oxygen within the treatment volume, for many photosensitizers. It is not known if those phagocytes contribute to the improved outcome of ALA-PDT. In this study we investigated the role of neutrophils in the response to PDT using systemic ALA with and without light fractionation.

METHODS

Rhabdomyosarcoma, transplanted in the thigh of female WAG/Rij rats were illuminated transdermally using 633 nm light following i.v. administration of 200 mg/kg ALA. The pharmacokinetics of protoporphyrin IX (PpIX) within the tumour tissue during therapy were determined to compare with that observed in other models for topical administration of ALA. PDT was performed under immunologically normal or neutropenic conditions using various illumination schemes. The number of neutrophils in tumour and in the circulation were determined as a function of time after treatment and compared with growth delay of each scheme.

RESULTS

Fluorescence spectroscopy revealed similar pharmacokinetics of PpIX to those observed during and after topical ALA-PDT. The number of neutrophils within the illuminated tumour and in the circulation increased significantly following therapy. This increase in the number of neutrophils was associated with an increase in the efficacy of therapy: the more effective the therapy the greater the increase in tumour and blood neutrophils. Administration of anti-granulocyte serum treatment prevented the influx of neutrophils after ALA-PDT, but did not lead to a significant decrease in the efficacy of the PDT treatment on the growth of the tumour for any illumination scheme investigated.

CONCLUSION

These results indicate that the magnitude of damage inflicted on the tumour by ALA-PDT does not depend on the presence of neutrophils in the tumour or circulation and that the role of neutrophils in ALA-PDT is much less important than in PDT using other photosensitizers. These data contribute to the understanding of the mechanism of response of tissue to systemic ALA-PDT.

Changes in vascularity and blood volume as a result of photodynamic therapy can be assessed with power Doppler ultrasonography

BACKGROUND AND OBJECTIVES

One principal mechanism of photodynamic therapy (PDT) in tumors is destruction of tumor-associated vasculature. In the present study, the vascular effects of PDT in tumors were investigated with power Doppler ultrasonography.

MATERIALS AND METHODS

Seven cutaneous squamous cell carcinomas in cats were treated. Tumors were examined via power Doppler ultrasonography before, 5 minutes, 1 hour, and 24 hours after PDT. Images were digitized for computer-aided assessment of vascularity and blood volume.

RESULTS

Mean baseline tumor vascularity and blood volume were moderate. During PDT, a significant decrease in vascularity and blood volume was noted. Lowest values were found 24 hours after PDT.

CONCLUSIONS

Power Doppler ultrasonography represents a non-invasive modality to successfully monitor the vascular effects and thus, treatment efficacy, of PDT.

5-aminolaevulinic acid photodynamic therapy in a transgenic mouse model of skin melanoma

Photodynamic therapy (PDT) is widely used to treat preneoplastic skin lesions and non-melanoma skin tumours. Studies analyzing the effects of PDT on malignant melanoma have yielded conflicting results. On the one hand, melanoma cell lines in culture as well as cell lines transplanted into experimental animals were sensitive to PDT. On the other hand, spontaneous melanomas of human patients responded poorly to most PDT regimens tested so far. Here, we analyzed effects of 5-aminolaevulinic acid (5-ALA)-based PDT on melanoma cell lines and on experimental melanomas. To mimic the clinical situation as closely as possible, metallothionein-I/ret (MT-ret) mice, a transgenic model of skin melanoma development, were used. Optimal doses of 5-ALA as well as energy doses and power densities were determined in vitro using a cell line (Mel25) established by us from a melanoma of an MT-ret transgenic mouse as well as commercially available human and mouse melanoma cell lines. Treatment with light irradiation alone had no effect. In combination with 5-ALA, however, this illumination readily induced the death of all mouse and human melanoma cell lines examined. Still, 5-ALA PDT caused only minor focal regressive changes including haemorrhages and fibrosis of MT-ret melanomas in vivo and did not significantly delay tumour growth. These results show that, even though MT-ret melanoma cells are vulnerable to 5-ALA PDT in vitro, malignant MT-ret melanomas in vivo are quite resistant to this type of therapy at doses which are highly effective in vitro.

Correlation of real-time haemoglobin oxygen saturation monitoring during photodynamic therapy with microvascular effects and tissue necrosis in normal rat liver

Photodynamic therapy (PDT) requires a photosensitising drug, light and oxygen. While it is known that the haemoglobin oxygen saturation (HbSat) can be altered by PDT, little has been done to correlate this with microvascular changes and the final biological effect. This report describes such studies on the normal liver of rats sensitised with aluminium disulphonated phthalocyanine. In total, 50 J of light at 670 nm, continuous or fractionated at 25 or 100 mW, was applied with a single laser fibre touching the liver surface. HbSat was monitored continuously 1.5-5.0 mm from the laser fibre using visible light reflectance spectroscopy (VLRS). Vascular shutdown was assessed by fluorescein angiography 2-40 min after light delivery. Necrosis was measured at post mortem 3 days after PDT. In all treatment groups at a 1.5 mm separation, HbSat fell to zero with little recovery after light delivery. At 2.5 mm, HbSat also decreased during light delivery, except with fractionated light, but then recovered. The greatest recovery of fluorescein perfusion after PDT was seen using 25 mW, suggesting an ischaemia/reperfusion injury. Necrosis was more extensive after low power and fractionated light than with 100 mW, continuous illumination. We conclude that VLRS is a useful technique for monitoring HbSat, although the correlation between HbSat, fluorescein exclusion and necrosis varied markedly with the light delivery regimen used.

A novel technique for light delivery through branched or bent anatomic structures

OBJECTIVE

Photodynamic therapy is an effective cancer treatment, but light delivery constraints currently limit its application to superficial, easily visualized tumors. The goal of this study was to determine whether it would be possible to manipulate the optical properties of irregularly shaped anatomic structures for the purpose of light delivery. Such a technique could potentially expand the role of photodynamic therapy to treat tumors currently viewed as inaccessible to visible light.

METHODS

Ex vivo sheep tracheas and lungs were filled with substances of varying refractive indices. The effects on transmission of visible light of a known wavelength introduced into the proximal lumen of the organs were studied. Data were collected with naked-eye observation, standard photography, charge-coupled device imaging, and direct light measurement.

RESULTS

Filling a lung or trachea with a liquid possessing a refractive index higher than that of tissue dramatically increases the ability to deliver light around bends and through a branched network.

CONCLUSION

It is possible to manipulate the optical properties of an ex vivo organ for the purpose of enhanced light delivery.

Activation of Poly(adenosine diphosphate–ribose) Polymerase in Mouse Tumors Treated by Photodynamic Therapy¶

Poly(adenosine diphosphate-ribose) polymerase (PARP) has recently been characterized as a key regulator of cell death-survival transcriptional programs associated with stress and inflammation. Possible participation of this enzyme in the response of tumors to photodynamic therapy (PDT) was investigated in this study. Immunohistochemical analysis of mouse FsaR tumors treated by PDT based on photosensitizers Photofrin or 5,10,15,20-tetra-(m-hydroxyphenyl)chlorine (mTHPC) revealed a strong positive staining for PARP product poly(ADP-ribose) at 30 min and 1 h after PDT, respectively, and even more intense positivity at 2 h after PDT with both photosensitizers. Flow cytometry-based examination showed the induction of poly-ADP-ribosylation in FsaR tumors at 30 min after PDT, with a trend for a further increase in the intensity by 2 h after PDT in both cancer cells and tumor-associated leukocytes. In FsaR cells treated in vitro by mTHPC-based PDT, flow cytometric analysis indicated that the activation of PARP concentrated in cells undergoing apoptosis and reached a maximum by 30 min after PDT. The administration of PARP inhibitors, 3-aminobenzamide or 1,5-isoquinolinediol, to FsaR tumor-bearing mice before PDT light treatment increased the resistance of these tumors to PDT. PARP appears to control the balance between apoptotic and necrotic cell death in PDT-treated tumors and regulate the progression of PDT-induced inflammatory or innate immune response.