Measurements of oxygen in vivo: overview and perspectives on methods to measure oxygen within cells and tissues

A New Methodology for the Oxygen Measurement in Lung Tissue of an Aged Ferret Model Proves Hypoxia during COVID-19

Oxygen as a key element has a high impact on cellular processes. Infection with a pathogen such as SARS-CoV-2 and after inflammation may lead to hypoxic conditions in tissue that impact cellular responses. To develop optimized translational in vitro models for a better understanding of physiologic and pathophysiologic oxygen conditions, it is a prerequisite to determine oxygen concentrations generated in vivo. Our study objective was the establishment of an invasive method for oxygen measurements using a luminescence-based microsensor to determine the dissolved oxygen in the lung tissue of ferrets as animal models for SARS-CoV-2 research. By way of analogy to humans, aged ferrets are more likely to show clinical signs after SARS-CoV-2 infection than are young animals. To investigate oxygen concentrations during a respiratory viral infection, we intratracheally infected nine aged (3-yr-old) ferrets with SARS-CoV-2. The aged SARS-CoV-2-infected ferrets showed mild to moderate clinical signs associated with prolonged viral RNA shedding until 14 days postinfection. SARS-CoV-2-infected ferrets showed histopathologic lung lesion scores that significantly negatively correlated with oxygen concentrations in lung tissue. At 4 days postinfection, oxygen concentrations in lung tissue were significantly lower (mean percentage O2, 3.89 ≙ ≈ 27.78 mm Hg) than in the negative control group (mean percentage O2, 8.65 ≙ ≈ 61.4 mm Hg). In summary, we succeeded in determining the pathophysiologic oxygen conditions in the lung tissue of aged SARS-CoV-2-infected ferrets.

Re-examining What the Results of "a Measurement of Oxygen Level in Tissues" Really Mean

Within this special issue, many eminent investigators report on measurements of oxygen (O2) levels in tissues. Given the complexities of spatial and temporal heterogeneities of O2 in tissues and its many sources, this commentary draws attention to what such measurements do and do not actually assess regarding O2 levels in tissues. Given this limitation, it also discusses how these results can be used most effectively. To provide a convenient mechanism to discuss these issues more fully, this analysis focuses on measurements using EPR oximetry, but these considerations apply to all other techniques. The nature of the delivery of O2 to tissues and the mechanisms by which O2 is consumed necessarily result in very different levels of O2 within the volume of each voxel of a measurement. Better spatial resolution cannot fully resolve the problem because the variations include O2 gradients within each cell. Improved resolution of the time-dependent variation in O2 is also very challenging because O2 levels within tissues can have fluctuations of O2 levels in the range of milliseconds, while most methods require longer times to acquire the data from each voxel. Based on these issues, we argue that the values obtained inevitably are complex aggregates of averages of O2 levels across space and time in the tissue. These complexities arise from the complex physiology of tissues and are compounded by the limitations of the technique and its ability to acquire data. However, one often can obtain very meaningful and useful results if these complexities and limitations are taken into account. We illustrate this, using results obtained with in vivo EPR oximetry, especially utilizing its capacity to make repeated measurements to follow changes in O2 levels that occur with interventions and/or over time.

Ratiometric Oxygen Sensing with H-NOX Protein Conjugates

Ratiometric sensors are self-referencing constructs that are functional in cells and tissues, and the read-out is independent of sensor concentration. One strategy for ratiometric sensing is to utilize two-color emission, where one component possesses analyte-dependent emission and the other is independent of analyte concentration, serving as an internal standard. In this way, the intensity ratio of the two components is a quantitative measure of the analyte. In this study, protein-based ratiometric oxygen sensors are prepared using the heme nitric oxide/oxygen-binding protein (H-NOX) from the thermophilic bacterium Caldanaerobacter subterraneus. The native heme cofactor is replaced with a Pd(II) or Pt(II) porphyrin as the oxygen-responsive phosphor. Mutagenesis is performed to incorporate a cysteine residue on the protein surface for thiol/maleimide coupling of the oxygen-insensitive dye, which serves as a Förster resonance energy transfer (FRET) donor for the porphyrin. While both Pd(II)- and Pt(II)-based sensors are responsive over biologically relevant ranges, the Pd sensor exhibits greater sensitivity at lower oxygen concentrations. Together, these sensors represent a new class of protein-based ratiometric oxygen sensors, and the modular platform allows the oxygen sensitivity to be tailored for a specific application. This proof-of-principle study has identified the key considerations and optimal methodologies to develop and subsequently refine protein-based ratiometric oxygen sensors.

3D computational model of oxygen depletion kinetics in brain vasculature during FLASH RT, and its implications for in vivo oximetry experiments

PURPOSE

Ultra-high dose rate irradiation, also known as FLASH, has been shown to improve the therapeutic ratio of radiation therapy (RT). The mechanism behind this effect has been partially explained by the radiochemical oxygen depletion (ROD) hypothesis, which attributes the protection of the normal tissue to the induction of transient hypoxia by ROD. To better understand the contribution of oxygen to the FLASH effect, it is necessary to measure oxygen (O₂ ) in vivo during FLASH irradiation. This study's goal is to determine the temporal resolution required to accurately measure the rapidly changing oxygen concentration immediately after FLASH irradiation.

METHODS

We conducted a computational simulation of oxygen dynamics using a real vascular model that was constructed from a public fluorescence microscopy dataset. The dynamic distribution of oxygen tension (p_o2 ) during and after FLASH RT was modeled by a partial differential equation (PDE) considering oxygen diffusion, metabolism, and ROD. The underestimation of ROD due to oxygen recovery was evaluated assuming either complete or partial depletion, and a range of possible values for parameters such as oxygen diffusion, consumption, vascular p_o2 and vessel density.

RESULT

The O₂ concentration recovers rapidly after FLASH RT. Assuming a temporal resolution of 0.5 s, the estimated ROD is only 50.7% and 36.7% of its actual value in cases of partial and complete depletion, respectively. Additionally, the underestimation of ROD is highly dependent on the vascular density. To estimate ROD rate with 90% accuracy, temporal resolution on the order of milliseconds is required considering the uncertainty in parameters involved, especially, the diverse vascular density of the tissue.

CONCLUSION

The rapid recovery of O₂ poses a great challenge for in vivo ROD measurements during FLASH RT. Temporal resolution on the order of milliseconds is recommended for ROD measurements in the normal tissue. Further work is warranted to investigate whether the same requirements apply to tumors, given their irregular vasculature. This article is protected by copyright. All rights reserved.

In vitro assays for investigating the FLASH effect

FLASH radiotherapy is a novel technique that has been shown in numerous preclinical in vivo studies to have the potential to be the next important improvement in cancer treatment. However, the biological mechanisms responsible for the selective FLASH sparing effect of normal tissues are not yet known. An optimal translation of FLASH radiotherapy into the clinic would require a good understanding of the specific beam parameters that induces a FLASH effect, environmental conditions affecting the response, and the radiobiological mechanisms involved. Even though the FLASH effect has generally been considered as an in vivo effect, studies finding these answers would be difficult and ethically challenging to carry out solely in animals. Hence, suitable in vitro studies aimed towards finding these answers are needed. In this review, we describe and summarise several in vitro assays that have been used or could be used to finally elucidate the mechanisms behind the FLASH effect.

Detection of Hypoxia in Cancer Models: Significance, Challenges, and Advances

The rapid proliferation of cancer cells combined with deficient vessels cause regions of nutrient and O2 deprivation in solid tumors. Some cancer cells can adapt to these extreme hypoxic conditions and persist to promote cancer progression. Intratumoral hypoxia has been consistently associated with a worse patient prognosis. In vitro, 3D models of spheroids or organoids can recapitulate spontaneous O2 gradients in solid tumors. Likewise, in vivo murine models of cancer reproduce the physiological levels of hypoxia that have been measured in human tumors. Given the potential clinical importance of hypoxia in cancer progression, there is an increasing need to design methods to measure O2 concentrations. O2 levels can be directly measured with needle-type probes, both optical and electrochemical. Alternatively, indirect, noninvasive approaches have been optimized, and include immunolabeling endogenous or exogenous markers. Fluorescent, phosphorescent, and luminescent reporters have also been employed experimentally to provide dynamic measurements of O2 in live cells or tumors. In medical imaging, modalities such as MRI and PET are often the method of choice. This review provides a comparative overview of the main methods utilized to detect hypoxia in cell culture and preclinical models of cancer.

First-In-Human Study in Cancer Patients Establishing the Feasibility of Oxygen Measurements in Tumors Using Electron Paramagnetic Resonance With the OxyChip

OBJECTIVE

The overall objective of this clinical study was to validate an implantable oxygen sensor, called the 'OxyChip', as a clinically feasible technology that would allow individualized tumor-oxygen assessments in cancer patients prior to and during hypoxia-modification interventions such as hyperoxygen breathing.

METHODS

Patients with any solid tumor at ≤3-cm depth from the skin-surface scheduled to undergo surgical resection (with or without neoadjuvant therapy) were considered eligible for the study. The OxyChip was implanted in the tumor and subsequently removed during standard-of-care surgery. Partial pressure of oxygen (pO2) at the implant location was assessed using electron paramagnetic resonance (EPR) oximetry.

RESULTS

Twenty-three cancer patients underwent OxyChip implantation in their tumors. Six patients received neoadjuvant therapy while the OxyChip was implanted. Median implant duration was 30 days (range 4-128 days). Forty-five successful oxygen measurements were made in 15 patients. Baseline pO2 values were variable with overall median 15.7 mmHg (range 0.6-73.1 mmHg); 33% of the values were below 10 mmHg. After hyperoxygenation, the overall median pO2 was 31.8 mmHg (range 1.5-144.6 mmHg). In 83% of the measurements, there was a statistically significant (p ≤ 0.05) response to hyperoxygenation.

CONCLUSIONS

Measurement of baseline pO2 and response to hyperoxygenation using EPR oximetry with the OxyChip is clinically feasible in a variety of tumor types. Tumor oxygen at baseline differed significantly among patients. Although most tumors responded to a hyperoxygenation intervention, some were non-responders. These data demonstrated the need for individualized assessment of tumor oxygenation in the context of planned hyperoxygenation interventions to optimize clinical outcomes.

What Is the Meaning of an Oxygen Measurement? : Analysis of Methods Purporting to Measure Oxygen in Targeted Tissues

Clinical measurements of O2 in tissues will inevitably provide data that are at best aggregated and will not reflect the inherent heterogeneity of O2 in tissues over space and time. Additionally, the nature of all existing techniques to measure O2 results in complex sampling of the volume that is sensed by the technique. By recognizing these potential limitations of the measures, one can focus on the very important and useful information that can be obtained from these techniques, especially data about factors that can change levels of O2 and then exploit these changes diagnostically and therapeutically. The clinical utility of such data ultimately needs to be verified by careful studies of outcomes related to the measured changes in levels of O2.

Measurement of Tissue Oxygen as a Novel Approach to Optimizing Red Blood Cell Quality Assessment

The effectiveness of blood transfusions can be impacted by storage and extensive processing techniques that involve treatment of red blood cells (RBCs) with pathogen reduction technologies (e.g., UV-light and chemical treatment), ex vivo stem cell derivation/maturation methods, and bioengineering of RBCs using nanotechnology. Therefore, there is a need to have methods that assess the evaluation of the effectiveness of transfusions to achieve their intended purpose: to increase oxygenation of critical tissues. Consequently, there has been intense interest in the development of techniques targeted at optimizing the assessment of RBC quality in preclinical and clinical settings. We provide a critical assessment of the ability of currently used methods to provide unambiguous information on oxygen levels in tissues and conclude that they cannot do this. This is because they are based on surrogates for the true goal of transfusion, which is to increase oxygenation of critical organs. This does not mean that they are valueless, but it does indicate that other methods are needed to provide direct measurements of oxygen in tissues. We report here on the initial results of a method that can provide direct assessment of the impact of the transfusion on tissue oxygen: EPR oximetry. It has the potential to provide such information in both preclinical and clinical settings for the assessment of blood quality posttransfusion.

Compact electron spin resonance skin oximeter: Properties and initial clinical results

PURPOSE

Skin oxygen level is of significance for the diagnosis and treatment of many clinical problems, such as chronic wounds and diabetic foot ulcers. Furthermore, skin oxygen levels can be correlated to arterial oxygen partial pressure, thereby revealing potentially dangerous conditions such as hyperoxia (too much oxygen), which may occur in ventilated neonates. Traditionally, skin oxygen levels are measured using electrochemical methods and, more recently, also by fluorescence lifetime techniques. These approaches suffer from several drawbacks, rendering them suboptimal. The purpose of this work is to develop an electron spin resonance (ESR) -based method for monitoring oxygen partial pressure (pO₂ ) in skin tissue.

METHODS

A compact sensor for pulsed ESR is designed and constructed. Our ESR-based method makes use of a unique exogenous paramagnetic spin probe that is placed on the skin in a special partially sealed sticker, and subsequently measuring its signal with the compact pulsed ESR sensor that includes a miniature magnet and a small S-band (~2.3 GHz) microwave resonator. The inverse of the spin-spin relaxation time (1/T₂ ) measured by ESR is shown to be linearly correlated with pO₂ levels.

RESULTS

The sensor and its matching sticker were tested both in vitro and in vivo (with human subjects). Measured skin pO₂ levels reached equilibrium after ~2-3 h and were found to be comparable to those measured by continuous-wave (CW) ESR using a large electromagnet.

CONCLUSIONS

A compact pulsed ESR sensor with a matching paramagnetic sticker can be used for pO₂ monitoring of the skin tissue, similar to large bulky CW ESR systems.

How best to interpret measures of levels of oxygen in tissues to make them effective clinical tools for care of patients with cancer and other oxygen-dependent pathologies

It is well understood that the level of molecular oxygen (O2 ) in tissue is a very important factor impacting both physiology and pathological processes as well as responsiveness to some treatments. Data on O2 in tissue could be effectively utilized to enhance precision medicine. However, the nature of the data that can be obtained using existing clinically applicable techniques is often misunderstood, and this can confound the effective use of the information. Attempts to make clinical measurements of O2 in tissues will inevitably provide data that are aggregated over time and space and therefore will not fully represent the inherent heterogeneity of O2 in tissues. Additionally, the nature of existing techniques to measure O2 may result in uneven sampling of the volume of interest and therefore may not provide accurate information on the "average" O2 in the measured volume. By recognizing the potential limitations of the O2 measurements, one can focus on the important and useful information that can be obtained from these techniques. The most valuable clinical characterizations of oxygen are likely to be derived from a series of measurements that provide data about factors that can change levels of O2 , which then can be exploited both diagnostically and therapeutically. The clinical utility of such data ultimately needs to be verified by careful studies of outcomes related to the measured changes in levels of O2 .

The clinical utility of imaging methods used to measure hypoxia in cervical cancer

While it is well-established that hypoxia is a major factor that affects clinical outcomes in cervical cancer, widespread usage of clinically available methods to detect and evaluate hypoxia during the course of treatment have not been established. This review compares these methods, summarizes their strengths and weaknesses, and assesses the pathways for their useful employment to alter clinical practice. We conducted a search on PubMed for literature pertaining to imaging hypoxic cervical cancer, and implemented keywords related to oxygen measurement tools to improve the relevance of the search results.Oxygenation level-dependent applications of MRI have demonstrated hypoxia-induced radioresistance, and changes in cervix tumor oxygenation from hyperoxic therapy.The hypoxic areas within tumors can be indirectly identified in dynamic contrast-enhanced images, where they generally display low signal enhancement, and diffusion-weighted images, which demonstrates areas of restricted diffusion (which correlates with hypoxia). Positron emmision tomography, used independently and with other imaging modalities, has demonstrated utility in imaging hypoxia through tracers specific for low oxygen levels, like Cu-ATSM tracers and nitroimidazoles. Detecting hypoxia in the tumors of patients diagnosed with cervical cancer via medical imaging and non-imaging tools like electron paramagnetic resonance oximetry can be utilized clinically, such as for guiding radiation and post-treatment surveillance, for a more personalized approach to treatment. The merits of these methods warrant further investigation via comparative effectiveness research and large clinical trials into their clinical applications.

'Oxygen Level in a Tissue' - What Do Available Measurements Really Report?

The aim of the paper is to discuss what currently is feasible clinically to measure the level of oxygen and how that measurement can be clinically useful. Because oxygen in tissues is quite heterogeneous and all methods of measurement can only provide an average across heterogeneities at some spatial and temporal resolution, the values that are obtained may have limitations on their clinical utility. However, even if such limitations are significant, if one utilizes repeated measurements and focuses on changes in the measured levels, rather than 'absolute levels', it may be possible to obtain very useful clinical information. While these considerations are especially pertinent in cancer, they also pertain to most other types of pathology.

Immunity, Hypoxia, and Metabolism-the Ménage à Trois of Cancer: Implications for Immunotherapy

It is generally accepted that metabolism is able to shape the immune response. Only recently we are gaining awareness that the metabolic crosstalk between different tumor compartments strongly contributes to the harsh tumor microenvironment (TME) and ultimately impairs immune cell fitness and effector functions. The major aims of this review are to provide an overview on the immune system in cancer; to position oxygen shortage and metabolic competition as the ground of a restrictive TME and as important players in the anti-tumor immune response; to define how immunotherapies affect hypoxia/oxygen delivery and the metabolic landscape of the tumor; and vice versa, how oxygen and metabolites within the TME impinge on the success of immunotherapies. By analyzing preclinical and clinical endeavors, we will discuss how a metabolic characterization of the TME can identify novel targets and signatures that could be exploited in combination with standard immunotherapies and can help to predict the benefit of new and traditional immunotherapeutic drugs.

Measuring Flap Oxygen Using Electron Paramagnetic Resonance Oximetry

OBJECTIVES/HYPOTHESIS

To determine if electron paramagnetic resonance (EPR) oximetry is a viable technology to aid in flap monitoring.

STUDY DESIGN

Prospective cohort.

METHODS

This was a cohort study assessing accuracy and speed of EPR oximetry in detecting ischemia of a saphenous artery-based flap in a rat model, using transcutaneous oximetry as a control. Measurements were obtained under both resting and ischemic conditions for nine Sprague Dawley rats (18 flaps), for 3 postoperative days following flap elevation.

RESULTS

The mean partial pressure of oxygen prior to tourniquet application was 66.9 ± 8.9 mm Hg with EPR oximetry and 64.7 ± 5.2 mm Hg with transcutaneous oximetry (P = .45). Mean partial pressures of oxygen during tourniquet application were 8.9 ± 3.2 mm Hg and 8.5 ± 2.9 mm Hg for EPR oximetry and transcutaneous oximetry, respectively (P = .48), and 67.2 ± 6.9 mm Hg and 65.3 ± 6.1 mm Hg after tourniquet release for EPR oximetry and transcutaneous oximetry, respectively (P = .44). The mean ischemia detection time of EPR oximetry was 49 ± 21 seconds.

CONCLUSIONS

Offering timely, accurate, and noninvasive tissue oxygen measurements, EPR oximetry is a promising adjunct in flap monitoring.

LEVEL OF EVIDENCE

NA Laryngoscope, 129:E415-E419, 2019.

A radical containing injectable in-situ-oleogel and emulgel for prolonged in-vivo oxygen measurements with CW EPR

Molecular oxygen, reactive oxygen species and free radicals derived from oxygen play important roles in a broad spectrum of physiological and pathological processes. The quantitative measurement of molecular oxygen in tissues by electron paramagnetic resonance (EPR) has great potential for understanding and diagnosing a number of diseases, and for developing and guiding therapies. This requires improvements in the free radical probe systems that sense and report molecular oxygen levels in vivo. We report on the encapsulation of existing free radical probes in lipophilic gel implants: an in-situ-oleogel and an emulgel, based only on well-known, safe excipients for the incorporation of lipophilic and hydrophilic radicals, respectively. The EPR signals of encapsulated radicals were not altered compared to dissolved radicals. The high solubility of oxygen in lipophilic solvents enhanced oxygen sensitivity. The gels extended the lifetime of the radicals in tissues from tens of minutes to many days, simplifying studies with extended series of measurements. The encapsulated radicals showed a good in vivo response to changes in oxygen supply and seem to circumvent concerns from toxicity of the radical probes. These gels simplify the development of new oxygen-sensitive free radical probes for EPR oximetry by making their in vivo stability, persistence and toxicity a function of the encapsulating gel and not a set of additional requirements for the free radical probe.

The Different Routes to Metastasis via Hypoxia-Regulated Programs

Hypoxia is linked to metastasis; however, how it affects metastatic progression is not clear due to limited consensus in the literature. We posit that this lack of consensus is due to hypoxia being studied using different approaches, such as in vitro, primary tumor, or metastasis assays in an isolated manner. Here, we review the pros and cons of in vitro hypoxia assays, highlight in vivo studies that inform on physiological hypoxia, and review the evidence that primary tumor hypoxia might influence the fate of disseminated tumor cells (DTCs) in secondary organs. Our analysis suggests that consensus can be reached by using in vivo methods of study, which also allow better modeling of how hypoxia affects DTC fate and metastasis.

Development of the Implantable Resonator System for Clinical EPR Oximetry

Hypoxic tumors are more resistant to radiotherapy and chemotherapy, which decreases the efficacy of these common forms of treatment. We have been developing implantable paramagnetic particulates to measure oxygen in vivo using electron paramagnetic resonance. Once implanted, oxygen can be measured repeatedly and non-invasively in superficial tissues (<3 cm deep), using an electron paramagnetic resonance spectrometer and an external surface-loop resonator. To significantly extend the clinical applications of electron paramagnetic resonance oximetry, we developed an implantable resonator system to obtain measurements at deeper sites. This system has been used to successfully obtain oxygen measurements in animal studies for several years. We report here on recent developments needed to meet the regulatory requirements to make this technology available for clinical use. radio frequency heating is discussed and magnetic resonance compatibility testing of the device has been carried out by a Good Laboratory Practice-certified laboratory. The geometry of the implantable resonator has been modified to meet our focused goal of verifying safety and efficacy for the proposed use of intracranial measurements and also for future use in tissue sites other than the brain. We have encapsulated the device within a smooth cylindrical-shaped silicone elastomer to prevent tissues from adhering to the device and to limit perturbation of tissue during implantation and removal. We have modified the configuration for simultaneously measuring oxygen at multiple sites by developing a linear array of oxygen sensing probes, which each provide independent measurements. If positive results are obtained in additional studies which evaluate biocompatibility and chemical characterization, we believe the implantable resonator will be at a suitable stage for initial testing in human subjects.

Single-cell time-lapse imaging of intracellular O2 in response to metabolic inhibition and mitochondrial cytochrome-c release

The detection of intracellular molecular oxygen (O₂) levels is important for understanding cell physiology, cell death, and drug effects, and has recently been improved with the development of oxygen-sensitive probes that are compatible with live cell time-lapse microscopy. We here provide a protocol for the use of the nanoparticle probe MitoImage-MM2 to monitor intracellular oxygen levels by confocal microscopy under baseline conditions, in response to mitochondrial toxins, and following mitochondrial cytochrome-c release. We demonstrate that the MitoImage-MM2 probe, which embeds Pt(II)-5,10,15,20-tetrakis-(2,3,4,5,6-pentafluorophenyl)-porphyrin as oxygen sensor and poly(9,9-dioctylfluorene) as an O₂-independent component, enables quantitative, ratiometric time-lapse imaging of intracellular O₂. Multiplexing with tetra-methyl-rhodamine-methyl ester in HeLa cervical cancer cells showed significant increases in intracellular O₂ accompanied by strong mitochondrial depolarization when respiratory chain complexes III or IV were inhibited by Antimycin A or sodium azide, respectively, and when cells were maintained at 'physiological' tissue O₂ levels (5% O₂). Multiplexing also allowed us to monitor intracellular O₂ during the apoptotic signaling process of mitochondrial outer membrane permeabilization in HeLa expressing cytochrome-c-eGFP, and demonstrated that mitochondria post cytochrome-c release are able to retain their capacity to respire at physiological O₂ despite a decrease in mitochondrial membrane potential.

A LED-based phosphorimeter for measurement of microcirculatory oxygen pressure

Quantitative measurements of microcirculatory and tissue oxygenation are of prime importance in experimental research. The noninvasive phosphorescence quenching method has given further insight into the fundamental mechanisms of oxygen transport to healthy tissues and in models of disease. Phosphorimeters are devices dedicated to the study of phosphorescence quenching. The experimental applications of phosphorimeters range from measuring a specific oxygen partial pressure (Po2) in cellular organelles such as mitochondria, finding values of Po2 distributed over an organ or capillaries, to measuring microcirculatory Po2 changes simultaneously in several organ systems. Most of the current phosphorimeters use flash lamps as a light excitation source. However, a major drawback of flash lamps is their inherent plasma glow that persists for tens of microseconds after the primary discharge. This complex distributed excitation pattern generated by the flash lamp can lead to inaccurate Po2 readings unless a deconvolution analysis is performed. Using light-emitting diode (LED), a rectangular shaped light pulse can be generated that provides a more uniformly distributed excitation signal. This study presents the design and calibration process of an LED-based phosphorimeter (LED-P). The in vitro calibration of the LED-P using palladium(II)-meso-tetra(4-carboxyphenyl)-porphyrin (Pd-TCCP) as a phosphorescent dye is presented. The pH and temperature were altered to assess whether the decay times of the Pd-TCCP measured by the LED-P were significantly influenced. An in vivo validation experiment was undertaken to measure renal cortical Po2 in a rat subjected to hypoxic ventilation conditions and ischemia/reperfusion. The benefits of using LEDs as a light excitation source are presented.

A monitor for Cellular Oxygen METabolism (COMET): monitoring tissue oxygenation at the mitochondrial level

After introduction of the protoporphyrin IX-triplet state lifetime technique as a new method to measure mitochondrial oxygen tension in vivo, the development of a clinical monitor was started. This monitor is the "COMET", an acronym for Cellular Oxygen METabolism. The COMET is a non-invasive electrically powered optical device that allows measurements on the skin. The COMET is easy to transport, due to its lightweight and compact size. After 5-aminolevulinic acid application on the human skin, a biocompatible sensor enables detection of PpIX in the mitochondria. PpIX acts as a mitochondrially located oxygen-sensitive dye. Three measurement types are available in the touchscreen-integrated user interface, 'Single', 'Interval' and 'Dynamic measurement'. COMET is currently used in several clinical studies in our institution. In this first description of the COMET device we show an incidental finding during neurosurgery. To treat persisting intraoperative hypertension a patient was administered clonidine, but due to rapid administration an initial phase of peripheral vasoconstriction occurred. Microvascular flow and velocity parameters measured with laser-doppler (O2C, LEA Medizintechnik) decreased by 44 and 16% respectively, but not the venous-capillary oxygen saturation. However, mitochondrial oxygen tension in the skin detected by COMET decreased from a steady state of 48 to 16 mmHg along with the decrease in flow and velocity. We conclude that COMET is ready for clinical application and we see the future for this bedside monitor on the intensive care, operating theater, and testing of mitochondrial effect of pharmaceuticals.

Contribution of Harold M. Swartz to In Vivo EPR and EPR Dosimetry

In 2015, we are celebrating half a century of research in the application of Electron Paramagnetic Resonance (EPR) as a biodosimetry tool to evaluate the dose received by irradiated people. During the EPR Biodose 2015 meeting, a special session was organized to acknowledge the pioneering contribution of Harold M. (Hal) Swartz in the field. The article summarizes his main contribution in physiology and medicine. Four emerging themes have been pursued continuously along his career since its beginning: (1) radiation biology; (2) oxygen and oxidation; (3) measuring physiology in vivo; and (4) application of these measurements in clinical medicine. The common feature among all these different subjects has been the use of magnetic resonance techniques, especially EPR. In this article, you will find an impressionist portrait of Hal Swartz with the description of the 'making of' this pioneer, a time-line perspective on his career with the creation of three National Institutes of Health-funded EPR centers, a topic-oriented perspective on his career with a description of his major contributions to Science, his role as a mentor and his influence on his academic children, his active role as founder of scientific societies and organizer of scientific meetings, and the well-deserved international recognition received so far.

Comparing the Effectiveness of Methods to Measure Oxygen in Tissues for Prognosis and Treatment of Cancer

Given the clinical evidence that hypoxic tumors are more resistant to standard therapy and that adjusting therapies can improve the outcomes for the subpopulation with hypoxic tumors, in vivo methods to measure oxygen in tissue have important clinical potential. This paper provides the rationale for and methodological strategies to use comparative effectiveness research to evaluate oximetry for cancer care. Nine oximetry methods that have been used in vivo to measure oxygen in human tumors are evaluated on several clinically relevant criteria to illustrate the value of applying comparative effectiveness to oximetry.

Direct and Repeated Clinical Measurements of pO2 for Enhancing Cancer Therapy and Other Applications

The first systematic multi-center study of the clinical use of EPR oximetry has begun, with funding as a PPG from the NCI. Using particulate oxygen sensitive EPR, materials in three complementary forms (India Ink, "OxyChips", and implantable resonators) the clinical value of the technique will be evaluated. The aims include using repeated measurement of tumor pO2 to monitor the effects of treatments on tumor pO2, to use the measurements to select suitable subjects for the type of treatment including the use of hyperoxic techniques, and to provide data that will enable existing clinical techniques which provide data relevant to tumor pO2 but which cannot directly measure it to be enhanced by determining circumstances where they can give dependable information about tumor pO2.

The external microenvironment of healing skin wounds

The skin wound microenvironment can be divided into two main components that influence healing: the external wound microenvironment, which is outside the wound surface; and the internal wound microenvironment, underneath the surface, to which the cells within the wound are exposed. Treatment methods that directly alter the features of the external wound microenvironment indirectly affect the internal wound microenvironment due to the exchange between the two compartments. In this review, we focus on the effects of temperature, pressure (positive and negative), hydration, gases (oxygen and carbon dioxide), pH, and anti-microbial treatment on the wound. These factors are well described in the literature and can be modified with treatment methods available in the clinic. Understanding the roles of these factors in wound pathophysiology is of central importance in wound treatment.

Electron spin resonance microscopic imaging of oxygen concentration in cancer spheroids

Oxygen (O2) plays a central role in most living organisms. The concentration of O2 is important in physiology and pathology. Despite the importance of accurate knowledge of the O2 levels, there is very limited capability to measure with high spatial resolution its distribution in millimeter-scale live biological samples. Many of the current oximetric methods, such as oxygen microelectrodes and fluorescence lifetime imaging, are compromised by O2 consumption, sample destruction, invasiveness, and difficulty to calibrate. Here, we present a new method, based on the use of the pulsed electron spin resonance (ESR) microimaging technique to obtain a 3D mapping of oxygen concentration in millimeter-scale biological samples. ESR imaging requires the incorporation of a suitable stable and inert paramagnetic spin probe into the desirable object. In this work, we use microcrystals of a paramagnetic spin probe in a new crystallographic packing form (denoted tg-LiNc-BuO). These paramagnetic species interact with paramagnetic oxygen molecules, causing a spectral line broadening that is linearly proportional to the oxygen concentration. Typical ESR results include 4D spatial-spectral images that give an indication about the oxygen concentration in different regions of the sample. This new oximetry microimaging method addresses all the problems mentioned above. It is noninvasive, sensitive to physiological oxygen levels, and easy to calibrate. Furthermore, in principle, it can be used for repetitive measurements without causing cell damage. The tissue model used in this research is spheroids of Human Colorectal carcinoma cell line (HCT-116) with a typical diameter of ∼600μm. Most studies of the microenvironmental O2 conditions inside such viable spheroids carried out in the past used microelectrodes, which require an invasive puncturing of the spheroid and are also not applicable to 3D O2 imaging. High resolution 3D oxygen maps could make it possible to evaluate the relationship between morphological and physiological alterations in the spheroids, which would help understand the oxygen metabolism in solid tumors and its correlation with the susceptibility of tumors to various oncologic treatments.

Pd-porphyrin-cross-linked implantable hydrogels with oxygen-responsive phosphorescence

Development of long-term implantable luminescent biosensors for subcutaneous oxygen has proved challenging due to difficulties in immobilizing a biocompatible matrix that prevents sensor aggregation yet maintains sufficient concentration for transdermal optical detection. Here, Pd-porphyrins can be used as PEG cross-linkers to generate a polyamide hydrogel with extreme porphyrin density (≈5 × 10(-3) m). Dye aggregation is avoided due to the spatially constraining 3D mesh formed by the porphyrins themselves. The hydrogel exhibits oxygen-responsive phosphorescence and can be stably implanted subcutaneously in mice for weeks without degradation, bleaching, or host rejection. To further facilitate oxygen detection using steady-state techniques, an oxygen-non-responsive companion hydrogel is developed by blending copper and free base porphyrins to yield intensity-matched luminescence for ratiometric detection.

Clinical EPR: unique opportunities and some challenges

Electron paramagnetic resonance (EPR) spectroscopy has been well established as a viable technique for measurement of free radicals and oxygen in biological systems, from in vitro cellular systems to in vivo small animal models of disease. However, the use of EPR in human subjects in the clinical setting, although attractive for a variety of important applications such as oxygen measurement, is challenged with several factors including the need for instrumentation customized for human subjects, probe, and regulatory constraints. This article describes the rationale and development of the first clinical EPR systems for two important clinical applications, namely, measurement of tissue oxygen (oximetry) and radiation dose (dosimetry) in humans. The clinical spectrometers operate at 1.2 GHz frequency and use surface-loop resonators capable of providing topical measurements up to 1 cm depth in tissues. Tissue pO2 measurements can be carried out noninvasively and repeatedly after placement of an oxygen-sensitive paramagnetic material (currently India ink) at the site of interest. Our EPR dosimetry system is capable of measuring radiation-induced free radicals in the tooth of irradiated human subjects to determine the exposure dose. These developments offer potential opportunities for clinical dosimetry and oximetry, which include guiding therapy for individual patients with tumors or vascular disease by monitoring of tissue oxygenation. Further work is in progress to translate this unique technology to routine clinical practice.

From elementary reactions to chemical relevance in the photodynamic therapy of cancer

Theories of radiationless conversions and of chemical processes were employed to design better photosensitizers for photodynamic therapy (PDT). In addition to photostability and intense absorption in the near infrared, these photosensitizers were required to generate high yields of long-lived triplet states that could efficiently transfer their energy, or an electron, to molecular oxygen. The guidance provided by the theories was combined with the ability to synthesize large quantities of pure photosensitizers and with the biological screening of graded hydrophilicities/lipophilicities. The theoretical prediction that halogenated sulfonamide tetraphenylbacteriochlorins could satisfy all the criteria for ideal PDT photosensitizers was verified experimentally.

Identifying HIF Activity in Three-Dimensional Cultures of Islet-Like Clusters

Purpose

Hypoxia is a major cause for failure of encapsulated islet grafts. Three-dimensional (3D) re-aggregation and hypoxic preconditioning are used to help overcome this obstacle. However, it is still difficult to identify hypoxic cells in a 3D system. We evaluate the efficacy of a fluorescent system for detecting HIF-1 activity in live β-cells. Identification of HIF-1 activity and correlation with insulin secretion and viability will allow for more informed implant construction and better prediction of post-transplantational function.

Methods

MIN6 cells were infected with the marker virus and rotationally cultured to form clusters. Clusters were encapsulated in PEG hydrogels and incubated in 20%, 2%, or 1% O2. Gels were imaged daily for hypoxia marker signaling and for morphological observation. Daily GSIS was quantified by insulin ELSIA and cell viability was assessed by LIVE/DEAD staining.

Results

Clusters cultured in 2% and 1% O2 displayed high levels of HIF activity compared to 20% O2 clusters. 20% O2 clusters maintained viability and achieved a smooth, islet-like morphology by Day 14. Clusters in 2% and 1% O2 failed to associate cohesively and showed reduced viability. As a whole, constructs cultured in 20% O2 exhibited 10-fold higher GSIS than constructs in 2% and 1% O2.

Conclusions

Our marker is an effective approach for identifying cellular hypoxia in 3D cultures. β-cell clusters in 2% and 1% O2 are similarly affected by reduced oxygen tension, with HIF-1 activity correlating to reduced GSIS and impaired cell/cluster morphology. Simultaneous aggregative culture and hypoxic conditioning may not be beneficial to β-cell transplantation.

Shedding light on mitochondrial function by real time monitoring of NADH fluorescence: II: human studies

Monitoring the mitochondrial function, alone or together with microcirculatory blood flow, volume and hemoglobin oxygenation in patients, is very rare. The integrity of microcirculation and mitochondrial activity is a key factor in keeping normal cellular activities. Many pathological conditions in patients are directly or indirectly related to dysfunction of the mitochondria. Evaluation of mitochondrial activity by measuring the autofluorescence of NADH has been the most practical approach since the 1950s. This review, which accompanies part I, presents the principles and technological aspects of various devices used in order to monitor mitochondrial NADH redox state and tissue viability in patients. In part I, the detailed technological aspects of NADH monitoring were described. Typical results accumulated in our studies since the mid-1990s are presented as well. We were able to apply the fiber optic based NADH fluorometry to several organs monitored in vivo in patients under various pathophysiological conditions.

Shedding light on mitochondrial function by real time monitoring of NADH fluorescence: I. Basic methodology and animal studies

Normal mitochondrial function in the process of metabolic energy production is a key factor in maintaining cellular activities. Many pathological conditions in animals, as well as in patients, are directly or indirectly related to dysfunction of the mitochondria. Monitoring the mitochondrial activity by measuring the autofluorescence of NADH has been the most practical approach since the 1950s. This review presents the principles and technological aspects, as well as typical results, accumulated in our laboratory since the early 1970s. We were able to apply the fiber-optic-based NADH fluorometry to many organs monitored in vivo under various pathophysiological conditions in animals. These studies were the basis for the development of clinical monitoring devices as presented in accompanying article. The encouraging experimental results in animals stimulated us to apply the same technology in patients after technological adaptations as described in the accompanying article. Our medical device was approved for clinical use by the FDA.

Validation of the protoporphyrin IX-triplet state lifetime technique for mitochondrial oxygen measurements in the skin

Mitochondrial oxygen tension can be measured in vivo by means of oxygen-dependent quenching of delayed fluorescence of protoporphyrin IX (PpIX). Here we demonstrate that mitochondrial PO(2) (mitoPO(2)) can be measured in the skin of a rat after topical application of the PpIX precursor 5-aminolevulinic acid (ALA). Calibration of mitoPO(2) measurements was done by comparison with simultaneous measurements of the cutaneous microvascular PO(2) This was done under three different conditions: in normal skin tissue, in nonrespiration skin tissue due to the application of cyanide, and in anoxic skin tissue after the ventilation with 100% nitrogen. The results of this study show that it is feasible to measure the mitoPO(2) after the topical application of ALA cream by means of the PpIX-triplet state lifetime technique.

Microvascular and mitochondrial PO(2) simultaneously measured by oxygen-dependent delayed luminescence

Measurement of tissue oxygenation is a complex task and various techniques have led to a wide range of tissue PO(2) values and contradictory results. Tissue is compartmentalized in microcirculation, interstitium and intracellular space and current techniques are biased towards a certain compartment. Simultaneous oxygen measurements in various compartments might be of great benefit for our understanding of determinants of tissue oxygenation. Here we report simultaneous measurement of microvascular PO(2) (μPO(2) ) and mitochondrial PO(2) (mitoPO(2) ) in rats. The μPO(2) measurements are based on oxygen-dependent quenching of phosphorescence of the near-infrared phosphor Oxyphor G2. The mitoPO(2) measurements are based on oxygen-dependent quenching of delayed fluorescence of protoporphyrin IX (PpIX). Favorable spectral properties of these porphyrins allow simultaneous measurement of the delayed luminescence lifetimes. A dedicated fiber-based time-domain setup consisting of a tunable pulsed laser, 2 red-sensitive gated photomultiplier tubes and a simultaneous sampling data-acquisition system is described in detail. The absence of cross talk between the channels is shown and the feasibility of simultaneous μPO(2) and mitoPO(2) measurements is demonstrated in rat liver in vivo. It is anticipated that this novel approach will greatly contribute to our understanding of tissue oxygenation in physiological and pathological circumstances.

Repeated assessment of orthotopic glioma pO(2) by multi-site EPR oximetry: a technique with the potential to guide therapeutic optimization by repeated measurements of oxygen

Tumor hypoxia plays a vital role in therapeutic resistance. Consequently, measurements of tumor pO(2) could be used to optimize the outcome of oxygen-dependent therapies, such as, chemoradiation. However, the potential optimizations are restricted by the lack of methods to repeatedly and quantitatively assess tumor pO(2) during therapies, particularly in gliomas. We describe the procedures for repeated measurements of orthotopic glioma pO(2) by multi-site electron paramagnetic resonance (EPR) oximetry. This oximetry approach provides simultaneous measurements of pO(2) at more than one site in the glioma and contralateral cerebral tissue. The pO(2) of intracerebral 9L, C6, F98 and U251 tumors, as well as contralateral brain, were measured repeatedly for five consecutive days. The 9L glioma was well oxygenated with pO(2) of 27-36 mm Hg, while C6, F98 and U251 glioma were hypoxic with pO(2) of 7-12mm Hg. The potential of multi-site EPR oximetry to assess temporal changes in tissue pO(2) was investigated in rats breathing 100% O(2). A significant increase in F98 tumor and contralateral brain pO(2) was observed on day 1 and day 2, however, glioma oxygenation declined on subsequent days. In conclusion, EPR oximetry provides the capability to repeatedly assess temporal changes in orthotopic glioma pO(2). This information could be used to test and optimize the methods being developed to modulate tumor hypoxia. Furthermore, EPR oximetry could be potentially used to enhance the outcome of chemoradiation by scheduling treatments at times of increase in glioma pO(2).

Oxygen-dependent delayed fluorescence measured in skin after topical application of 5-aminolevulinic acid

Mitochondrial oxygen tension can be measured in vivo by means of oxygen-dependent quenching of delayed fluorescence of protoporphyrin IX (PpIX). Here we demonstrate that delayed fluorescence is readily observed from skin in rat and man after topical application of the PpIX precursor 5-aminolevulinic acid (ALA). Delayed fluorescence lifetimes respond to changes in inspired oxygen fraction and blood supply. The signals contain lifetime distributions and the fitting of rectangular distributions to the data appears more adequate than mono-exponential fitting. The use of topically applied ALA for delayed fluorescence lifetime measurements might pave the way for clinical use of this technique.

The evaluation of new and isotopically labeled isoindoline nitroxides and an azaphenalene nitroxide for EPR oximetry

Isoindoline nitroxides are potentially useful probes for viable biological systems, exhibiting low cytotoxicity, moderate rates of biological reduction and favorable Electron Paramagnetic Resonance (EPR) characteristics. We have evaluated the anionic (5-carboxy-1,1,3,3-tetramethylisoindolin-2-yloxyl; CTMIO), cationic (5-(N,N,N-trimethylammonio)-1,1,3,3-tetramethylisoindolin-2-yloxyl iodide, QATMIO) and neutral (1,1,3,3-tetramethylisoindolin-2-yloxyl; TMIO) nitroxides and their isotopically labeled analogs ((2)H(12)- and/or (2)H(12)-(15)N-labeled) as potential EPR oximetry probes. An active ester analogue of CTMIO, designed to localize intracellularly, and the azaphenalene nitroxide 1,1,3,3-tetramethyl-2,3-dihydro-2-azaphenalen-2-yloxyl (TMAO) were also studied. While the EPR spectra of the unlabeled nitroxides exhibit high sensitivity to O(2) concentration, deuteration resulted in a loss of superhyperfine features and a subsequent reduction in O(2) sensitivity. Labeling the nitroxides with (15)N increased the signal intensity and this may be useful in decreasing the detection limits for in vivo measurements. The active ester nitroxide showed approximately 6% intracellular localization and low cytotoxicity. The EPR spectra of TMAO nitroxide indicated an increased rigidity in the nitroxide ring, due to dibenzo-annulation.

Two-photon microscopy of oxygen: polymersomes as probe carrier vehicles

Oxygen concentration distributions in biological systems can be imaged by the phosphorescence quenching method in combination with two-photon laser scanning microscopy. In this paper, we identified the excitation regime in which the signal of a two-photon-enhanced phosphorescent probe (Finikova, O. S.; Lebedev, A. Y.; Aprelev, A.; Troxler, T.; Gao, F.; Garnacho, C.; Muro, S.; Hochstrasser, R. M.; Vinogradov, S. A. ChemPhysChem 2008, 9, 1673-1679) is dependent quadratically on the excitation power (quadratic regime), and performed simulations that relate the photophysical properties of the probe to the imaging resolution. Further, we characterized polymersomes as a method of probe encapsulation and delivery. Photophysical and oxygen sensing properties of the probe were found unchanged when the probe is encapsulated in polymersomes. Polymersomes were found capable of sustaining high probe concentrations, thereby serving to improve the signal-to-noise ratios for oxygen detection compared to the previously employed probe delivery methods. Imaging of polymersomes loaded with the probe was used as a test-bed for a new method.

Microimaging of oxygen concentration near live photosynthetic cells by electron spin resonance

We present what is, to our knowledge, a new methodology for high-resolution three-dimensional imaging of oxygen concentration near live cells. The cells are placed in the buffer solution of a stable paramagnetic probe, and electron spin-resonance microimaging is employed to map out the probe's spin-spin relaxation time (T(2)). This information is directly linked to the concentration of the oxygen molecule. The method is demonstrated with a test sample and with a small amount of live photosynthetic cells (cyanobacteria), under conditions of darkness and light. Spatial resolution of approximately 30 x 30 x 100 microm is demonstrated, with approximately microM oxygen concentration sensitivity and sub-fmol absolute oxygen sensitivity per voxel. The use of electron spin-resonance microimaging for oxygen mapping near cells complements the currently available techniques based on microelectrodes or fluorescence/phosphorescence. Furthermore, with the proper paramagnetic probe, it will also be readily applicable for intracellular oxygen microimaging, a capability which other methods find very difficult to achieve.

Evaluation of multi-exponential curve fitting analysis of oxygen-quenched phosphorescence decay traces for recovering microvascular oxygen tension histograms

Although it is generally accepted that oxygen-quenched phosphorescence decay traces can be analyzed using the exponential series method (ESM), its application until now has been limited to a few (patho)physiological studies, probably because the reliability of the recovered oxygen tension (pO(2)) histograms has never been extensively evaluated and lacks documentation. The aim of this study was, therefore, to evaluate the use of the ESM to adequately determine pO(2) histograms from phosphorescence decay traces. For this purpose we simulated decay traces corresponding to uni- and bimodal pO(2) distributions and recovered the pO(2) histograms at different signal-to-noise ratios (SNRs). Ultimately, we recovered microvascular pO(2) histograms measured in the rat kidney in a model of endotoxemic shock and fluid resuscitation and showed that the mean microvascular oxygen tension, [Symbol: see text]pO(2)[Symbol: see text], decreased after induction of endotoxemia and that after 2 h of fluid resuscitation, [Symbol: see text]pO(2)[Symbol: see text] remained low, but the hypoxic peak that had arisen during endotoxemia was reduced. This finding illustrates the importance of recovering pO(2) histograms under (patho)physiological conditions. In conclusion, this study has characterized how noise affects the recovery of pO(2) histograms using the ESM and documented the reliability of the ESM for recovering both low- and high-pO(2) distributions for SNRs typically found in experiments. This study might therefore serve as a frame of reference for investigations focused on oxygen (re)distribution during health and disease and encourage researchers to (re-)analyze data obtained in (earlier) studies possibly revealing new insights into complex disease states and treatment strategies.

In vivo multisite oximetry using EPR-NMR coimaging

Coimaging employing electron paramagnetic resonance (EPR) imaging and MRI is used for rapid in vivo oximetry conducted simultaneously across multiple organs of a mouse. A recently developed hybrid EPR-NMR coimaging instrument is used for both EPR and NMR measurements. Oxygen sensitive particulate EPR probe is implanted in small localized pockets, called sites, across multiple regions of a live mouse. Three dimensional MRI is used to generate anatomic visualization, providing precise locations of implant sites. The pO₂ values, one for every site, are then estimated from EPR measurements. To account for radio frequency (RF) phase inhomogeneities inside a large resonator carrying a lossy sample, a generalization of an existing EPR data model is proposed. Utilization of known spectral lineshape, sparse distribution, and known site locations reduce the EPR data collection by more than an order of magnitude over a conventional spectral-spatial imaging, enhancing the feasibility of in vivo EPR oximetry for clinically relevant models.

Optical imaging of tumor hypoxia dynamics

The influence of the tumor microenvironment and hypoxia plays a significant role in determining cancer progression, treatment response, and treatment resistance. That the tumor microenvironment is highly heterogeneous with significant intratumor and intertumor variability presents a significant challenge in developing effective cancer therapies. Critical to understanding the role of the tumor microenvironment is the ability to dynamically quantify oxygen levels in the vasculature and tissue in order to elucidate the roles of oxygen supply and consumption, spatially and temporally. To this end, we describe the use of hyperspectral imaging to characterize hemoglobin absorption to quantify hemoglobin content and oxygen saturation, as well as dual emissive fluorescent∕phosphorescent boron nanoparticles, which serve as ratiometric indicators of tissue oxygen tension. Applying these techniques to a window-chamber tumor model illustrates the role of fluctuations in hemoglobin saturation in driving changes in tissue oxygenation, the two being significantly correlated (r = 0.77). Finally, a green-fluorescence-protein reporter for hypoxia inducible factor-1 (HIF-1) provides an endpoint for hypoxic stress in the tumor, which is used to demonstrate a significant association between tumor hypoxia dynamics and HIF-1 activity in an in vivo demonstration of the technique.