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Recent Insights into the Pathogenesis of Acute Porphyria Attacks and Increasing Hepatic PBGD as an Etiological Treatment. LIFE (BASEL, SWITZERLAND) 2022; 12:life12111858. [PMID: 36430993 PMCID: PMC9694773 DOI: 10.3390/life12111858] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/20/2022] [Revised: 11/03/2022] [Accepted: 11/09/2022] [Indexed: 11/16/2022]
Abstract
Rare diseases, especially monogenic diseases, which usually affect a single target protein, have attracted growing interest in drug research by encouraging pharmaceutical companies to design and develop therapeutic products to be tested in the clinical arena. Acute intermittent porphyria (AIP) is one of these rare diseases. AIP is characterized by haploinsufficiency in the third enzyme of the heme biosynthesis pathway. Identification of the liver as the target organ and a detailed molecular characterization have enabled the development and approval of several therapies to manage this disease, such as glucose infusions, heme replenishment, and, more recently, an siRNA strategy that aims to down-regulate the key limiting enzyme of heme synthesis. Given the involvement of hepatic hemoproteins in essential metabolic functions, important questions regarding energy supply, antioxidant and detoxifying responses, and glucose homeostasis remain to be elucidated. This review reports recent insights into the pathogenesis of acute attacks and provides an update on emerging treatments aimed at increasing the activity of the deficient enzyme in the liver and restoring the physiological regulation of the pathway. While further studies are needed to optimize gene therapy vectors or large-scale production of liver-targeted PBGD proteins, effective protection of PBGD mRNA against the acute attacks has already been successfully confirmed in mice and large animals, and mRNA transfer technology is being tested in several clinical trials for metabolic diseases.
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Petrides PE. Therapy Follows Diagnosis: Old and New Approaches for the Treatment of Acute Porphyrias, What We Know and What We Should Know. Diagnostics (Basel) 2022; 12:1618. [PMID: 35885523 PMCID: PMC9325038 DOI: 10.3390/diagnostics12071618] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Revised: 06/29/2022] [Accepted: 06/30/2022] [Indexed: 12/18/2022] Open
Abstract
Heme, iron protoporphyrin IX, is one of life's most central molecules. Hence, availability of the enzymatic machinery necessary for its synthesis is crucial for every cell. Consequently, inborn errors of porphyrin metabolism that compromise normal synthesis, namely the family of porphyrias, undermine normal cellular metabolism given that heme has functions in catalytic centers, signal transduction and functional regulation and its synthesis is fully integrated into the center of intermediary metabolism. Very often, diagnosis of porphyrias is difficult and therefore delayed. Therapy can be as complicated. Over the last 50 years, several strategies have been developed: because of its integration with other parts of intermediary metabolism, the infusion of glucose (glucose effect) was one of the first attempts to counterbalance the dysregulation of porphyrin synthesis in porphyrias. Since heme synthesis is impaired, infusional replacement of heme was the next important therapeutic step. Recently, siRNA technology has been introduced in order to downregulate 5-ALA-synthase 1, which contributes to the patho-physiology of these diseases. Moreover, other novel therapies using enzyme protein replacement, mRNA techniques or proteostasis regulators are being developed.
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Affiliation(s)
- Petro E. Petrides
- Hematology Oncology Center & EPNET-Center for Acute Porphyrias Munich, Zweibrückenstr. 2, 80331 Munich, Germany; or ; Tel.: +49-89-229009; Fax: +49-89-229448
- Munich School of Medicine, Ludwig Maximilians University (LMU), 80539 Munich, Germany
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Sardh E, Harper P. RNAi therapy with givosiran significantly reduces attack rates in acute intermittent porphyria. J Intern Med 2022; 291:593-610. [PMID: 35067977 DOI: 10.1111/joim.13443] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Acute hepatic porphyria (AHP) is a group of inherited metabolic disorders that affect hepatic heme biosynthesis. They are associated with attacks of neurovisceral manifestations that can be life threatening and constitute what is considered an acute porphyria attack. Until recently, the sole specific treatment for acute porphyria attacks consisted of the intravenous administration of hemin. Although attacks are often sporadic, some patients develop recurrent acute attacks, with devastating effects on quality of life. Liver transplantation has historically been the sole curative treatment option. The clinical manifestations of AHP are attributed to the accumulation of the heme precursor 5-aminolevulinic acid (ALA) and porphobilinogen (PBG). Advances in molecular engineering have provided new therapeutic possibilities for modifying the heme synthetic pathway. We reviewed the background and current status of AHP treatment using liver-directed small interfering RNA targeting ALAS1. The therapeutic aim was to normalize the levels of ALAS1, which is highly upregulated during acute porphyria attacks. Givosiran is now an approved drug for use in adults and adolescents aged 12 years and older. The results of clinical trials have shown that givosiran treatment leads to a rapid and sustained reduction of ALAS1 mRNA, decreased heme precursor levels, and a decreased rate of acute attacks compared with placebo. The clinical trials (phases I, II, and III) were all randomized and placebo controlled. Many patients enrolled in the initial clinical trials have continued treatment in open label extension and extended/compassionate-use programs in countries where givosiran is not yet commercially available.
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Affiliation(s)
- Eliane Sardh
- Department of Molecular Medicine and Surgery, Centre for Inherited Metabolic Diseases, Porphyria Centre Sweden, Department of Endocrinology, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Pauline Harper
- Department of Medical Biochemistry and Biophysics, Centre for inherited Metabolic Diseases, Porphyria Centre Sweden., Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
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Photodynamic diagnostic ureteroscopy using the VISERA ELITE video system for diagnosis of upper-urinary tract urothelial carcinoma: a prospective cohort pilot study. BMC Urol 2021; 21:45. [PMID: 33765999 PMCID: PMC7995577 DOI: 10.1186/s12894-021-00819-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2021] [Accepted: 03/15/2021] [Indexed: 11/24/2022] Open
Abstract
Background The advantages of photodynamic diagnostic technology using 5-aminolevulinic acid (ALA-PDD) have been established. The aim of this prospective cohort study was to evaluate the usefulness of ALA-PDD to diagnose upper tract urothelial carcinoma (UT-UC) using the Olympus VISERA ELITE video system. Methods We carried out a prospective, interventional, non-randomized, non-contrast and open label cohort pilot study that involved patients who underwent ureterorenoscopy (URS) to detect UT-UC. 5-aminolevulinic acid hydrochloride was orally administered before URS. The observational results and pathological diagnosis with ALA-PDD and traditional white light methods were compared, and the proportion of positive subjects and specimens were calculated. Results A total of 20 patients were enrolled and one patient who had multiple bladder tumors did not undergo URS. Fifteen of 19 patients were pathologically diagnosed with UT-UC and of these 11 (73.3%) were ALA-PDD positive. Fourteen of 19 patients were ALA-PDD positive and of these 11 were pathologically diagnosed with UC. For the 92 biopsy specimens that were malignant or benign, the sensitivity for both traditional white light observation and ALA-PDD was the same at 62.5%, whereas the specificities were 73.1% and 67.3%, respectively. Of the 38 specimens that were randomly biopsied without any abnormality under examination by both white light and ALA-PDD, 11 specimens (28.9%) from 5 patients were diagnosed with high grade UC. In contrast, four specimens from 4 patients, which were negative in traditional white light observation but positive in ALA-PDD, were diagnosed with carcinoma in situ (CIS). Conclusions Our results suggest that ALA-PDD using VISERA ELITE is not sufficiently applicable for UT-UC. Nevertheless, it might be better particularly for CIS than white light and superior results would be obtained using VISERA ELITE II video system. Trial registration: The present clinical study was approved by the Okayama University Institutional Review Board prior to study initiation (Application no.: RIN 1803–002) and was registered with the UMIN Clinical Trials Registry (UMIN-CTR), Japan (Accession no.: UMIN000031205).
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Shiratori T, Hotta K, Satoh M, Kiuchi C, Ogawa N, Kamigaito T. Preanesthetic severe postural hypotension following 5-aminolevulinic acid pretreatment in patients for photodynamic diagnosis-assisted urological surgery. JA Clin Rep 2019; 5:74. [PMID: 32025937 PMCID: PMC6967019 DOI: 10.1186/s40981-019-0295-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2019] [Accepted: 10/23/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND 5-Aminolevulinic acid (5-ALA) is utilized for photodynamic diagnosis-assisted (PDD) surgery. However, it has been associated with vasodilation, hence, occasional hypotension. CASE PRESENTATION We encountered two patients who had severe postural hypotension following 5-ALA pretreatment prior to an operation. They were scheduled for urological PDD surgery, but upon standing to walk to the operation room, they felt sick because of severe hypotension. One of them underwent the surgery after recovery, but the other surgery was canceled due to a prolonged hypotension that lasted for more than a day. CONCLUSIONS Severe postural hypotension may develop as a result of the high concentration of porphyrin precursors, which may affect the nervous system. Severe postural hypotension may be due to 5-ALA-induced autonomic dysfunction as well as vasodilative action of 5-ALA. These observations suggest that in addition to the careful monitoring of patients' vital signs, standing should be avoided following 5-ALA pretreatment.
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Affiliation(s)
- Tohru Shiratori
- Department of Anesthesiology, Ina Central Hospital, 1313-1 Koshiroukubo, Ina, Nagano 396-8555 Japan
| | - Kunihisa Hotta
- Department of Anesthesiology and Critical Care Medicine, Jichi Medical University, 3311-1 Yakushiji, Shimotsuke, Tochigi, 329-0498 Japan
| | - Masaaki Satoh
- Department of Urology, Ina Central Hospital, 1313-1 Koshiroukubo, Ina, Nagano 396-8555 Japan
| | - Chiaki Kiuchi
- Department of Anesthesiology, Ina Central Hospital, 1313-1 Koshiroukubo, Ina, Nagano 396-8555 Japan
| | - Noriyuki Ogawa
- Department of Urology, Ina Central Hospital, 1313-1 Koshiroukubo, Ina, Nagano 396-8555 Japan
| | - Takayuki Kamigaito
- Department of Urology, Ina Central Hospital, 1313-1 Koshiroukubo, Ina, Nagano 396-8555 Japan
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Phillips JD. Heme biosynthesis and the porphyrias. Mol Genet Metab 2019; 128:164-177. [PMID: 31326287 PMCID: PMC7252266 DOI: 10.1016/j.ymgme.2019.04.008] [Citation(s) in RCA: 106] [Impact Index Per Article: 21.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2018] [Revised: 04/10/2019] [Accepted: 04/18/2019] [Indexed: 01/08/2023]
Abstract
Porphyrias, is a general term for a group of metabolic diseases that are genetic in nature. In each specific porphyria the activity of specific enzymes in the heme biosynthetic pathway is defective and leads to accumulation of pathway intermediates. Phenotypically, each disease leads to either neurologic and/or photocutaneous symptoms based on the metabolic intermediate that accumulates. In each porphyria the distinct patterns of these substances in plasma, erythrocytes, urine and feces are the basis for diagnostically defining the metabolic defect underlying the clinical observations. Porphyrias may also be classified as either erythropoietic or hepatic, depending on the principal site of accumulation of pathway intermediates. The erythropoietic porphyrias are congenital erythropoietic porphyria (CEP), and erythropoietic protoporphyria (EPP). The acute hepatic porphyrias include ALA dehydratase deficiency porphyria, acute intermittent porphyria (AIP), hereditary coproporphyria (HCP) and variegate porphyria (VP). Porphyria cutanea tarda (PCT) is the only porphyria that has both genetic and/or environmental factors that lead to reduced activity of uroporphyrinogen decarboxylase in the liver. Each of the 8 enzymes in the heme biosynthetic pathway have been associated with a specific porphyria (Table 1). Mutations affecting the erythroid form of ALA synthase (ALAS2) are most commonly associated with X-linked sideroblastic anemia, however, gain-of-function mutations of ALAS2 have also been associated with a variant form of EPP. This overview does not describe the full clinical spectrum of the porphyrias, but is meant to be an overview of the biochemical steps that are required to make heme in both erythroid and non-erythroid cells.
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Affiliation(s)
- John D Phillips
- Division of Hematology, Department of Medicine, University of Utah School of Medicine, Salt Lake City, UT, United States of America.
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Yang JZ, Van Vugt DA, Roy BN, Kennedy JC, Foster WG, Reid RL. Intrauterine 5-Aminolevulinic Acid Induces Selective Endometrial Fluorescence in the Rhesus and Cynomolgus Monkey. ACTA ACUST UNITED AC 2016. [DOI: 10.1177/107155769600300309] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
| | | | | | | | - Warren G. Foster
- Department of Obsterics and Gynecology, the Department of Physiology, the Department of Oncology and Pathology, Queen's University, Kingston, Ontario, Canada, and the Reproductive Toxicology Section, Health Protection Branch, Health Canada, Ottawa, Ontario, Canada
| | - Robert L. Reid
- Department of Obsterics and Gynecology, the Department of Physiology, the Department of Oncology and Pathology, Queen's University, Kingston, Ontario, Canada, and the Reproductive Toxicology Section, Health Protection Branch, Health Canada, Ottawa, Ontario, Canada; Division of Reproductive Endocrinology, Department of Obstetrics and Gynecology, Queen's University, Kingston, Ontario, Canada K7L 3N6
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Homedan C, Schmitt C, Laafi J, Gueguen N, Desquiret-Dumas V, Lenglet H, Karim Z, Gouya L, Deybach JC, Simard G, Puy H, Malthièry Y, Reynier P. Mitochondrial energetic defects in muscle and brain of a Hmbs-/- mouse model of acute intermittent porphyria. Hum Mol Genet 2015; 24:5015-23. [PMID: 26071363 DOI: 10.1093/hmg/ddv222] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2015] [Accepted: 06/09/2015] [Indexed: 12/24/2022] Open
Abstract
Acute intermittent porphyria (AIP), an autosomal dominant metabolic disease (MIM #176000), is due to a deficiency of hydroxymethylbilane synthase (HMBS), which catalyzes the third step of the heme biosynthetic pathway. The clinical expression of the disease is mainly neurological, involving the autonomous, central and peripheral nervous systems. We explored mitochondrial oxidative phosphorylation (OXPHOS) in the brain and skeletal muscle of the Hmbs(-/-) mouse model first in the basal state (BS), and then after induction of the disease with phenobarbital and treatment with heme arginate (HA). The modification of the respiratory parameters, determined in mice in the BS, reflected a spontaneous metabolic energetic adaptation to HMBS deficiency. Phenobarbital induced a sharp alteration of the oxidative metabolism with a significant decrease of ATP production in skeletal muscle that was restored by treatment with HA. This OXPHOS defect was due to deficiencies in complexes I and II in the skeletal muscle whereas all four respiratory chain complexes were affected in the brain. To date, the pathogenesis of AIP has been mainly attributed to the neurotoxicity of aminolevulinic acid and heme deficiency. Our results show that mitochondrial energetic failure also plays an important role in the expression of the disease.
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Affiliation(s)
- Chadi Homedan
- UMR INSERM 1063, Département de Biochimie et Génétique and
| | - Caroline Schmitt
- Assistance Publique Hôpitaux de Paris, Centre Français des Porphyries, Hôpital Louis Mourier AP-HP, 178 rue des Renouillers, Colombes 92701, France, INSERM U1149, CNRS ERL 8252, Center for Research on Inflammation (CRI), Université Paris Diderot, site Bichat, Sorbonne Paris Cité, 16 rue Henri Huchard, Paris 75018, France and Laboratory of Excellence, GR-Ex, Sorbonne Paris Cité, 16 rue Henri Huchard, Paris 75018, France
| | | | - Naïg Gueguen
- Département de Biochimie et Génétique and UMR CNRS 6214 - INSERM 1083, Centre Hospitalier Universitaire, 4 rue Larrey, Angers 49933, France
| | - Valérie Desquiret-Dumas
- Département de Biochimie et Génétique and UMR CNRS 6214 - INSERM 1083, Centre Hospitalier Universitaire, 4 rue Larrey, Angers 49933, France
| | - Hugo Lenglet
- INSERM U1149, CNRS ERL 8252, Center for Research on Inflammation (CRI), Université Paris Diderot, site Bichat, Sorbonne Paris Cité, 16 rue Henri Huchard, Paris 75018, France and Laboratory of Excellence, GR-Ex, Sorbonne Paris Cité, 16 rue Henri Huchard, Paris 75018, France
| | - Zoubida Karim
- INSERM U1149, CNRS ERL 8252, Center for Research on Inflammation (CRI), Université Paris Diderot, site Bichat, Sorbonne Paris Cité, 16 rue Henri Huchard, Paris 75018, France and Laboratory of Excellence, GR-Ex, Sorbonne Paris Cité, 16 rue Henri Huchard, Paris 75018, France
| | - Laurent Gouya
- Assistance Publique Hôpitaux de Paris, Centre Français des Porphyries, Hôpital Louis Mourier AP-HP, 178 rue des Renouillers, Colombes 92701, France, INSERM U1149, CNRS ERL 8252, Center for Research on Inflammation (CRI), Université Paris Diderot, site Bichat, Sorbonne Paris Cité, 16 rue Henri Huchard, Paris 75018, France and Laboratory of Excellence, GR-Ex, Sorbonne Paris Cité, 16 rue Henri Huchard, Paris 75018, France
| | - Jean-Charles Deybach
- Assistance Publique Hôpitaux de Paris, Centre Français des Porphyries, Hôpital Louis Mourier AP-HP, 178 rue des Renouillers, Colombes 92701, France, INSERM U1149, CNRS ERL 8252, Center for Research on Inflammation (CRI), Université Paris Diderot, site Bichat, Sorbonne Paris Cité, 16 rue Henri Huchard, Paris 75018, France and Laboratory of Excellence, GR-Ex, Sorbonne Paris Cité, 16 rue Henri Huchard, Paris 75018, France
| | - Gilles Simard
- UMR INSERM 1063, Département de Biochimie et Génétique and
| | - Hervé Puy
- Assistance Publique Hôpitaux de Paris, Centre Français des Porphyries, Hôpital Louis Mourier AP-HP, 178 rue des Renouillers, Colombes 92701, France, INSERM U1149, CNRS ERL 8252, Center for Research on Inflammation (CRI), Université Paris Diderot, site Bichat, Sorbonne Paris Cité, 16 rue Henri Huchard, Paris 75018, France and Laboratory of Excellence, GR-Ex, Sorbonne Paris Cité, 16 rue Henri Huchard, Paris 75018, France
| | - Yves Malthièry
- UMR INSERM 1063, Département de Biochimie et Génétique and
| | - Pascal Reynier
- Département de Biochimie et Génétique and UMR CNRS 6214 - INSERM 1083, Centre Hospitalier Universitaire, 4 rue Larrey, Angers 49933, France,
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10
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Abstract
Porphyric neuropathy often poses a diagnostic dilemma; it is typically associated with the hepatic porphyrias, characterized by acute life-threatening attacks of neurovisceral symptoms that mimic a range of acute medical and psychiatric conditions. The development of acute neurovisceral attacks is responsive to environmental factors, including drugs, hormones, and diet. This chapter reviews the clinical manifestations, genetics, pathophysiology, and mechanisms of neurotoxicity of the acute hepatic porphyrias. While the etiology of the neurological manifestations in the acute porphyrias remains undefined, the main hypotheses include toxicity of porphyrin precursors and deficiency of heme synthesis. These hypotheses will be discussed with reference to novel experimental models of porphyric neuropathy.
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Affiliation(s)
- Cindy Shin-Yi Lin
- School of Medical Sciences, Faculty of Medicine, University of New South Wales, Sydney, Australia.
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11
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Lin CSY, Lee MJ, Park SB, Kiernan MC. Purple pigments: the pathophysiology of acute porphyric neuropathy. Clin Neurophysiol 2011; 122:2336-44. [PMID: 21855406 DOI: 10.1016/j.clinph.2011.07.036] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2011] [Revised: 07/07/2011] [Accepted: 07/08/2011] [Indexed: 10/15/2022]
Abstract
The porphyrias are inherited metabolic disorders arising from disturbance in the haem biosynthesis pathway. The neuropathy associated with acute intermittent porphyria (AIP) occurs due to mutation involving the enzyme porphobilinogen deaminase (PBGD) and is characterised by motor-predominant features. Definitive diagnosis often encompasses a combination of biochemical, enzyme analysis and genetic testing, with clinical neurophysiological findings of a predominantly motor axonal neuropathy. Symptomatic and supportive treatment are the mainstays during an acute attack. If administered early, intravenous haemin may prevent progression of neuropathy. While the pathophysiology of AIP neuropathy remains unclear, axonal dysfunction appears intrinsically linked to the effects of neural energy deficits acquired through haem deficiency coupled to the neurotoxic effects of porphyrin precursors. The present review will provide an overview of AIP neuropathy, including discussion of recent advances in understanding developed through neurophysiological approaches that have further delineated the pathophysiology of axonal degeneration.
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Affiliation(s)
- Cindy S-Y Lin
- School of Medical Sciences, Faculty of Medicine, University of New South Wales, Sydney, Australia.
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12
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Intraoperative 5-aminolevulinic-acid-induced fluorescence in meningiomas. Acta Neurochir (Wien) 2010; 152:1711-9. [PMID: 20535506 DOI: 10.1007/s00701-010-0708-4] [Citation(s) in RCA: 76] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2010] [Accepted: 05/28/2010] [Indexed: 10/19/2022]
Abstract
OBJECT 5-aminolevulinic acid (5-ALA) has gained importance as an intraoperative photodynamic diagnostic agent for the extirpation of malignant gliomas. The application of this technique for resection of meningiomas has barely been explored. The aim of this study was to evaluate the utility of 5-ALA-induced fluorescence as a visual tool in meningioma resection and its correlation with histological findings. METHODS A total of 33 consecutive patients undergoing resection of intracranial meningiomas from December 2007 to August 2009 were included in this study. After confirmation of normal liver function, 5-ALA was administered orally (20 mg/kg) within 3-5 h prior to skin incision. All cases were operated on using standard microsurgical and neuronavigation-guided techniques. Intraoperative 440 nm fluorescence was applied periodically during and at the end of resection in order to detect tumor-infiltrated sites. The fluorescence of the tumor was evaluated intraoperatively by the surgeon and confirmed by subsequent video analysis. RESULTS A total of 32 (97%) patients presented with benign meningiomas (WHO I-II). In 1 (3%) patient, histological anaplastic signs (WHO III) could be demonstrated. 5-ALA-induced fluorescence of the tumor was confirmed in a total of 31 (94%) patients. The fluorescence did not correlate with the histological findings (n = 30 WHO I-II, n = 1 WHO grade III) or with preoperative brain edema and administration of steroids. A total resection could be postoperatively demonstrated in 25 (76%) patients. No adverse effects attributable to 5-ALA occurred. CONCLUSIONS 5-ALA-induced fluorescence is a useful and promising intraoperative tool for the visualization of meningioma tissue. The novel findings demonstrated in this study in terms of high fluorescence and poor correlation with histological findings highlight the usefulness of this technique as a routine visual tool to achieve optimal resection of meningiomas.
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Dwyer BE, Stone ML, Zhu X, Perry G, Smith MA. Heme deficiency in Alzheimer's disease: a possible connection to porphyria. J Biomed Biotechnol 2010; 2006:24038. [PMID: 17047301 PMCID: PMC1559910 DOI: 10.1155/jbb/2006/24038] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
Mechanisms that cause Alzheimer's disease (AD), an invariably
fatal neurodegenerative disease, are unknown. Important recent
data indicate that neuronal heme deficiency may
contribute to AD pathogenesis. If true, factors that contribute to
the intracellular heme deficiency could potentially alter the
course of AD. The porphyrias are metabolic disorders characterized
by enzyme deficiencies in the heme biosynthetic pathway. We
hypothesize that AD may differ significantly in individuals
possessing the genetic trait for an acute hepatic porphyria. We
elaborate on this hypothesis and briefly review the
characteristics of the acute hepatic porphyrias that may be
relevant to AD. We note the proximity of genes encoding enzymes of
the heme biosynthesis pathway to genetic loci linked to sporadic,
late-onset AD. In addition, we suggest that identification of
individuals carrying the genetic trait for acute porphyria may
provide a unique resource for investigating AD pathogenesis and
inform treatment and management decisions.
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Affiliation(s)
- Barney E. Dwyer
- Research Service (151), VA Medical & Regional Office
Center, White River Junction, VT 05009, USA
- Department of Medicine (Neurology), Dartmouth Medical
School, Hanover, NH 03755, USA
- *Barney E. Dwyer:
| | - Meghan L. Stone
- Research Service (151), VA Medical & Regional Office
Center, White River Junction, VT 05009, USA
| | - Xiongwei Zhu
- Institute of Pathology, Case Western Reserve
University, Cleveland, OH 44106, USA
| | - George Perry
- Institute of Pathology, Case Western Reserve
University, Cleveland, OH 44106, USA
| | - Mark A. Smith
- Institute of Pathology, Case Western Reserve
University, Cleveland, OH 44106, USA
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Bisland SK, Lilge L, Lin A, Rusnov R, Wilson BC. Metronomic Photodynamic Therapy as a New Paradigm for Photodynamic Therapy: Rationale and Preclinical Evaluation of Technical Feasibility for Treating Malignant Brain Tumors¶. Photochem Photobiol 2007. [DOI: 10.1111/j.1751-1097.2004.tb00044.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Ogasawara T, Miyoshi N, Sano K, Kitagawa Y, Yamada T, Ogawa T, Miyauchi K, Kinoshita H. Influence of administration methods on the accumulation of ALA-induced Pp-IX in mouse tongue tumors. Oral Dis 2006; 12:415-9. [PMID: 16792728 DOI: 10.1111/j.1601-0825.2006.01216.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE 5-Aminolevulinic acid (ALA)-induced protoporphyrin IX (PpIX) has been used as a photosensitizer in photodynamic therapy (PDT) for oral cancer. This study investigates the optimal method of administrating ALA by analyzing PpIX fluorescence in tongue tumor tissue. METHODS Protoporphyrin IX intensities in the mouse (C3H)-transplanted tongue cancer (NR-S1) were compared with those in normal tongue after intraperitoneal (i.p.), oral (p.o.) or topical administration of ALA. Tongues were sampled at various times after ALA administration. PpIX intensities were obtained from frozen sections of each sample by using a spectrophotometer. RESULTS Protoporphyrin IX intensity in the tumor group peaked at 3 h after the i.p. and 5 h after the p.o. administration of ALA, and these levels were about twice as high as those in the normal group. Maximum PpIX accumulation in the tongue tumor tissue was seen at 5 h after p.o. administration of ALA. In contrast, the topical administration of 20% ALA cream was associated with the lowest PpIX accumulation in the tumor throughout the experiments. CONCLUSION These results suggested that p.o. administration of ALA was the most effective method in ALA-PDT for oral cancer.
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Affiliation(s)
- T Ogasawara
- Division of Dentistry and Oral Surgery, Department of Sensory and Locomotor Medicine, School of Medicine, Faculty of Medical Sciences, University of Fukui, Matsuoka, Fukui, Japan.
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Wang L, Yan D, Gu Y, Sun LG, Ruan DY. Effects of extracellular δ-aminolaevulinic acid on sodium currents in acutely isolated rat hippocampal CA1 neurons. Eur J Neurosci 2005; 22:3122-8. [PMID: 16367778 DOI: 10.1111/j.1460-9568.2005.04471.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
The effects of delta-aminolaevulinic acid (ALA) on voltage-gated sodium channel (VGSC) currents (I(Na)) in acutely isolated hippocampal CA1 neurons from 10- to 12-day-old Wistar rats were examined by using the whole-cell patch-clamp technique under voltage-clamp conditions. ALA from 0.01 microm to 20 microm was applied to the recorded neurons. Low concentrations of ALA (0.01-1.0 microM) increased I(Na) amplitude, whereas high concentrations of ALA (5.0-20.0 microM) decreased it. The average I(Na) amplitude reached a maximum of 117.4 +/- 3.9% (n = 9, P < 0.05) with 0.1 microM ALA, and decreased to 78.1 +/- 3.8% (n = 13, P < 0.05) with 10 microm ALA. ALA shifted the steady-state activation and inactivation curves of I(Na) in the hyperpolarizing direction with different V0.5, suggesting that ALA could depress the opening threshold of the voltage-gated sodium channel (VGSC) and thus increase the excitability of neurons through facilitating the opening of VGSC. The time course of recovery from inactivation was significantly prolonged at both low and high concentrations of ALA, whereas either low or high concentrations of ALA had no significant effect on the attenuation of I(Na) during stimulation at 5 Hz, indicating that the effect of ALA on VGSC is state-independent. Furthermore, we found that application of ascorbic acid, which blocks pro-oxidative effects in neurons, could prevent the increase of I(Na) amplitude at low concentrations of ALA. Baclofen, an agonist of GABAb receptors, induced some similar effects to ALA on VGSC, whereas bicuculline, an antagonist of GABAa receptors, could not prevent ALA-induced effects on VGSC. These results suggested that ALA regulated VGSC mainly through its pro-oxidative effects and GABAb receptor-mediated effects.
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Affiliation(s)
- Lang Wang
- School of Life Science and Institute of Polar Environment, University of Science & Technology of China, Hefei, Anhui 230027, People's Republic of China
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17
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Sylantiev C, Schoenfeld N, Mamet R, Groozman GB, Drory VE. Acute neuropathy mimicking porphyria induced by aminolevulinic acid during photodynamic therapy. Muscle Nerve 2005; 31:390-3. [PMID: 15490483 DOI: 10.1002/mus.20167] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
An 82-year-old man developed severe, acute, predominantly motor polyneuropathy, signs of autonomic involvement, and skin changes following aminolevulinic acid (ALA) administration. The compound was used as a prodrug for photodynamic therapy of Barrett's esophagitis. Changes were observed in various parameters of the heme pathway. The case reported represents a rare response to ALA treatment, resembling an acute attack of hepatic porphyria with neurological features.
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Affiliation(s)
- Constantin Sylantiev
- Department of Neurology, Tel Aviv Sourasky Medical Center, 6, Weizman Street, Tel Aviv 642 39, Israel
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18
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Bisland SK, Lilge L, Lin A, Rusnov R, Wilson BC. Metronomic photodynamic therapy as a new paradigm for photodynamic therapy: rationale and preclinical evaluation of technical feasibility for treating malignant brain tumors. Photochem Photobiol 2004; 80:22-30. [PMID: 15339204 DOI: 10.1562/2004-03-05-ra-100.1] [Citation(s) in RCA: 116] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
The concept of metronomic photodynamic therapy (mPDT) is presented, in which both the photosensitizer and light are delivered continuously at low rates for extended periods of time to increase selective tumor cell kill through apoptosis. The focus of the present preclinical study is on mPDT treatment of malignant brain tumors, in which selectivity tumor cell killing versus damage to normal brain is critical. Previous studies have shown that low-dose PDT using 5-aminolevulinic acid (ALA)-induced protoporphyrin IX (PpIX) can induce apoptosis in tumor cells without causing necrosis in either tumor or normal brain tissue or apoptosis in the latter. On the basis of the levels of apoptosis achieved and model calculations of brain tumor growth rates, metronomic delivery or multiple PDT treatments, such as hyperfractionation, are likely required to produce enough tumor cell kill to be an effective therapy. In vitro studies confirm that ALA-mPDT induces a higher incidence of apoptotic (terminal deoxynucleotidyl transferase-mediated 2'-deoxyuridine 5'-triphosphate, sodium salt nick-end labeling positive) cells as compared with an acute, high-dose regimen (ALA-aPDT). In vivo, mPDT poses two substantial technical challenges: extended delivery of ALA and implantation of devices for extended light delivery while allowing unencumbered movement. In rat models, ALA administration via the drinking water has been accomplished at very high doses (up to 10 times therapeutic dose) for up to 10 days, and ex vivo spectrofluorimetry of tumor (9L gliosarcoma) and normal brain demonstrates a 3-4 fold increase in the tumor-to-brain ratio of PpIX concentration, without evidence of toxicity. After mPDT treatment, histological staining reveals extensive apoptosis within the tumor periphery and surrounding microinvading colonies that is not evident in normal brain or tumor before treatment. Prototype light sources and delivery devices were found to be practical, either using a laser diode or light-emitting diode (LED) coupled to an implanted optical fiber in the rat model or a directly implanted LED using a rabbit model. The combined delivery of both drug and light during an extended period, without compromising survival of the animals, is demonstrated. Preliminary evidence of selective apoptosis of tumor under these conditions is presented.
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Affiliation(s)
- Stuart K Bisland
- Ontario Cancer Institute, University Health Network, 610 University Avenue, Toronto, Ontario, Canada M5G 2M9.
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Sabban F, Collinet P, Cosson M, Mordon S. Technique d’imagerie par fluorescence : intérêt diagnostique et thérapeutique en gynécologie. ACTA ACUST UNITED AC 2004; 33:734-8. [PMID: 15687945 DOI: 10.1016/s0368-2315(04)96635-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Fluorescence techniques are presently used by several medical and surgical disciplines (dermatology, pneumology, urology, gastrointestinal surgery) for the diagnosis of pre-cancerous and cancerous lesions. The technique is based on the application of 5-aminolevulinic acid (5-ALA) which induces the production of an endogen photosensitizer: protoporphyrin IX (PpIX). Fluorescence detection of the infraclinical dysplasia lesion is based on the contrast between fluorescent pathological tissue and non-fluorescent healthy tissue. Moreover, there is a correlation between the degree of tissue dysplasia and fluorescence intensity. Fluorescence imaging could allow easier detection of infraclinical lesions enabling more well-targeted treatment. In gynecology, many experimental and clinical studies have been conducted on the detection and treatment of cervical dysplasia and the diagnosis and treatment of vaginal and vulvar diseases as well as the diagnosis of peritoneal micrometastasis from ovarian cancer, the diagnosis and treatment of endometrial alterations, and the treatment of locoregional recurrent skin breast cancer. The aim of this work is to present the fundamental principles of fluorescence imaging technical and to expose the diagnostic and therapeutic prospects in gynecology.
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Affiliation(s)
- F Sabban
- Maternité Jeanne de Flandre, avenue Eugène-Avinée, 59037 Lille Cedex
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20
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Photodynamic therapy for pancreatic carcinoma: experimental and clinical studies. Photodiagnosis Photodyn Ther 2004; 1:145-55. [DOI: 10.1016/s1572-1000(04)00038-9] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2004] [Revised: 07/28/2004] [Accepted: 07/28/2004] [Indexed: 01/03/2023]
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21
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Lee C, Qiao X, Goeger DE, Anderson KE. Fluorometric measurement of 5-aminolevulinic acid in serum. Clin Chim Acta 2004; 347:183-8. [PMID: 15313157 DOI: 10.1016/j.cccn.2004.04.015] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2004] [Revised: 04/19/2004] [Accepted: 04/19/2004] [Indexed: 10/26/2022]
Abstract
BACKGROUND Measurement of 5-aminolevulinic acid (ALA) in serum is potentially useful in acute porphyrias, lead poisoning and hereditary tyrosinemia. Because levels of ALA in serum are about 100 times less than in urine, a highly sensitive method is required. We describe a simple and sensitive fluorometric method that does not require HPLC. METHODS ALA is separated from serum using a cation-exchange resin (DOWEX 50WX8-400), followed by addition of acetylacetone and formaldehyde to produce a fluorescent ALA derivative by the Hantzsch reaction. The fluorescence was measured at an excitation wavelength of 370 nm, and the emission peak was near 463 nm. Results were compared with measurements of ALA by a published HPLC method on the same samples. RESULTS The fluorometric method was linear for ALA concentrations up to 500 microg/l with a detection limit of about 8.7 microg/l. Within-run variations (N=8) at 25 and 100 microg/l ALA were 3.7% and 3.1%, respectively, and day-to-day variations (N=10) for the same levels were 7.2% and 6.1%, respectively. The regression equation for this method in reference to the HPLC method (Y=0.99X+10.34 for N=34, r=0.98, S(y/x)=36.1) had a slope of near unity and an insignificant y-intercept, although values less than 50 microg/l were generally slightly higher by the fluorometric method than by HPLC. The reference range for serum ALA was 0-79.4 microg/l (35.2+/-22.1, mean+/-S.D., N=42), with a distribution skewed to the left because levels in eight subjects were below the detection limit. CONCLUSIONS This simple, fluorometric method for serum ALA correlated well with the results of the HPLC method, and may be suitable for assessing biochemical expression of acute porphyrias and response to treatment especially when HPLC is not available.
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Affiliation(s)
- Chul Lee
- Division of Human Nutrition, Department of Preventive Medicine and Community Health, The University of Texas Medical Branch, 700 Harborside Drive, Galveston, TX 77555-1109, USA.
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22
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Johansson A, Möller C, Fogh J, Harper P. Biochemical characterization of porphobilinogen deaminase-deficient mice during phenobarbital induction of heme synthesis and the effect of enzyme replacement. Mol Med 2003; 9:193-9. [PMID: 15208740 PMCID: PMC1430985 DOI: 10.2119/2004-00002.johansson] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2004] [Accepted: 04/24/2004] [Indexed: 11/06/2022] Open
Abstract
Acute intermittent porphyria (AIP) is a genetic disorder caused by a deficiency of porphobilinogen deaminase (PBGD), the 3rd enzyme in heme synthesis. It is clinically characterized by acute attacks of neuropsychiatric symptoms and biochemically by increased urinary excretion of the porphyrin precursors porphobilinogen (PBG) and 5-aminolevulinic acid (ALA). A mouse model that is partially deficient in PBGD and biochemically mimics AIP after induction of the hepatic ALA synthase by phenobarbital was used in this study to identify the site of formation of the presumably toxic porphyrin precursors and study the effect of enzyme-replacement therapy by using recombinant human PBGD (rhPBGD). After 4 d of phenobarbital administration, high levels of PBG and ALA were found in liver, kidney, plasma, and urine of the PBGD-deficient mice. The administration of rhPBGD intravenously or subcutaneously after a 4-d phenobarbital induction was shown to lower the PBG level in plasma in a dose-dependent manner with maximal effect seen after 30 min and 2 h, respectively. Injection of rhPBGD subcutaneously twice daily during a 4-d phenobarbital induction reduced urinary PBG excretion to 25% of the levels found in PBGD-deficient mice administered with only phenobarbital. This study points to the liver as the main producer of PBG and ALA in the phenobarbital-induced PBGD-deficient mice and demonstrates efficient removal of accumulated PBG in plasma and urine by enzyme-replacement therapy.
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Affiliation(s)
- Annika Johansson
- Porphyria Centre Sweden, Department of Laboratory Medicine, Division of Clinical Chemistry, Karolinska Institute, Karolinska University Hospital, Stockholm, Sweden.
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23
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Kelty CJ, Brown NJ, Reed MWR, Ackroyd R. The use of 5-aminolaevulinic acid as a photosensitiser in photodynamic therapy and photodiagnosis. Photochem Photobiol Sci 2002; 1:158-68. [PMID: 12659511 DOI: 10.1039/b201027p] [Citation(s) in RCA: 102] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Photodynamic therapy (PDT) is a treatment for cancer and pre-malignant conditions, which involves the administration of a photosensitising agent followed by exposure of the tissue to light. 5-Aminolaevulinic acid (ALA) is a naturally occurring compound in the haem biosynthetic pathway, which is metabolised to a photosensitive product, protoporphyrin IX (PpIX). The major advantage of ALA when compared to synthetic photosensitisers is the rapid metabolism, which significantly reduces the period of cutaneous photosensitivity. This review focuses on the development of ALA as a photosensitiser in photodynamic therapy and photodiagnosis, and the wide range of clinical applications in which ALA is now being used as a therapeutic modality.
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Affiliation(s)
- Clive J Kelty
- Academic Surgical Oncology Unit, Section of Clinical Sciences, University of Sheffield, Glossop Road, Sheffield, UK S10 2JF
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24
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Piot B, Rousset N, Lenz P, Eléouet S, Carré J, Vonarx V, Bourré L, Patrice T. Enhancement of delta aminolevulinic acid-photodynamic therapy in vivo by decreasing tumor pH with glucose and amiloride. Laryngoscope 2001; 111:2205-13. [PMID: 11802027 DOI: 10.1097/00005537-200112000-00026] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES/HYPOTHESIS Delta aminolevulinic acid (ALA)-induced protoporphyrin IX (PpIX) is a fluorescent sensitizer that permits detection and treatment of squamous cell carcinoma of the oral cavity. An exogenously induced decrease in tissue pH was evaluated for its effect in enhancing cellular uptake of ALA and facilitating its transformation into PpIX. STUDY DESIGN Mice grafted with HT29 colonic cancers had been given glucose and amiloride to modify the pH of tissues. Influence of pH changes has been evaluated on ALA-induced PPIX fluorescence by optic fiber spectrofluorimetry as well as on tumor growth. METHODS RESULTS The pH in HT 29 tumor decreased from 7.1 to 6.67 (P < .05) after intraperitoneal injection of glucose and amiloride. The PpIX fluorescence ratios in tumor or muscle before, between, and 2 hours after glucose and amiloride injection were not higher than control ratios. Aminolevulinic acid-photodynamic therapy was more efficient on HT 29 tumor-bearing mice when the pH value was decreased with glucose and amiloride, showing a difference in the tumor growth index ratio from the 1st to 14th day of 22% between amiloride-glucose aminolevulinic acid-photodynamic therapy and aminolevulinic acid-photodynamic therapy alone (P < .05). CONCLUSIONS Glucose and amiloride did not change PpIX fluorescence in HT 29 tumor after intraperitoneal injection of aminolevulinic acid but enhanced aminolevulinic acid-photodynamic therapy efficacy. This was probably a result of mechanisms other than an increase in aminolevulinic acid cellular penetration and PpIX production, such as susceptibility to free radical toxicity or alteration of cellular repair enzymes under acidotic conditions. If a decrease of pH induces a more efficient photodynamic therapy as suggested by our results, an easier way to obtain this decrease than glucose and amiloride would be necessary for clinical applications.
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Affiliation(s)
- B Piot
- Laboratoire de Photobiologie des Cancers, Centre Hospitalier Régional et Universitaire de Nantes, Nantes, France
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25
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Ackroyd R, Brown N, Vernon D, Roberts D, Stephenson T, Marcus S, Stoddard C, Reed M. 5-Aminolevulinic Acid Photosensitization of Dysplastic Barrett's Esophagus: A Pharmacokinetic Study. Photochem Photobiol 1999. [DOI: 10.1111/j.1751-1097.1999.tb08266.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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26
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Lindberg RL, Martini R, Baumgartner M, Erne B, Borg J, Zielasek J, Ricker K, Steck A, Toyka KV, Meyer UA. Motor neuropathy in porphobilinogen deaminase-deficient mice imitates the peripheral neuropathy of human acute porphyria. J Clin Invest 1999; 103:1127-34. [PMID: 10207164 PMCID: PMC408280 DOI: 10.1172/jci5986] [Citation(s) in RCA: 78] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
Acute porphyrias are inherited disorders caused by partial deficiency of specific heme biosynthesis enzymes. Clinically, porphyrias are manifested by a neuropsychiatric syndrome that includes peripheral neuropathy. Although much is known about the porphyrias' enzyme defects and their biochemical consequences, the cause of the neurological manifestations remains unresolved. We have studied porphyric neuropathy in mice with a partial deficiency of porphobilinogen deaminase (PBGD). PBGD-deficient mice (PBGD-/-) imitate acute porphyria through massive induction of hepatic delta-aminolevulinic acid synthase by drugs such as phenobarbital. Here we show that PBGD-/- mice develop impairment of motor coordination and muscle weakness. Histologically femoral nerves of PBGD-/- mice exhibit a marked decrease in large-caliber (>8 microm) axons and ultrastructural changes consistent with primary motor axon degeneration, secondary Schwann cell reactions, and axonal regeneration. These findings resemble those found in studies of affected nerves of patients with acute porphyria and thus provide strong evidence that PBGD deficiency causes degeneration of motor axons without signs of primary demyelination, thereby resolving a long-standing controversy. Interestingly, the neuropathy in PBGD-/- mice developed chronically and progressively and in the presence of normal or only slightly (twofold) increased plasma and urinary levels of the putative neurotoxic heme precursor delta-aminolevulinic acid. These data suggest that heme deficiency and consequent dysfunction of hemeproteins can cause porphyric neuropathy.
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Affiliation(s)
- R L Lindberg
- Biozentrum, University of Basel, CH-4056 Basel, Switzerland
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27
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Abstract
Many patients with cutaneous porphyria have curable or controllable disease; untreated porphyria may prove fatal. The genetic defects and mechanisms underlying porphyria are steadily being delineated, treatments have become more appropriate and genetic counselling is now more accurate. A summary of the basic diagnostic features, management and recent advances in the cutaneous porphyrias is presented, based on a workshop held by the British Photodermatology Group.
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Affiliation(s)
- G M Murphy
- Photobiology Unit, Beaumont and Mater Misericordiae Hospitals, Dublin 7, Ireland.
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28
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Herman MA, Webber J, Fromm D, Kessel D. Hemodynamic effects of 5-aminolevulinic acid in humans. JOURNAL OF PHOTOCHEMISTRY AND PHOTOBIOLOGY. B, BIOLOGY 1998; 43:61-5. [PMID: 9639916 DOI: 10.1016/s1011-1344(98)00086-4] [Citation(s) in RCA: 54] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Endogenous protoporphyrin IX (PpIX), which results from the oral administration of 5-aminolevulinic acid (ALA), is being investigated for its efficacy as a photosensitizing agent for photodynamic therapy (PDT). Clinical use of ALA has been associated with only mild gastrointestinal side effects. The hemodynamic effects of orally administered ALA in doses used for PDT are unknown. Six patients with a significant history of cardiac disease underwent Swan-Ganz catheterization prior to ALA administration and abdominal operation for PDT. Hemodynamic data collection began at least 1 h prior to ALA, and continued for at least 4 h subsequently, during which time no other medications were administered. When compared to measurements made prior to ALA administration, all patients displayed a significant decrease in systolic and diastolic blood pressures, pulmonary artery systolic and diastolic pressures as well as pulmonary vascular resistance. Five of the six patients also developed a decrease in systemic vascular resistance. No significant changes in pulmonary capillary wedge pressure, cardiac output or cardiac index was observed, but the mean pulse rate rose significantly. These findings cannot be explained on the basis of other cardiovascular depressants or to poor central volume status. Although no adverse sequela were appreciated as a result of the observed hemodynamic changes, this potential should be recognized in patients undergoing PDT using ALA.
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Affiliation(s)
- M A Herman
- Department of Surgery, Wayne State University, Detroit, MI 48201, USA
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Rick K, Sroka R, Stepp H, Kriegmair M, Huber RM, Jacob K, Baumgartner R. Pharmacokinetics of 5-aminolevulinic acid-induced protoporphyrin IX in skin and blood. JOURNAL OF PHOTOCHEMISTRY AND PHOTOBIOLOGY. B, BIOLOGY 1997; 40:313-9. [PMID: 9372622 DOI: 10.1016/s1011-1344(97)00076-6] [Citation(s) in RCA: 90] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
The fluorescence and photosensitivity of endogenously synthesized protoporphyrin IX (PPIX) is increasingly used for the diagnosis and treatment of malignant and certain non-malignant diseases. A selective accumulation of PPIX can be induced by application of 5-aminolevulinic acid (5-ALA), which is a precursor of PPIX in the cellular biosynthetic pathway of heme. The purpose of this study was to monitor the in vivo accumulation of PPIX in different locations of the skin after oral ingestion and to determine the pharmacokinetics of 5-ALA and PPIX in human blood plasma for various routes of application. At the same time we wanted to achieve an optimal treatment scheme but also study possible side-effects of 5-ALA administration. After oral application of 5-ALA in a concentration of 40 mg kg-1 body weight, the fluorescence intensities of PPIX in the skin showed maxima between 6.5 and 9.8 h depending on the location and decreased to values lower than 5% related to the maximum after a mean time of about 40 h. The measured absolute intensities of PPIX fluorescence varied strongly between different patients and different locations on one patient. In the plasma of blood samples, PPIX could be detected via its fluorescence for all studied routes of application with the exception of the ointment, where PPIX levels were below the detection limit of 1 microgram l-1. The highest mean concentration of 742 micrograms l-1 PPIX in the plasma was measured 6.7 h after oral application. For inhalation of 5-ALA, a mean maximum concentration of 12 micrograms l-1 could be detected 4.1 h after application, for intravesical instillation, the mean maximum concentration was found to be 1 microgram l-1 2.9 h after application. The kinetics of 5-ALA in the plasma peaked much earlier with a maximum concentration of 32 mg l-1 about 30 min. after oral administration. The 5-ALA levels did not exceed normal reference values after topical application. The results of our experiments suggest that for a systemic application of 5-ALA side-effects in sensitive patients cannot be excluded.
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Affiliation(s)
- K Rick
- Department of Urology, University of Munich, Germany
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30
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Herman MA, Webber J, Luo Y, Patacsil V, Kessel D, Fromm D. Effects of fractionated 5-aminolevulinic acid administration on tissue levels of protoporphyrin in vivo. JOURNAL OF PHOTOCHEMISTRY AND PHOTOBIOLOGY. B, BIOLOGY 1997; 40:107-10. [PMID: 9345781 DOI: 10.1016/s1011-1344(97)00033-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
The photodynamic therapy (PDT) of malignant tissues can be achieved via the administration of 5-aminolevulinic acid (ALA), which is naturally converted to the photoreactive substance protoporphyrin IX (PP). This study compares bolus with fractionated ALA dosing in order to determine whether one of these methods results in a higher tissue concentration of PP. Mice bearing a subcutaneously implanted colon-26 tumor were treated with ALA (200 mg kg-1), given intravenously either as a single bolus or as three equally divided doses at 50 min intervals. Tissue samples of tumor, kidney, skin, liver, skeletal muscle, colon and plasma were obtained 2, 3, 4 and 6 h later for the analysis of PP concentrations. Fractionated dosing results in significantly higher concentrations of PP at 4 and 6 h for kidney, 3 and 6 h for skin, 3 h for colon and 6 h for liver. In contrast, fractionated dosing has no significant effect on the PP concentrations of muscle and plasma. Fractionated dosing results in a significantly greater PP concentration in the tumor at 3 h relative to that observed for the bolus dose. However, from a consideration of the time of PP measurement, it is concluded that fractionated dosing may not cause a significant increase in the PP concentration in colon-26 tumors relative to that observed for the bolus dose.
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Affiliation(s)
- M A Herman
- Department of Surgery, Wayne State University, Detroit, MI 48201, USA
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Peng Q, Warloe T, Berg K, Moan J, Kongshaug M, Giercksky KE, Nesland JM. 5-Aminolevulinic acid-based photodynamic therapy. Clinical research and future challenges. Cancer 1997; 79:2282-308. [PMID: 9191516 DOI: 10.1002/(sici)1097-0142(19970615)79:12<2282::aid-cncr2>3.0.co;2-o] [Citation(s) in RCA: 683] [Impact Index Per Article: 25.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND Photodynamic therapy (PDT) for cancer patients has developed into an important new clinical treatment modality in the past 25-years. PDT involves administration of a tumor-localizing photosensitizer or photosensitizer prodrug (5-aminolevulinic acid [ALA], a precursor in the heme biosynthetic pathway) and the subsequent activation of the photosensitizer by light. Although several photosensitizers other than ALA-derived protoprophyrin IX (PpIX) have been used in clinical PDT, ALA-based PDT has been the most active area of clinical PDT research during the past 5 years. Studies have shown that a higher accumulation of ALA-derived PpIX in rapidly proliferating cells may provide a biologic rationale for clinical use of ALA-based PDT and diagnosis. However, no review updating the clinical data has appeared so far. METHODS A review of recently published data on clinical ALA-based PDT and diagnosis was conducted. RESULTS Several individual studies in which patients with primary nonmelanoma cutaneous tumors received topical ALA-based PDT have reported promising results, including outstanding cosmetic results. However, the modality with present protocols does not in general, appear to be superior to conventional therapies with respect to initial complete response rates and long term recurrence rates, particularly in the treatment of nodular skin tumors. Topical ALA-PDT does have the following advantages over conventional treatments: it is noninvasive; it produces excellent cosmetic results; it is well tolerated by patients; it can be used to treat multiple superficial lesions in short treatment sessions; it can be applied to patients who refuse surgery or have pacemakers and bleeding tendency; it can be used to treat lesions in specific locations, such as the oral mucosa or the genital area; it can be used as a palliative treatment; and it can be applied repeatedly without cumulative toxicity. Topical ALA-PDT also has potential as a treatment for nonneoplastic skin diseases. Systemic administration of ALA does not seem to be severely toxic, but the advantage of using this approach for PDT of superficial lesions of internal hollow organs is still uncertain. The ALA-derived porphyrin fluorescence technique would be useful in the diagnosis of superficial lesions of internal hollow organs. CONCLUSIONS Promising results of ALA-based clinical PDT and diagnosis have been obtained. The modality has advantages over conventional treatments. However, some improvements need to be made, such as optimization of parameters of ALA-based PDT and diagnosis; increased tumor selectivity of ALA-derived PpIX; better understanding of light distribution in tissue: improvement of light dosimetry procedure; and development of simpler, cheaper, and more efficient light delivery systems.
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Affiliation(s)
- Q Peng
- Department of Pathology, Norwegian Radium Hospital, University of Oslo, Norway
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Grönlund-Pakkanen S, Mäkinen K, Talja M, Kuusisto A, Alhava E. The importance of fluorescence distribution and kinetics of ALA-induced PpIX in the bladder in photodynamic therapy. JOURNAL OF PHOTOCHEMISTRY AND PHOTOBIOLOGY. B, BIOLOGY 1997; 38:269-73. [PMID: 9203390 DOI: 10.1016/s1011-1344(96)00007-3] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Photodynamic therapy (PDT) is a new anticancer technique directed at the selective destruction of neoplastic tissue. Aminolevulinic acid (ALA), a precursor in the biosynthesis of home, induces the production of the endogenous photosensitizer protoporphyrin IX (PpIX). In this study the fluorescence distribution of ALA-induced PpIX was investigated in the rat bladder wall by fluorescence microscopy. The fluorescence studies showed that PpIX concentrates in bladder mucosa and that the highest fluorescence levels are achieved after four hours of 300 mg/kg ALA administration. A clear trend in difference between mucosa and muscularis layers was found in all samples taken after 1, 2, 4 and 6 hours of ALA administration. Our results suggest that to get the highest PpIX fluorescence intensity in bladder mucosa it is best to use 300 mg/kg ALA administration. Four hours is the time point when the highest difference in fluorescence between mucosa and muscularis is reached.
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Heyerdahl H, Wang I, Liu DL, Berg R, Andersson-Engels S, Peng Q, Moan J, Svanberg S, Svanberg K. Pharmacokinetic studies on 5-aminolevulinic acid-induced protoporphyrin IX accumulation in tumours and normal tissues. Cancer Lett 1997; 112:225-31. [PMID: 9066732 DOI: 10.1016/s0304-3835(96)04576-4] [Citation(s) in RCA: 53] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Laser-induced fluorescence (LIF) for in vivo point monitoring and fluorescence microscopy incorporating a CCD camera were used to study the fluorescence distribution of 5-aminolevulinic acid (ALA)-induced protoporphyrin IX (PpIX) in tumours. Fluorescence in a chemically-induced adenocarcinoma in the liver of rats and in an aggressive basal cell carcinoma in a patient were studied after intravenous injection of ALA at a dose of 30 mg/kg body weight. The LIF technique demonstrated slightly more ALA-induced PpIX fluorescence in the tumour than in the surrounding normal liver and abdominal muscle of rats. The visible parts of the human basal cell carcinoma exhibited strong ALA-induced fluorescence, while this fluorescence was much weaker in the necrotic areas of the tumour and in the surrounding normal skin.
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Affiliation(s)
- H Heyerdahl
- Department of Surgical Oncology, Norwegian Radium Hospital, Montebello, Oslo, Norway
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34
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Webber J, Kessel D, Fromm D. Plasma levels of protoporphyrin IX in humans after oral administration of 5-aminolevulinic acid. JOURNAL OF PHOTOCHEMISTRY AND PHOTOBIOLOGY. B, BIOLOGY 1997; 37:151-3. [PMID: 9043101 DOI: 10.1016/s1011-1344(96)07348-4] [Citation(s) in RCA: 50] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
We report on the pharmacokinetics of PP formation and elimination in 4 patients after the administration of oral ALA (60 mg kg-1). After a brief distribution phase, plasma PP levels decline (half life = 8 h) and was almost undetectable by 48 h post-administration. This confirms pharmacokinetic clinical data which show that ALA in a shortened interval of skin photosensitization compared with other sensitizers such as Photofrin and 'HPD'. A brief summary of other clinical-toxicity findings is reported.
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Affiliation(s)
- J Webber
- Department of Surgery, Wayne State University, Detroit, MI 48201, USA
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Fan KF, Hopper C, Speight PM, Buonaccorsi G, MacRobert AJ, Bown SG. Photodynamic therapy using 5-aminolevulinic acid for premalignant and malignant lesions of the oral cavity. Cancer 1996; 78:1374-83. [PMID: 8839541 DOI: 10.1002/(sici)1097-0142(19961001)78:7<1374::aid-cncr2>3.0.co;2-l] [Citation(s) in RCA: 142] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
BACKGROUND Premalignant changes in the mouth, which are often widespread, are frequently excised or vaporized, whereas cancers are treated by excision or radiotherapy, both of which have cumulative morbidity. Photodynamic therapy (PDT) is another option that produces local tissue necrosis with light after prior administration of a photosensitizing agent. This heals with remarkably little scarring and no cumulative toxicity. This article describes the use of PDT with the photosensitizing agent 5-aminolevulinic acid (ALA) for premalignant and malignant lesions of the mouth. METHODS Eighteen patients with histologically proven premalignant and malignant lesions of the mouth were sensitized with 60 mg/kg ALA by mouth and treated with laser light at 628 nanometers (100 or 200 Joules/cm2). The results were assessed macroscopically and microscopically. Biopsies were taken immediately prior to PDT for fluorescence studies, a few days after PDT to assess the depth of necrosis, when healing was complete, and up to 88 weeks later. RESULTS The depth of necrosis varied from 0.1 to 1.3 mm, but complete epithelial necrosis was present in all cases. All 12 patients with dysplasia showed improvement (repeat biopsy was normal or less dysplastic) and the treated areas healed without scarring. Some benefit was observed in five of six patients with squamous cell carcinoma, but only two became tumor free (one with persistent mild dysplasia). No patient had cutaneous photosensitivity for longer than 2 days. CONCLUSIONS PDT using ALA for dysplasia of the mouth produces consistent epithelial necrosis with excellent healing and is a simple and effective way to manage these patients. Results in invasive cancers are less satisfactory, mainly because the PDT effect is too superficial with current treatment regimens using ALA as the photosensitizing agent.
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Affiliation(s)
- K F Fan
- Department of Surgery, University College London Medical School, United Kingdom
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36
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Peng Q, Warloe T, Moan J, Heyerdahl H, Steen HB, Nesland JM, Giercksky KE. Distribution of 5-aminolevulinic acid-induced porphyrins in noduloulcerative basal cell carcinoma. Photochem Photobiol 1995; 62:906-13. [PMID: 8570730 DOI: 10.1111/j.1751-1097.1995.tb09154.x] [Citation(s) in RCA: 118] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Microscopic fluorescence photometry incorporating a light-sensitive thermo-electrically cooled charge-coupled device (CCD) camera was employed to investigate the fluorescence distribution of 5-aminolevulinic acid (ALA)-induced porphyrins in 22 patients with a total number of 52 noduloulcerative basal cell carcinomas (BCC) after topical ALA application with or without dimethylsulfoxide (DMSO)/ethylenediaminetetraacetic acid (EDTA) or after intravenous administration of ALA. Both localization patterns and amounts of ALA-induced porphyrins in the BCC were studied. The ALA-induced porphyrins were localized only in the superficial layers of the noduloulcerative BCC lesions after topical application of 20% ALA alone for 3 h. However, both the penetration of ALA into deep lesions and the production of the ALA-induced porphyrin fluorescence were increased after topical administration of 20% ALA and 20% DMSO/4% EDTA for 3 h. Prior treatment with 99% DMSO for 15 min further enhanced the ALA penetration into the BCC lesions after topical application of the ALA/DMSO/EDTA mixture and produced more ALA-induced porphyrins by a factor of about three compared with those treated with ALA alone. The penetration of ALA into the deep BCC lesions could also be increased by prolonging the time of topical application of 20% ALA/4% EDTA to 29-48 h (without DMSO). Intravenous injection of ALA led to a more homogeneous distribution of the ALA-derived porphyrins in the whole noduloulcerative BCC lesions.
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Affiliation(s)
- Q Peng
- Department of Pathology, Norwegian Radium Hospital, Montebello, Oslo, Norway
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37
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Mlkvy P, Messmann H, Debinski H, Regula J, Conio M, MacRobert A, Spigelman A, Phillips R, Bown SG. Photodynamic therapy for polyps in familial adenomatous polyposis--a pilot study. Eur J Cancer 1995; 31A:1160-5. [PMID: 7577013 DOI: 10.1016/0959-8049(95)00276-o] [Citation(s) in RCA: 23] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
Photodynamic therapy (PDT) produces localised necrosis with light after prior administration of a photosensitising drug. As PDT lesions in the gastrointestinal tract heal so well, the technique is suitable for repeated endoscopic use. In this study, PDT was used to treat large polyps (four duodenal and two colorectal) unsuitable for surgery in 6 patients with familial adenomatous polyposis (FAP). Patients were sensitised with 60 mg/kg 5-aminolaevulinic acid (ALA) orally or intravenous (i.v.) 2.0 mg/kg Photofrin. Laser treatment was performed 6 h after ALA or 48 h after Photofrin using a gold vapour laser. Necrosis was only superficial (up to 1.8 mm) using ALA but much deeper using Photofrin. The one malignant polyp (8 mm diameter in the colon) showed a complete response using Photofrin. All healed safely with no complications. Photofrin worked better, but caused cutaneous photosensitivity lasting up to 3 months. ALA cleared within 2 days, but its use is limited by the superficial effect. Better results with ALA may be obtained using higher drug doses or modified light dosimetry. Fluorescence microscopy showed no evidence of selectivity of photosensitisation between neoplastic and normal tissue. PDT is a promising treatment for inoperable polyps in patients with FAP, but further work is required to optimise the treatment conditions.
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Affiliation(s)
- P Mlkvy
- Oncology Centre Bratislava, Czech Republic
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38
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Regula J, MacRobert AJ, Gorchein A, Buonaccorsi GA, Thorpe SM, Spencer GM, Hatfield AR, Bown SG. Photosensitisation and photodynamic therapy of oesophageal, duodenal, and colorectal tumours using 5 aminolaevulinic acid induced protoporphyrin IX--a pilot study. Gut 1995; 36:67-75. [PMID: 7890239 PMCID: PMC1382355 DOI: 10.1136/gut.36.1.67] [Citation(s) in RCA: 272] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
The first study of photodynamic therapy in the human gastrointestinal tract using 5 aminolaevulinic acid (ALA) induced protoporphyrin IX as the photosensitising agent is described. Eighteen patients with colorectal, duodenal, and oesophageal tumours were studied. After 30-60 mg/kg of ALA given orally, biopsy specimens of tumour and adjacent normal mucosa were taken 1-72 hours later. These specimens were examined by quantitative fluorescence microscopy for assessment of sensitisation with protoporphyrin IX. Ten patients were given a second dose of ALA a few weeks later and their tumours were treated with red laser light (628 nm). With 30 mg/kg ALA, the highest fluorescence values were detected in the duodenum and oesophagus, and the lowest in the large bowel. Doubling the ALA dose in patients with colorectal tumours gave protoporphyrin IX fluorescence intensities similar to those in patients with upper gastrointestinal lesions and improved the tumour:normal mucosa protoporphyrin IX sensitisation ratio. The treated patients showed superficial mucosal necrosis in the areas exposed to laser light. Six patients had transient rises in serum aspartate aminotransferases, two mild skin photosensitivity reactions, and five mild nausea and vomiting. In conclusion, photodynamic therapy with systemically administered ALA may be a promising technique for the treatment of small tumours and areas of dysplasia such as in Barrett's oesophagus.
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Affiliation(s)
- J Regula
- National Medical Laser Centre, Department of Surgery, University College London Medical School
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Regula J, Ravi B, Bedwell J, MacRobert AJ, Bown SG. Photodynamic therapy using 5-aminolaevulinic acid for experimental pancreatic cancer--prolonged animal survival. Br J Cancer 1994; 70:248-54. [PMID: 8054272 PMCID: PMC2033503 DOI: 10.1038/bjc.1994.288] [Citation(s) in RCA: 76] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
Experimental studies have been carried out using 5-aminolaevulinic acid (ALA) to induce transient porphyrin photosensitisation for photodynamic therapy (PDT) in a pancreatic cancer model in Syrian golden hamsters. ALA was given either intravenously or orally (in bolus or fractionated doses) with the laser light delivered by means of a bare fibre touching the tissue surface or external irradiation using a light-integrating cylindrical applicator. Animals were killed 1-24 h after ALA administration for pharmacokinetic studies and 3-7 days after light exposure to study PDT-induced necrosis. A separate survival study was also performed after a fractionated oral dose of ALA and external irradiation. Protoporphyrin IX sensitisation in the tumour tissue as measured by quantitative fluorescence microscopy was highest after intravenous administration of 200 mg kg-1 ALA and then in decreasing order after oral fractionated and oral bolus doses (both 400 mg kg-1). Laser light application at 630 nm to give 12-50 J from the bare fibre or 50 J cm-2 using surface illumination with the cylindrical applicator resulted in tumour necrosis up to 8 mm in depth. In larger tumours a rim of viable tumour was observed on the side opposite to illumination. In a randomised study, survival of treated animals was significantly longer than in the untreated control group (log-rank test, P < 0.02), although all animals died of recurrent tumour. This technique shows promise in the treatment of small volumes of tumour in the pancreas.
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Affiliation(s)
- J Regula
- Department of Surgery, University College London Medical School, Rayne Institute, UK
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40
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Loh CS, MacRobert AJ, Bedwell J, Regula J, Krasner N, Bown SG. Oral versus intravenous administration of 5-aminolaevulinic acid for photodynamic therapy. Br J Cancer 1993; 68:41-51. [PMID: 8318419 PMCID: PMC1968297 DOI: 10.1038/bjc.1993.284] [Citation(s) in RCA: 205] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
Abstract
Endogenously synthesised protoporphyrin IX (PpIX) following the administration of 5-amino-laevulinic acid (ALA) is an effective photosensitiser for photodynamic therapy (PDT). Following intravenous administration, PpIX accumulates predominantly in mucosa of hollow viscera and on light exposure, mucosal ablation results with relative sparing of the submucosa and muscularis layers. Oral administration is effective with ALA in contrast to conventional exogenous photosensitisers such as haematoporphyrin derivative and phthalocyanines. Oral administration of ALA is also simpler, safer, cheaper and more acceptable to patients. We studied the porphyrin sensitisation kinetics profile in the stomach, colon and bladder in normal rats following enterally and parenterally administered ALA using microscopic fluorescence photometric studies of frozen tissue sections. Mucosal cells in all three organs exhibit higher fluorescence levels as compared with underlying smooth muscle following both intravenous and oral administration. Peak concentration were seen 4 h after sensitisation at the highest doses used (200 mg kg-1 i.v., 400 mg kg-1 oral), and slightly earlier with lower doses. The temporal kinetics of both routes of administration were similar although a higher oral dose was required to achieve the same tissue concentration of PpIX. The highest level of fluorescence was achieved in the gastric mucosa and in decreasing levels, colonic and bladder mucosa. A similar degree of mucosal selectivity was achieved in each organ with each route of administration but an oral dose in excess of 40 mg kg-1 was required to achieve measurable PpIX sensitisation. In a pilot clinical study, two patients with inoperable rectal adenocarcinomas were given 30 mg kg-1 and one patient with sigmoid colon carcinoma was given 60 mg kg-1 ALA orally. Serial biopsies of normal and tumour areas were taken over the subsequent 24 h. Fluorescence microscopy of these specimens showed maximum accumulation of PpIX 4 to 6 h after administration of 30 mg kg-1 ALA. There was greater PpIX accumulation in tumour than adjacent normal mucosa in two patients. Preferential PpIX accumulation in tumour was greater in the patient receiving 60 mg kg-1 ALA.
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Affiliation(s)
- C S Loh
- National Medical Laser Centre, Faculty of Clinical Sciences, University College London, Rayne Institute, UK
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