Photodynamic Therapy for Patients with Advanced Non–Small-Cell Carcinoma of the Lung

The impact of photodynamic therapy on immune system in cancer - an update

Photodynamic therapy (PDT) is a therapeutic approach that has gained significant attention in recent years with its promising impact on the immune system. Recent studies have shown that PDT can modulate both the innate and adaptive arms of the immune system. Currently, numerous clinical trials are underway to investigate the effectiveness of this method in treating various types of cancer, as well as to evaluate the impact of PDT on immune system in cancer treatment. Notably, clinical studies have demonstrated the recruitment and activation of immune cells, including neutrophils, macrophages, and dendritic cells, at the treatment site following PDT. Moreover, combination approaches involving PDT and immunotherapy have also been explored in clinical trials. Despite significant advancements in its technological and clinical development, further studies are needed to fully uncover the mechanisms underlying immune activation by PDT. The main objective of this review is to comprehensively summarize and discuss both ongoing and completed studies that evaluate the impact of PDT of cancer on immune response.

Photodynamic Therapy of Non-Small Cell Lung Cancer. Narrative Review and Future Directions

Photodynamic therapy (PDT) is an established treatment modality for non-small cell lung cancer. Phototoxicity, the primary adverse event, is expected to be minimized with the introduction of new photosensitizers that have shown promising results in phase I and II clinical studies. Early-stage and superficial endobronchial lesions less than 1 cm in thickness can be effectively treated with external light sources. Thicker lesions and peripheral lesions may be amenable to interstitial PDT, where the light is delivered intratumorally. The addition of PDT to standard-of-care surgery and chemotherapy can improve survival and outcomes in patients with pleural disease. Intraoperative PDT has shown promise in the treatment of non-small cell lung cancer with pleural spread. Recent preclinical and clinical data suggest that PDT can increase antitumor immunity. Crosslinking of signal transducer and activator of transcription-3 molecules is a reliable biomarker to quantify the photoreaction induced by PDT. Randomized studies are required to test the prognosis value of this biomarker, obtain approval for the new photosensitizers, and test the potential efficacy of interstitial and intraoperative PDT in the treatment of patients with non-small cell lung cancer.

Photodynamic therapy for lung cancer and malignant pleural mesothelioma

Photodynamic therapy (PDT) is a form of non-ionizing radiation therapy that uses a drug, called a photosensitizer, combined with light to produce singlet oxygen ((1)O2) that can exert anti-cancer activity through apoptotic, necrotic, or autophagic tumor cell death. PDT is increasingly being used to treat thoracic malignancies. For early-stage non-small cell lung cancer (NSCLC), PDT is primarily employed as an endobronchial therapy to definitively treat endobronchial or roentgenographically occult tumors. Similarly, patients with multiple primary lung cancers may be definitively treated with PDT. For advanced or metastatic NSCLC and small cell lung cancer (SCLC), PDT is primarily employed to palliate symptoms from obstructing endobronchial lesions causing airway compromise or hemoptysis. PDT can be used in advanced NSCLC to attempt to increase operability or to reduce the extent of operation intervention required, and selectively to treat pleural dissemination intraoperatively following macroscopically complete surgical resection. Intraoperative PDT can be safely combined with macroscopically complete surgical resection and other treatment modalities for malignant pleural mesothelioma (MPM) to improve local control and prolong survival. This report reviews the mechanism of and rationale for using PDT to treat thoracic malignancies, details prospective and major retrospectives studies of PDT to treat NSCLC, SCLC, and MPM, and describes improvements in and future roles and directions of PDT.

The effect of Radachlorin® PDT in advanced NSCLC: a pilot study

BACKGROUND

Palliative effect of PDT in advanced NSCLC has been proven. Radachlorin® is a second generation photosensitizer that has quicker pharmacokinetics than first generation photosensitizers. Although there are reports describing Radachlorin®, limited data are available regarding its advantages in PDT.

METHODS

Advanced NSCLC patients with central airway obstruction were enrolled. Patients who had comorbidity effects on drug metabolism were excluded. All patients received 1mg/kg of Radachlorin®, 4 h before light irradiation. 200 J/cm² of laser was irradiated during 11 min 6 s. Bronchial toileting was performed the following day. A PFT was performed before and after PDT. The primary treatment outcome was improvement of airway obstruction, which was evaluated according to bronchoscopic findings and improvement of FEV1. Secondary treatment outcomes included the rate of PDT-related complications, one year survival rate and progression free survival.

RESULTS

Ten patients were enrolled between June 2010 and May 2011. Their median age was 58.5 years and their baseline cancer stage was more than IIIA. 20% of patients showed successful results, 70% showed partially successful results and 10% showed an unsuccessful result. All patients showed improvement in their obstructive symptoms. The mean FEV1 before PDT was 1.70±0.69 L, while the mean FEV1 after PDT was 1.99±0.60 L (P=0.029). No patients had major complications. Eight patients were undergoing additional treatment after resolving airway obstruction. The one year survival rate after PDT was 70%.

CONCLUSIONS

Radachlorin®-based PDT is safe and effective treatment for relieving central airway obstruction in advanced NSCLC.

Photodynamic therapy for the treatment of non-small cell lung cancer

Photodynamic therapy is increasingly being utilized to treat thoracic malignancies. For patients with early-stage non-small cell lung cancer, photodynamic therapy is primarily employed as an endobronchial therapy to definitely treat endobronchial, roentgenographically occult, or synchronous primary carcinomas. As definitive monotherapy, photodynamic therapy is most effective in treating bronchoscopically visible lung cancers ≤1 cm with no extracartilaginous invasion. For patients with advanced-stage non-small cell lung cancer, photodynamic therapy can be used to palliate obstructing endobronchial lesions, as a component of definitive multi-modality therapy, or to increase operability or reduce the extent of operation required. A review of the available medical literature detailing all published studies utilizing photodynamic therapy to treat at least 10 patients with non-small cell lung cancer is performed, and treatment recommendations and summaries for photodynamic therapy applications are described.

Surgical and endoscopic palliation of advanced lung cancer

Pulmonary symptoms from advanced-stage lung cancer often require palliative treatments for compassionate patient care. Although many of these symptoms can result from complications of advanced lung cancer treatment regimens (ie, radiation/chemotherapy-induced lung toxicity) or the patient's underlying comorbid conditions and poor constitution, a significant number of patients have symptoms that originate from the primary tumor itself or from locoregional metastases within the thoracic cavity. These complications from advanced-stage lung cancer can be a serious threat to life and require appropriate intervention.

Rottlerin Inhibits Lonicera japonica-Induced Photokilling in Human Lung Cancer Cells through Cytoskeleton-Related Signaling Cascade

This study demonstrated that many apoptotic signaling pathways, such as Rho family, PKC family, MAP kinase family, and mitochondria-mediated apoptotic pathway, were triggered by Lonicera japonica extracts and irradiation in CH27 cells. Rottlerin, a PKCδ -selective inhibitor, reversed the photoactivated Lonicera japonica extract-induced decrease in PKCδ protein expression and change in cell morphology in this study. In addition, rottlerin inhibited the photoactivated Lonicera japonica-induced decrease in protein expression of Ras, ERK, p38, PKCα, and PKCε, which are the kinases of prosurvival signaling pathway. We also demonstrated that pretreatment with rottlerin prevented actin microfilaments and microtubules from damage during the photoactivated Lonicera japonica-induced CH27 cell death. Furthermore, the promotion of the cytoskeleton-related signaling cascade following rottlerin by upregulation of cytoskeleton-related mediators (p38, HSP27, FAK, paxillin, and tubulin) and molecules of downstream of F-actin (mitochondria-mediated apoptosis pathway) reduces CH27 cell death, indicating that cytoskeleton is the potential target in the photoactivated Lonicera japonicaextract-induced photokilling of CH27 cells.

Photodynamic activity of aloe-emodin induces resensitization of lung cancer cells to anoikis

Aloe-emodin was found to be a photosensitizer and possess anti-tumor activity. However, the detailed mechanism underlying the biological effects of aloe-emodin remains unknown. In this study, we explored the mechanisms of photocytotoxicity induced by aloe-emodin in lung cancer H460 cells. According to the results of the photoactivated aloe-emodin-induced disruption of cytoskeleton, we verify that aloe-emodin with irradiation induces anoikis of H460 cells. Photosensitized aloe-emodin-induced anoikis is associated with the protein expression of α-actinin and mitogen-activated protein (MAP) kinase members. In this study, a rapid opening of the mitochondrial permeability transition pore and the change in apoptosis-related protein expression were involved in photoactivated aloe-emodin-induced cell death. We also demonstrated that anoikis induced by aloe-emodin with irradiation is mediated through the intrinsic and extrinsic death pathways in a caspase-dependent manner in H460 cells.

Role of mitochondria in cell death induced by Photofrin-PDT and ursodeoxycholic acid by means of SLIM

The present study was undertaken to find new ways to improve efficacy of photodynamic therapy (PDT). We investigated the combinatory effect of the photosensitizer Photofrin and ursodeoxycholic acid (UDCA). UDCA is a relatively non-toxic bile acid which is used inter alia as a treatment for cholestatic disorders and was reported to enhance PDT efficiency of two other photosensitizers. Since besides necrosis and autophagic processes apoptosis has been found to be a prominent form of cell death in response to PDT for many cells in culture, several appropriate tests, such as cytochrome c release, caspase activation and DNA fragmentation were performed. Furthermore spectral resolved fluorescence lifetime imaging (SLIM) was used to analyse the cellular composition of Photofrin and the status of the enzymes of the respiratory chain. Our experiments with two human hepatoblastoma cell lines revealed that the combination of Photofrin with UDCA significantly enhanced efficacy of PDT for both cell lines even though the underlying molecular mechanism for the mode of action of Photofrin seems to be different to some extent. In HepG2 cells cell death was clearly the consequence of mitochondrial disturbance as shown by cytochrome c release and DNA fragmentation, whereas in Huh7 cells these features were not observed. Other mechanisms seem to be more important in this case. One reason for the enhanced PDT effect when UDCA is also applied could be that UDCA destabilizes the mitochondrial membrane. This could be concluded from the fluorescence lifetime of the respiratory chain enzymes which turned out to be longer in the presence of UDCA in HepG2 cells, suggesting a perturbation of the mitochondrial membrane. The threshold at which PDT damages the mitochondrial membrane was therefore lower and correlated with the enhanced cytochrome c release observed post PDT. Thus enforced photodamage leads to a higher loss of cell viability.

Sonodynamic therapy of cancer using a novel porphyrin derivative, DCPH-P-Na(I), which is devoid of photosensitivity

To improve the efficacy of sonodynamic therapy of cancer using photosensitizers, we developed a novel porphyrin derivative designated DCPH-P-Na(I) and investigated its photochemical characteristics and sonotoxicity on tumor cells. DCPH-P-Na(I) exhibited a minimum fluorescent emission by excitation with light, compared with a strong emission from ATX-70, which is known to reveal both photo- and sonotoxicity. According to this observation, when human tumor cells were exposed to light in the presence of DCPH-P-Na(I) in vitro, the least phototoxicity was observed, in contrast to the strong phototoxicity of ATX-70. However, DCPH-P-Na(I) exhibited a potent sonotoxicity on tumor cells by irradiation with ultrasound in vitro. This sonotoxicity was reduced by the addition of L-histidine, but not D-mannitol, thus suggesting that singlet oxygen may be responsible for the sonotoxicity of DCPH-P-Na(I). DCPH-P-Na(I) demonstrated significant sonotoxicity against a variety of cancer cell lines derived from different tissues. In addition, in a mouse xenograft model, a potent growth inhibition of the tumor was observed using sonication after the administration of DCPH-P-Na(I) to the mouse. These results suggest that sonodynamic therapy with DCPH-P-Na(I) may therefore be a useful clinical treatment for cancers located deep in the human body without inducing skin sensitivity, which tends to be a major side-effect of photosensitizers.

Pulmonary Resection After Successful Downstaging with Photodynamic Therapy

Photodynamic therapy (PDT) is a treatment option for lung cancer that involves the administration of a photosensitizing agent and selective, bronchoscopic delivery of light to tumor tissue that has retained the agent. Currently, PDT is used either to treat microinvasive endobronchial nonsmall cell lung cancer (NSCLC) or to palliate patients with completely or partially obstructing endobronchial NSCLC. Herein is a case of PDT that successfully downstaged an obstructing endobronchial NSCLC, thereby enabling a complete resection. At 9 months postoperatively, the patient was treated for a chest wall recurrence with no evidence of disease in the airway or mediastinum.

Endobronchial photodynamic therapy for lung cancer

BACKGROUND AND OBJECTIVE

Endobronchial photodynamic therapy (PDT) is a minimally invasive technique for the palliation of major airway obstruction from lung cancer, and for the treatment of endobronchial microinvasive lung cancer.

STUDY DESIGN

Results of reported clinical trials were compared, and the author's preliminary results with second generation photosensitizers were also reviewed.

RESULTS

A review of the clinical experience with endobronchial PDT is provided. Potential advantages of PDT include the duration of palliation achieved through the delayed cellular effects of PDT within tumor. Side-effects from FDA-approved photosensitizer (Photofrin, Porfimer sodium, Axcan Scandipharm, Montreal, Quebec) include skin photosensitivity. HPPH (2-[1-hexyloxyethyl]-2 devinyl pyropheophorbide) is an example of a second-generation photosensitize that shows promise in the treatment of lung cancer, and appears to be free from significant skin photosensitivity.

CONCLUSION

PDT is an effective tool for the palliation of endobronchial lung cancers which obstruct the central airways and is also effective for the treatment of central microinvasive carcinoma and carcinoma in situ of the central airways.

Incorporation of photodynamic therapy as an induction modality in non-small cell lung cancer

BACKGROUND AND OBJECTIVES

Incorporation of photodynamic therapy (PDT) into the induction therapy regimen utilized for treatment of locally advanced primary non-small cell bronchogenic carcinoma (NSCLC) is explored.

STUDY DESIGN/MATERIALS AND METHODS

We present a retrospective review of 41 patients diagnosed with non-metastatic NSCLC who underwent induction PDT with chemotherapy and/or radiation.

RESULTS

Fifty percent of patients initially deemed unresectable, were able to undergo definitive surgical resection after trimodality induction therapy. Twenty-seven percent of patients considered to require pneumonectomy were able to have a lobectomy. The pathological stage was less than the preinduction clinical stage in 14 of 22 cases; of which four patients had no residual tumor. There was no 30/90-day postoperative mortality. Mean survival was 35.9 months (lobectomy), 25.5 months (pneumonectomy) and 14.7 months (no surgery). Median survival was 78% (12 months) and 46% (36 months). The main postoperative complication following pneumonectomy was bronchopleural fistula formation. All patients who developed this complication had undergone trimodality induction therapy. Incorporation of PDT into the induction arsenal for patients with loco-regionally advanced NSCLC may be safely performed.

CONCLUSIONS

PDT may define an alternative induction strategy for patients requiring pneumonectomy; further studies exploring the true efficacy of PDT as an induction modality are encouraged.

Photoinduced One-Electron Reduction of Alkyl Halides by Dirhodium(II,II) Tetraformamidinates and a Related Complex with Visible Light

Various substituted dirhodium tetraformamidinate complexes, Rh(2)(R-form)(4) (R = p-CF(3), p-Cl, p-OCH(3), m-OCH(3); form = N,N'-diphenylformamidinate), and the new complex Rh(2)(tpgu)(4) (tpgu = 1,2,3-triphenylguanidinate) have been investigated as potential agents for the photoremediation of saturated halogenated aliphatic compounds, RX (R = alkyl group). The synthesis and characterization of the complexes is reported, and the crystal structure of Rh(2)(tpgu)(4) is presented. The lowest energy transition of the complexes is observed at approximately 870 nm and the complexes react with alkyl chlorides and alkyl bromides under low energy irradiation (lambda(irr) > or = 795 nm), but not when kept in the dark. The metal-containing product of the photochemical reaction with RX (X = Cl, Br) is the corresponding mixed-valent Rh(2)(II,III)X (X = Cl, Br) complex, and the crystal structure of Rh(2)(p-OCH(3)-form)(4)Cl generated photochemically from the reaction of the corresponding Rh(2)(II,II) complex in CHCl(3) is presented. In addition, the product resulting from the dimerization of the alkyl fragment, R(2), is also formed during the reaction of each dirhodium complex with RX. A comparison of the dependence of the relative reaction rates on the reduction potentials of the alkyl halides and their C-X bond dissociation energies are consistent with an outer-sphere mechanism. In addition, the relative reaction rates of the metal complexes with CCl(4) decrease with the oxidation potential of the dirhodium compounds. The mechanism of the observed reactivity is discussed and compared to related systems.

DNA binding and photocleavage in vitro by new dirhodium(II) dppz complexes: correlation to cytotoxicity and photocytotoxicity

Two new dirhodium(II) complexes possessing the intercalating dppz ligand (dppz = dipyrido[3,2-a:2',3'-c]phenazine), cis-[Rh(2)(mu-O(2)CCH(3))(2)(dppz)(eta(1)-O(2)CCH(3))(CH(3)OH)](+) (1) and cis-[Rh(2)(mu-O(2)CCH(3))(2)(dppz)(2)](2+) (2), were synthesized and characterized as potential agents for photochemotherapy. Various techniques show that 1 binds to DNA through intercalation, although some aggregation of the complex on the DNA surface is also present. In contrast, 2 does not intercalate between the DNA bases; however, strong hypochromic behavior is observed in the presence of DNA, which can be attributed to intermolecular pi-stacking of 2 enhanced by the polyanion. The apparent DNA binding constants determined using optical titrations are compared to those from dialysis experiments. Both complexes photocleave pUC18 plasmid in vitro under irradiation with visible light (lambda(irr) >or= 395 nm, 15 min), resulting in the nicked, circular form. Greater photocleavage is observed for 1 relative to 2, which may be due to the ability of 1 to intercalate between the DNA bases. The cytotoxicity toward human skin cells (Hs-27) measured as the concentration at which 50% cell death is recorded, LC(50), was found to be 135 +/- 8 microM for 2 in the dark (30 min), which is significantly lower than those of 1 (LC(50) = 27 +/- 2 microM) and Rh(2)(O(2)CCH(3))(4) (LC(50) = 15 +/- 2 microM). Irradiation of cell cultures containing 1 and Rh(2)(O(2)CCH(3))(4) with visible light (400-700 nm, 30 min) has little effect on their cytotoxicity, with LC(50) values of 21 +/- 3 and 13 +/- 2 microM, respectively. Interestingly, a 3.4-fold increase in the toxicity of 2 is observed when the cell cultures are irradiated (400-700 nm, 30 min), resulting in LC(50) = 39 +/- 1 microM. The greater toxicity of 1 compared to 2 in the dark may be related to the ability of the former compound to intercalate between the DNA bases. The lower cytotoxicity of 2, together with its significantly greater photocytotoxicity, makes this complex a potential agent for photodynamic therapy (PDT). These results suggest that intercalation or strong DNA binding may not be a desirable property of a potential PDT agent.

Direct DNA Photocleavage by a New Intercalating Dirhodium(II/II) Complex: Comparison to Rh2(μ-O2CCH3)4

Transition metal complexes possessing the intercalating dppz ligand (dppz = dipyrido[3,2-a:2',3'-c]phenazine) typically bind ds-DNA through intercalation (K(b) approximately 10(5)-10(6) M(-1)), and DNA photocleavage by these complexes with visible light proceeds through the generation of a reactive oxygen species. The DNA binding and photocleavage by [Rh(2)(mu-O(2)CCH(3))(2)(eta(1)-O(2)CCH(3))(CH(3)OH)(dppz)](+) (2) is reported and compared to that of Rh(2)(mu-O(2)CCH(3))(4) (1). Spectral changes and an increase in viscosity provide evidence for the intercalation of 2 to double stranded DNA with K(b) = 1.8 x 10(5) M(-1). DNA photocleavage by 2 is observed upon irradiation with lambda(irr) > 395 nm both in air and deoxygenated solution. DNA photocleavage is not observed for 1 or free dppz ligand under these irradiation conditions. The coupling of a single dppz ligand to a dirhodium(II/II) bimetallic core in 2 provides a means to access oxygen-independent DNA photocleavage with visible light.