Non-invasive diagnostics of the maxillary and frontal sinuses based on diode laser gas spectroscopy

PROBLEM

Suspected, but objectively absent, rhinosinusitis constitutes a major cause of visits to the doctor, high health care costs, and the over-prescription of antibiotics, contributing to the serious problem of resistant bacteria. This situation is largely due to a lack of reliable and widely applicable diagnostic methods.

METHOD

A novel method for the diagnosis of rhinosinusitis based on non-intrusive diode laser gas spectroscopy is presented. The technique is based on light absorption by free gas (oxygen and water vapour) inside the sinuses, and has the potential to be a complementary diagnostic tool in primary health care. The method was evaluated on 40 patients with suspected sinus problems, referred to the diagnostic radiology clinic for low-dose computed tomography (CT), which was used as the reference technique.

MAIN RESULTS

The data obtained with the new laser-based method correlated well with the grading of opacification and ventilation using CT. The sensitivity and specificity were estimated to be 93% and 61%, respectively, for the maxillary sinuses, and 94% and 86%, respectively, for the frontal sinuses. Good reproducibility was shown.

PRINCIPAL CONCLUSION

The laser-based technique presents real-time clinical data that correlate well to CT findings, while being non-intrusive and avoiding the use of ionizing radiation.

Diagnostics of Human Body Cavities Using Diode Laser Gas Spectroscopy

We have developed a technique to measure gas non-intrusive in scattering media, such as human tissue. The technique was first demonstrated for test samples in 2001 by our group and utilizes diode laser absorption spectroscopy to monitor molecular oxygen and water vapor. The focus of medical application has been on sinuses, both maxillary and frontal sinuses and the potential of the technique has been shown on volunteers. A spin-off company named GasPorOx AB has been formed with the aim to develop a product used to improve the diagnosis of the sinus infections. A portable fiber-guided system has been developed and is used in an ongoing initial clinical trial in collaboration with the Ear, Nose and Throat Clinic, the Oncology and Diagnostic radiology clinics at the Lund University Hospital.

Kinetics of the superficial perfusion and temperature in connection with photodynamic therapy of basal cell carcinomas using esterified and non-esterified 5-aminolaevulinic acid

BACKGROUND

Photodynamic therapy (PDT) is a local treatment modality with increasing indications for various malignant and non malignant diseases. The treatment parameters have not yet been optimized as there is a need for a better understanding of the process. The skin is an important target and serves as a good model for monitoring and evaluating the interaction of light with biological tissue.

OBJECTIVES

The tissue perfusion and the temperature of basal cell carcinomas were measured in connection with PDT in order to investigate the biological mechanisms involved.

METHODS

An infrared camera was used during the treatment to measure skin temperature and a laser Doppler perfusion imaging device was used to image the superficial perfusion before and after treatment. Six hours after topical application of 5-aminolaevulinic acid (ALA) or methyl esterified ALA (ALA-ME), 38 basal cell carcinomas were treated using light from a diode laser at 633 nm.

RESULTS

In the lesions, the perfusion immediately after PDT was similar to that before PDT. One hour after the treatment the perfusion in the lesion was increased 50% compared with before PDT. However, in the skin surrounding the lesions the perfusion was doubled immediately after PDT and was still increasing 1 h after treatment. A temperature increase in the lesions of about 1-3 degrees C was observed for light fluence rates of 100-150 mW cm-2. In all patients treated, a diffuse temperature increase was visible outside the lesions. In some of the patients, the outlines of the blood vessels surrounding the treated lesions became visible in the thermal images. Measurements of temperature on healthy volunteers not administered photosensitizer, but illuminated with light of the same fluence rate, showed a similar increase in temperature in the illuminated spots. However, no temperature increase was observed outside the illuminated area. No statistically significant differences were found between the measurements on patients treated with ALA and ALA-ME.

CONCLUSIONS

The increased perfusion in the area surrounding the lesions after PDT, as seen by perfusion and temperature measurements, is the result of an inflammatory reaction to the PDT process. However, directly after PDT the perfusion in the lesions was the same as before irradiation. The combination of these observations suggests the presence of local blood stasis during and immediately after the treatment. The temperature measurements showed that the increased temperature was well below the temperature limit of hyperthermal damage. Furthermore, the measurements indicate that the increase in temperature was primarily a consequence of the heat absorbed in the tissue.

Multivariate analysis of laryngeal fluorescence spectra recorded in vivo

BACKGROUND AND OBJECTIVE

The potential of using various multivariate analysis methods for classification of fluorescence spectra acquired in vivo from laryngeal tissues in Patients was investigated.

STUDY DESIGN/MATERIALS AND METHODS

Autofluorescence spectra were measured on 29 normal tissue sites and 25 laryngeal lesions using 337-nm excitation. Four different multivariate analysis schemes were applied. Laryngeal fluorescence spectra from patients who had been administered delta-aminolevulinic acid (ALA) were obtained using 405-nm excitation and were classified using partial least squares discriminant analysis (PLS-DA).

RESULTS

For autofluorescence spectra, logistic regression based on principal component analysis (PCA) or PLS, or PLS-DA all resulted in sensitivities and specificities around 90% for lesion vs. normal. Using ALA and 405-nm excitation gave a sensitivity of 100% and a specificity of 69%.

CONCLUSION

Multivariate analysis of fluorescence spectra could allow classification of laryngeal lesions in vivo with high sensitivity and specificity. PLS performs at least as well as PCA, and PLS-DA performs as well as logistic regression techniques on these data.

Photodynamic therapy vs. cryosurgery of basal cell carcinomas: results of a phase III clinical trial

BACKGROUND

A previously reported randomized clinical trial showed treatment of Bowen's disease using photodynamic therapy (PDT) with topically applied delta-aminolaevulinic acid (ALA) to be at least as effective as cryosurgery and to be associated with fewer adverse effects.

OBJECTIVES

To compare ALA-PDT and cryotherapy in the treatment of histopathologically verified basal cell carcinomas (BCCs) in a non-blinded, prospective phase III clinical trial.

METHODS

One lesion from each of 88 patients was included. The BCCs were divided into superficial and nodular lesions. The follow-up period was restricted to 1 year with close follow-up for the first 3 months. Efficacy was assessed as the recurrence rate 12 months after the first treatment session, verified by histopathology. Tolerability was evaluated as the time of healing, pain and discomfort during and after the treatment, and final cosmetic outcome.

RESULTS

Histopathologically verified recurrence rates in the two groups were statistically comparable and were 25% (11 of 44) for ALA-PDT and 15% (six of 39) for cryosurgery. However, clinical recurrence rates were only 5% (two of 44) for PDT and 13% (five of 39) for cryosurgery. Additional treatments, usually one, had to be performed in 30% of the lesions in the PDT group. The healing time was considerably shorter and the cosmetic outcome significantly better with PDT. Pain and discomfort during the treatment session and in the following week were low, and were equivalent with the two treatment modalities.

CONCLUSIONS

In terms of efficacy, ALA-PDT is comparable with cryosurgery as a treatment modality for BCCs. Retreatments are more often required with PDT than with cryosurgery. This can easily be performed due to the shorter healing time, less scarring and better cosmetic outcome that follows ALA-PDT.

Laser-induced fluorescence studies of normal and malignant tumour tissue of rat following intravenous injection of delta-amino levulinic acid

BACKGROUND AND OBJECTIVE

Laser-induced fluorescence was studied in normal and tumour tissue of rat after intravenous injection of delta-amino levulinic acid (ALA). The aim of the study was to investigate the protoporphyrin IX accumulation in different tissue types in rat after systemically administered ALA.

STUDY DESIGN/MATERIAL AND METHODS

A malignant rat tumour and normal tissue from 13 different organs were investigated in eight rats. The rats were injected with two different ALA doses, 30 and 90 mg/kg b.w., and the investigations were performed at 10, 30 and 240 min after the injection. The fluorescence was recorded utilising an optical fibre based fluorosensor at 405 nm excitation.

RESULTS

Fluorescence spectra were recorded in the 400-750 nm wavelength region including the dual-peaked PpIX fluorescence at about 635 and 705 nm, and the tissue autofluorescence peaking at about 500 nm. The maximum tumour build-up of PpIX was achieved already in less than 1 hr after ALA injection. The fluorescence demarcation between tumour and surrounding tissue was a factor of 7-8:1 after 30 min and decreased for longer retention times. The accumulation in 13 different organs was investigated and a particularly high PpIX build-up was found in stomach and intestine.

CONCLUSIONS

Fluorescence detection following i.v. injection of ALA provides attractive diagnostics for the experimental tumour used, indicating clinical usefulness.

Laser Doppler perfusion imaging: new technique for determination of perfusion and reperfusion of splanchnic organs and tumor tissue

BACKGROUND AND OBJECTIVE

Several investigations indicated that laser Doppler flowmetry on the liver surface reflects relative changes of the total liver blood flow. In this study, Laser Doppler Perfusion Imaging (LDI), monitoring the surface only, was used for measurements of tissue perfusion of normal and/or impaired liver, pancreas, spleen, stomach and intestines, and the blood flow of hepatic tumors in rats.

STUDY DESIGN/MATERIALS AND METHODS

Eighty Wistar/Furth rats were divided into five groups. Group I served as controls. Groups II and III underwent ischemic injury of the liver and intestine with or without the administration of WEB2170, a platelet-activating factor receptor antagonist. Laser-induced photodynamic therapy (PDT) utilizing delta-amino levulinic acid sensitization was performed in Groups IV and V.

RESULTS

Normal pancreas and intestine had a high LDI perfusion value and the liver and stomach exhibited a medium perfusion value whereas the perfusion value from the spleen was low. WEB2170 improved the reperfusion of the postischemic liver and intestine. An immediate decrease in surface blood flow of hepatic tissue treated by laser-induced PDT and a decreased blood flow in large tumors were observed.

CONCLUSION

LDI is a useful technique for the measurement of tissue perfusion of various splanchnic organs or tumor tissues.

Preliminary evaluation of two fluorescence imaging methods for the detection and the delineation of basal cell carcinomas of the skin

BACKGROUND AND OBJECTIVE

Fluorescence techniques can provide powerful noninvasive means for medical diagnosis, based on the detection of either endogenous or exogenous fluorophores. The fluorescence of delta-aminolevulinic acid (ALA)-induced protoporphyrin IX (PpIX) has already shown promise for the diagnosis of tumors. The aim of the study was to investigate the localization of skin tumors after the topical application of ALA, by detecting the PpIX fluorescence either in the spectral or in the time domain. STUDY DESIGN/MATERIALS N AND METHODS: Two fluorescence imaging systems were used to identify basal cell carcinomas of the skin in humans, after topical application of 20% ALA ointment. Both systems rely on the comparison between the exogenous and the endogenous fluorescence, performed either in the spectral domain or in the time domain. The first system works by using three images acquired through different spectral filters, whereas the second one measures the spatial map of the average fluorescence lifetime of the sample.

RESULTS

A clear demarcation of skin malignancies was successfully performed in vivo noninvasively with both fluorescence imaging systems.

CONCLUSION

The two complementary approaches considered in the present study show promise for skin tumor detection and delineation based on specific fluorescence features.

Blood perfusion studies on basal cell carcinomas in conjunction with photodynamic therapy and cryotherapy employing laser-Doppler perfusion imaging

Superficial blood perfusion was monitored using laser-Doppler perfusion imaging in connection with a phase III clinical trial comparing photodynamic therapy, utilizing topically applied delta-aminolevulinic acid, with cryotherapy of basal cell carcinomas. A total of 526 images were recorded before and immediately after the treatment and during the follow-up period. Before treatment, the lesions exhibited a blood perfusion 3+/-2 times that in normal tissue. Both treatment modalities induced an increased blood perfusion inside the lesions, which slowly approached normal values in conjunction with successful treatments. The blood perfusion in successfully treated lesions approached normal values 2 months after photodynamic therapy, and about 1 year after cryotherapy. The tissue perfusion in recurrent lesions did not decrease to normal values after the treatment, suggesting that the laser-Doppler perfusion imaging technique can be used to follow the healing process and discover possible persistent tumour growth.

Photodynamic therapy utilising topical delta-aminolevulinic acid in non-melanoma skin malignancies of the eyelid and the periocular skin

PURPOSE

Photodynamic therapy utilising delta-aminolevulinic acid-induced protoporphyrin IX photosensitisation, was evaluated as a treatment modality for nonmelanoma skin malignancies of the eyelids and the periocular skin.

METHODS

Photodynamic therapy with laser light at 635 nm was performed in 13 patients with 19 basal cell carcinomas and one patient with 3 cutaneous T-cell lymphoma lesions. A topical application regimen was used and in median 3 treatment sessions were given to each lesion.

RESULTS

A visually judged complete response was achieved in 42% (8/19) of the basal cell carcinomas and in 100% of the T-cell lymphoma lesions (3/3). Partial tumour response was seen in 42% (8/19) and no response in 16% (3/19) of the basal cell carcinomas. The median follow-up time was 12 months. No, or very little scarring and loss of cilia were induced by the treatment.

CONCLUSION

Photodynamic therapy with delta-aminolevulinic acid can eradicate eye-close non-melanoma skin malignancies without compromising the function of the eyelids. Further development of the method is needed to reach the same cure rates as those of the conventional treatment modalities.

Kinetic fluorescence studies of 5-aminolaevulinic acid-induced protoporphyrin IX accumulation in basal cell carcinomas

Laser-induced fluorescence (LIF) investigations have been performed in connection with photodynamic therapy (PDT) of basal cell carcinomas and adjacent normal skin following topical application of 5-aminolaevulinic acid (ALA) in order to study the kinetics of the protoporphyrin IX (PpIX) build-up. Five superficial and 10 nodular lesions in 15 patients are included in the study. Fluorescence measurements are performed prior to the application of ALA, 2, 4 and 6 h post ALA application, immediately post PDT (60 J cm-2 at 635 nm), and 2 h after the treatment. Hence, the build-up, photobleaching and re-accumulation of PpIX can be followed. Superficial lesions show a maximum PpIX fluorescence 6 h post ALA application, whereas the intensity is already the highest 2-4 h after the application in nodular lesions. Immediately post PDT, the fluorescence contribution at 670 nm from the photoproducts is about 2% of the pre-PDT PpIX fluorescence at 635 nm. Two hours after the treatment, a uniform distribution of PpIX is found in the lesion and surrounding normal tissue. During the whole procedure, the autofluorescence of the lesions and the normal skin does not vary significantly from the values recorded before the application of ALA.

Clinical spectral characterisation of colonic mucosal lesions using autofluorescence and delta aminolevulinic acid sensitisation

BACKGROUND AND AIMS

Laser induced fluorescence (LIF) from colonic mucosa was measured in vivo with and without delta aminolevulinic acid (ALA) in an attempt to differentiate between neoplasia and non-neoplasia in real time during colonoscopy.

METHODS

Spectra from 32 adenomas, 68 normal sites, and 14 hyperplastic polyps in 41 patients were obtained with a point monitoring system. Twenty one of the patients had been given a low dose of ALA as a photosensitiser before the examination. Light of 337, 405, or 436 nm wavelength was used as excitation. Stepwise multivariate linear regression analysis was performed.

RESULTS

With 337 nm excitation, 100% sensitivity and 96% specificity was obtained between normal mucosa and adenomas. Seventy seven per cent of the hyperplastic polyps were classified as non-neoplastic. When exciting with 405 and 436 nm, the possibility of distinguishing different types of tissue was considerably better in the ALA patients than in the non-ALA patients.

CONCLUSIONS

The in vivo point measurements imply that a good discrimination between normal tissue and adenomatous polyps can be obtained using the LIF technique. Excitation at 337 nm and at 405 nm or 436 nm using ALA gives good results. LIF also shows potential for distinguishing adenomatous from hyperplastic polyps. The number of detection wavelengths could be reduced if chosen properly.

Fluorescence diagnostics and kinetic studies in the head and neck region utilizing low-dose delta-aminolevulinic acid sensitization

Diagnostic measurements and pharmacokinetic studies were performed in 17 patients with various kinds of malignant, premalignant and benign lesions in the head and neck region by means of point monitoring laser-induced fluorescence. For marking different types of tissue, delta-aminolevulinic acid (ALA)-induced protoporphyrin IX (PpIX) was used. The ALA-induced PpIX synthesis was monitored at different time intervals after oral administration of ALA in low doses, 5 and 15 mg/kg b.w. Besides the porphyrin-related signal the tissue endogenous fluorescence was also recorded. The fluorescence spectra were evaluated at two different wavelengths corresponding to the specific drug-related fluorescence peak and the endogenous tissue fluorescence emission at 635 and 490 nm, respectively. The evaluated fluorescence data were correlated to the histopathological tissue investigation. A fall-off in the overall fluorescence intensity at 490 nm was obtained for all the malignant and premalignant areas, as well as an increased red fluorescence. A ratio between the red and the blue/green fluorescence intensity was formed for each time interval after the ALA administration. The lower drug dose seems to be sufficient to obtain a useful demarcation ratio between normal and diseased tissue with a very low PpIX fluorescence intensity in the normal tissue. A PpIX fluorescence maximum seems to occur between 3 and 4 h in normal tissues, whereas malignant tumour tissue shows a higher level for a longer period of time.

Laser-based spectroscopic methods in tissue characterization

Laser-based spectroscopic techniques were developed for tumor tissue characterization utilizing different tumor-localizing substances. In particular, sensitization with the heme precursor delta-amino levulinic acid (ALA) administered topically, orally or intravenously was used for the induction of protoporphyrin IX (PpIX). The autofluorescence as well as the PpIX-related fluorescence signals were monitored, and tumor demarcation functions were calculated for different human malignant tumors, such as tumors in the urinary bladder and the prostatic gland, in the head and neck region, in the breast and in the gastrointestinal tract. In the gastrointestinal tract, colon tumors were examined as well as tumors and dysplastic lesions in the esophagus, where patients with Barrett's esophagus were examined. Time-integrated laser-induced fluorescence measurements utilizing a point monitoring fluorosensor and a multicolor fluorescence imaging system were performed in vivo in patients in different clinical specialities.

Clinical multi-colour fluorescence imaging of malignant tumours--initial experience

PURPOSE

The detection of malignant tumours relies on a variety of diagnostic procedures including X-ray images and, for hollow organs, endoscopy. The purpose of this study was to present a new technique for non-invasive tumour detection based on tissue fluorescence imaging.

MATERIAL AND METHODS

A clinically adapted multi-colour fluorescence system was employed in the real-time imaging of malignant tumours of the skin, breast, head and neck region, and urinary bladder. Tumour detection was based on the contrast displayed in fluorescence between normal and malignant tissue, related to the selective uptake of tumour-marking agents, such as haematoporphyrin derivative (HPD) and delta-amino levulinic acid (ALA), and natural chromophore differences between various tissues. In order to demarcate basal cell carcinomas of the skin, ALA was applied topically 4-6 h before the fluorescence investigation. For urinary bladder tumour visualisation (transitional cell carcinoma of different stages including carcinoma in situ), ALA was instilled into the bladder 1-2 h prior to the study. Malignant and premalignant lesions in the head and neck region were imaged after i.v. injection of HPD (Photofrin). Finally, the extent of in situ and invasive carcinomas of the breast was investigated in surgically excised specimens from patients that received a low-dose injection of HPD 24 h prior to the study. The tumour imaging system was coupled to an endoscope. Fluorescence light emission from the tissue surface was induced with 100-ns-long optical pulses at 390 nm, generated from a frequency-doubled alexandrite laser. With the use of special image-splitting optics, the tumour fluorescence, intensified in a micro-channel plate, was imaged in 3 selected wavelength bands. These 3 images were processed together to form a new optimised-contrast image of the tumour. This image, updated at a rate of about 3 frames/s, was mixed with a normal colour video image of the tissue.

RESULTS

A clear demarcation from normal surrounding tissue was found during in vivo measurements of superficial bladder carcinoma, basal cell carcinoma of the skin, and leukoplakia with dysplasia of the lip, and in in vitro investigations of resected breast cancer.

CONCLUSIONS

The initial clinical experience of using multi-colour fluorescence imaging has shown that the technique has the potential to reveal malignant tumour tissue, including non-invasive early carcinoma and also precancerous tissue. Further investigations are needed to fully develop the method.

In vivo fluorescence imaging for tissue diagnostics

Non-invasive fluorescence imaging has the potential to provide in vivo diagnostic information for many clinical specialties. Techniques have been developed over the years for simple ocular observations following UV excitation to sophisticated spectroscopic imaging using advanced equipment. Much of the impetus for research on fluorescence imaging for tissue diagnostics has come from parallel developments in photodynamic therapy of malignant lesions with fluorescent photosensitizers. However, the fluorescence of endogenous molecules (tissue autofluorescence) also plays an important role in most applications. In this paper, the possibilities of imaging tissues using fluorescence spectroscopy as a mean of tissue characterization are discussed. The various imaging techniques for extracting diagnostic information suggested in the literature are reviewed. The development of exogenous fluorophores for this purpose is also presented. Finally, the present status of clinical evaluation and future directions are discussed.

Superficial blood flow following photodynamic therapy of malignant non-melanoma skin tumours measured by laser Doppler perfusion imaging

Laser Doppler perfusion imaging offers a new modality for in vivo monitoring of the superficial blood perfusion in biological tissue. In this study, the superficial blood perfusion of malignant non-melanoma skin tumours and the surrounding normal skin was measured in conjunction with photodynamic therapy (PDT) using topical delta-aminolaevulinic acid (ALA)-induced protoporphyrin IX as a photosensitizer. The results clearly show that, in contradiction to PDT with the intravenously administered photosensitizer Photofrin, no direct vascular damage can be seen. With the topical sensitization the blood perfusion is increased immediately after the treatment irradiation. The increased blood flow is seen up to a week after treatment, in a similar way as for an inflammatory reaction. Despite this, all basal cell carcinoma and squamous cell carcinoma in situ lesions in this study healed without any sign of residual tumour after the treatment, suggesting an efficient direct tumour cell destruction induced by PDT.

Pharmacokinetic studies on 5-aminolevulinic acid-induced protoporphyrin IX accumulation in tumours and normal tissues

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.

Tumour vessel damage resulting from laser-induced hyperthermia alone and in combination with photodynamic therapy

This study examined tumour vessel injury resulting from laser-induced hyperthermia alone and in combination with photodynamic therapy (PDT) in the treatment of rat liver tumours by means of scanning electron microscopy. A total of 18 Wistar rats were divided into three groups. Group I (six animals) underwent hyperthermia for 15 min (15-min hyperthermia). Group II (six animals) underwent hyperthermia for 30 min (30-min hyperthermia). Group III (six animals) received the combined treatment of PDT and 30-min hyperthermia. For PDT, delta-amino laevulinic acid at a dose of 60 mg/kg of body weight was intravenously administered 60 min before irradiation at 635 nm. The morphological results indicated that 15-min hyperthermia gave rise to an increase in permeability of the vessels in the treated tumour. Thirty-min hyperthermia caused extreme oedema of vascular endothelial cells and restrictive openings of tumour branch vessels. The combined therapy of PDT and hyperthermia destroyed tumour vasculature. Large breaks of the inner wall of the treated tumour vessels were deeply involved in the basement membrane of the vessel. The results indicate that there may be a close link between inhibition of tumour growth and degree of damage to tumour vessels.

Laser-induced fluorescence studies of the biodistribution of carotenoporphyrins in mice

The biodistribution of two recently developed tumour markers, trimethylated (CP(Me)3) and trimethoxylated (CP(OMe)3) carotenoporphyrin, was investigated by means of laser-induced fluorescence (LIF) after i.v. injection into 38 tumour-bearing (MS-2 fibrosarcoma) female Balb/c mice. At 3, 24, 48 or 96 h after administration, the carotenoporphyrin fluorescence was measured in tumoral and peritumoral tissue, as well as in the abdominal, thoracic and cranial cavities. The fluorescence was induced by a nitrogen laser-pumped dye laser, emitting light at 425 nm, and analysed by a polychromator equipped with an image-intensified CCD camera. The fluorescence was evaluated at 490, 655 and 720 nm: the second and third wavelengths represent the carotenoporphyrin (CP)-related peaks, whereas the first one is close to the peak of the tissue autofluorescence. The tumour and the liver were the two tissue types showing the strongest carotenoporphyrin-related fluorescence, whereas the cerebral cortex and muscle consistently exhibited weak substance-related fluorescence. In most tissue types, the fluorescence intensities decreased over time. A few exceptions were observed, notably the liver, in which the intensity remained remarkably constant over the time period investigated.

Photodynamic therapy using intravenous delta-aminolaevulinic acid-induced protoporphyrin IX sensitisation in experimental hepatic tumours in rats

The efficacy of photodynamic therapy (PDT) using delta-aminolaevulinic acid (ALA)-induced protoporphyrin IX (PpIX) sensitisation and laser light at 635 nm was investigated in the treatment of experimental hepatic tumours. The model of liver tumours was induced either by local inoculation or by administration of tumour cells through the portal vein in rats. ALA at a dose of 60 mg kg(-1) b.w. was intravenously administered 60 min before PDT. PpIX accumulation in tumour, normal liver and abdominal wall muscle was detected by means of laser-induced fluorescence (LIF). Laser Doppler imaging (LDI) was used to determine changes in the superficial blood flow in connection with PDT. Histopathological examinations were performed to evaluate the PDT effects on the tumour and the surrounding liver tissue, including pathological features in the microvascular system. The accumulation of PpIX, as monitored by LIF, showed high fluorescence intensities at about 635 nm in both the hepatic tumour tissue and normal liver and low values in the abdominal wall. LDI demonstrated that the blood flow in the treated tumour and its surrounding normal liver tissue decreased immediately after the PDT, indicating an effect on the vascular system. A large number of thrombi in the irradiated tumour were found microscopically 3 h after the PDT. The tumour growth rate showed a marked decrease when evaluated 3 and 6 days after the treatment. These results show that the ALA-PDT is effective in the inhibition of growth of experimental hepatic tumours.

Detection of adenocarcinoma in Barrett's oesophagus by means of laser induced fluorescence

PATIENTS

Seven patients with Barrett's metaplastic epithelium and oesophageal adenocarcinoma were investigated by means of laser induced fluorescence after low dose intravenous injection (0.35 mg/kg bw) of Photofrin (QLT, Vancouver, Canada). Laser induced fluorescence measurements were performed immediately after resection of the oesophagus.

METHODS

Laser induced fluorescence spectra were recorded from 15-30 locations in each surgical specimen from normal mucosa, Barrett's epithelium, and tumour tissue. Histological examination was performed on each location to correlate the fluorescence spectral characteristics with histological status of the epithelium (normal, metaplastic or malignant). Measurements were also performed during endoscopy in five patients to test the applicability of the method in a clinical setting. Fluorescence spectra were recorded and evaluated at characteristic wavelengths, and biopsy specimens were collected. Fluorescence ratios were calculated as the quotient of Photofrin fluorescence divided by autofluorescence.

RESULTS

The mean (SD) fluorescence ratio values were 0.10 (0.058) for normal oesophageal mucosa, 0.16 (0.073) for normal gastric mucosa, 0.205 (0.17) for Barrett's epithelium with moderate dysplasia, 0.79 (0.54) for severe dysplasia, and 0.78 (0.56) for adenocarcinoma. The highest fluorescence ratios were obtained for adenocarcinoma tissue, which could generally be distinguished from all nonmalignant tissue. Metaplastic Barrett's epithelium also yielded higher fluorescence ratios than did normal mucosa.

CONCLUSIONS

The results suggest that the technique can be used during endoscopy for real time tissue characterisation in the oesophagus, as an aid in detecting malignant transformation not macroscopically apparent at endoscopy.

Intra-operative laser-induced photodynamic therapy in the treatment of experimental hepatic tumours

OBJECTIVE

To examine the effect of photodynamic therapy (PDT) on experimental liver tumours in rats.

DESIGN

An experimental liver tumour model was used. Each of a group of rats had two tumours simultaneously inoculated into its liver. The tumour located in the left hepatic lobe was used for PDT, and the other one, in the median lobe, as a control. The haem precursor delta-amino laevulinic acid (ALA), at a dose of 30 mg/kg body weight, was injected 60 min before laser irradiation. Rats in group I received ALA through a femoral vein. Those in group II received ALA through the portal vein. Group III had an injection of ALA solution through the portal vein plus hepatic inflow occlusion. Three and 6 days after the treatment, the rats were killed, and the tumours were measured, and ultrastructural changes were examined using scanning electron microscopy.

SETTING

Lund University Medical Laser Centre, Lund, Sweden.

RESULTS

The mean tumour volume of the treated tumours increased by factors of 1.9, 1.5 and 1.7 in groups I, II and III, respectively, compared with the pretreatment baseline value. However, the mean tumour volume in the control tumours increased by factors of 9.5, 4.3 and 4.8 in the respective groups. Under the light microscope, marked necrosis of the treated tumour and the surrounding liver tissue was observed. Scanning electron microscopy revealed heavy damage to the cells and vessels in the treated tumour.

CONCLUSION

PDT with ALA is an effective treatment modality for rat liver tumours.

Management of genital warts in women with human leukocyte interferon-alpha vs. podophyllotoxin in cream: a placebo-controlled, double-blind, comparative study

The purpose of this double-blind, placebo-controlled, comparative study was to evaluate the specific clinical efficacy and tolerance of human leukocyte interferon-alpha (2 x 10(6) IU/g) and podophyllotoxin 0.5% incorporated in a hydrophilic cream to cure genital warts. Preselected Asian women (n = 60) aged 18-40 years (mean 22.9), with a clinical and biopsy-confirmed diagnosis of genital warts, harboring 322 lesions (mean 5.36) were randomly assigned to three parallel groups to receive one of the two test drugs or placebo. Each patient received a precoded tube (40 g) containing either human leukocyte interferon-alpha, podophyllotoxin, or identically appearing placebo cream for 3 days' usage. In addition to written instructions, each subject was shown how to apply a minimal amount of trial medication on their lesions thrice daily for 3 consecutive days per week (maximum nine topical applications per week). Patients were examined on a weekly basis, and a cure was considered to be a biopsy-confirmed, total elimination of a lesion. Moreover, patients cured during the study period were spared further therapy, and were requested to return in 16 weeks to monitor for the occurrence of a relapse. The remaining patients' empty tubes were collected, and similarly precoded replacement tubes were given to continue the treatment; a total of 214 tubes were used. The study was scheduled for 16 weeks with 4 weeks of active treatment. Individuals were excluded from the study due to pregnancy, breast feeding, or the receiving of any type of antiviral therapy during the 4 weeks preceding enrollment.(ABSTRACT TRUNCATED AT 250 WORDS)

Immunotherapy in liver tumors: III. A new experimental model of metastatic liver tumors from colorectal carcinoma for cytokine therapy

A new model of metastatic liver tumors in Wistar/Furth rats is introduced. A colorectal adenocarcinoma cell line (LDLX40) induced by 1,2-dimethylhydrazine was injected through one of the branches of the ileal mesenteric vein to develop metastatic liver tumors in rats. On day 30 after the inoculation of tumor cells, micrometastases were detected under microscopy in all animals that received tumor inoculation. Macrometastases in 87.7% of animals were found by either the tumor staining test or ultrasonography. No extrahepatic tumor developed in this tumor model. To observe the effects of different treatment strategies on metastatic liver tumors, 35 animals were randomly divided into four groups. Group I served as control. Group II underwent hepatic artery ligation (HAL). Group III received intraportal administration of recombinant interleukin-2 (rIL-2) and interferon-alpha (IFN-alpha). Group IV had intraportal medication of rIL-2 and IFN-alpha + HAL (the IIH protocol). Results indicated that rapid tumor growth was seen in the control tumors. HAL produced little response to metastatic liver tumors as compared to the control group (P > 0.05). The combined application of rIL-2 and IFN-alpha showed an improved result, with 22% of tumor growth inhibition or regression (P < 0.05 compared to the control group). Twenty-eight percent of tumor growth restraint or regression was found in the group treated with the IIH protocol (P < 0.05 compared to the control group). We conclude that this new experimental model of metastatic liver tumors is reproducible, and that the IIH protocol is effective in the treatment of metastatic liver tumors in rats. These beneficial effects from the IIH protocol may be introduced into patients with metastatic liver tumors.

Laser-induced fluorescence studies of meso-tetra(hydroxyphenyl)chlorin in malignant and normal tissues in rats

meso-Tetra(hydroxyphenyl)chlorin (mTHPC) is an attractive second-generation dihydroporphyrin photosensitiser for use in photodynamic therapy. In this study, 1.3 mg kg-1 body weight mTHPC was administered intravenously, and laser-induced fluorescence was used to characterise and compare its localisation and retention in different rat tissues, including an induced experimental adenocarcinoma, 24 h and 48 h post injection. These studies were performed in an attempt to predict the anatomical locations where mTHPC PDT might be most effective and suggest suitable injection--irradiation intervals in each case. Of particular interest were the intra-abdominal and intrathoracic tissues. The fluorescence was induced at 405 nm and the fluorescence spectrum in the region 450-750 nm was analysed. All collected spectra were dominated by the fluorescence signature of mTHPC with its peak at 652 nm, and all values in this study are in terms of background-free drug-specific fluorescence intensity at that wavelength. The photosensitiser accumulated in high concentrations in the tumour and the reticuloendothelial system. Muscular organs, such as the heart and the abdominal wall, were characterised by a low drug fluorescence signature.

Laser-induced fluorescence in malignant and normal tissue in mice injected with two different carotenoporphyrins

Laser-induced fluorescence (LIF) was used to characterise the localisation of an intravenously administered trimethylated carotenoporphyrin [CP(Me)3] and a trimethoxylated carotenoporphyrin [CP(OMe)3] in an intramuscularly transplanted malignant tumour (MS-2 fibrosarcoma) and healthy muscle in female Balb/c mice, 3, 24, 48 and 96 h post injection. The fluorescence was induced with a dye laser pumped by a nitrogen laser, emitting light at 425 nm. The fluorescence spectra were recorded in the region 455-760 nm using a polychromator equipped with an image-intensified CCD camera. The tumour/peritumoral muscle ratio was about 5:1 for CP(Me)3 and about 6:1 for CP(OMe)3 in terms of the background-free fluorescence intensity, which peaked at about 655 nm. By including the endogenous tissue fluorescence, the contrast was further enhanced by a factor of approximately 2.

Photodynamic therapy of non-melanoma malignant tumours of the skin using topical delta-amino levulinic acid sensitization and laser irradiation

Eighty basal cell carcinomas (BCCs) in 21 patients, 10 lesions of Bowen's disease in three patients, and four lesions of cutaneous T-cell lymphoma in two patients, were treated with photodynamic laser therapy (PDT), using topical application of the haem precursor delta-amino levulinic acid (ALA). The diagnoses were confirmed histologically prior to treatment. Fifty-five of the BCCs were superficial lesions, and 25 were nodular. Of the 80 BCCs, 39 (49%) were located on the trunk, 36 (45%) on the head and neck region, four (15%) on the leg and one on the arm. The two principal locations of the 10 Bowen's disease lesions were the leg (50%) and the trunk (40%). The T-cell lymphoma lesions were located on the shoulder and on the arm. A water-in-oil based cream containing 20% ALA was applied to the lesions, with a margin of about 10-20 mm beyond the visible tumour border, 4-6 h before the laser procedure. During this period of time the highly fluorescent and photodynamically active substance protoporphyrin IX (Pp IX) is synthesized via the haem cycle. Laser-induced fluorescence (LIF) was used for real-time monitoring of the Pp IX distribution in the tumour and in the normal surrounding skin, before and after treatment in all patients. Before laser treatment the Pp IX distribution demonstrated by LIF showed a demarcation between tumour and normal skin of about 15:1 for BCC and Bowen's disease, and 5:1 for T-cell lymphomas.(ABSTRACT TRUNCATED AT 250 WORDS)

Laser-induced fluorescence in malignant and normal tissue of rats injected with benzoporphyrin derivative

Laser-induced fluorescence was used to characterize the localization of intravenously administered benzoporphyrin derivative-monoacid (BPD-MA) 3 h postinjection in different rat tissue types, including an induced experimental malignant tumor. A comparison of the fluorescence properties and demarcation potential between the newer sensitizer BPD-MA and four other substances, hematoporphyrin (HP), polyhematoporphyrin ester (PHE), tetrasulfonated phthalocyanine (TSPc) and the commercially available Photofrin earlier investigated, is included. The fluorescence light was induced with a nitrogen laser, emitting at 337 nm. The fluorescence spectrum in the region 380-750 nm was analyzed by a polychromator equipped with a diode array detector. The demarcation potential between tumor and surrounding tissue in terms of fluorescence signal for the tumor model used was 2:1 for BPD-MA. In comparison with the other drugs, HP shows about the same demarcation potential, whereas Photofrin and PHE exhibit about 3 times better and TSPc about 1.5 times better demarcation. By also employing the endogenous tissue fluorescence signature the contrast was enhanced by a factor of about 2 for each of the five drugs.

Clinical fluorescence diagnosis of human bladder carcinoma following low-dose Photofrin injection

A point-monitoring fluorescence diagnostic system based on a low-energy pulsed laser, fiber transmission optics, and an optical multichannel analyzer was used for diagnosis of patients with bladder malignancies. Twenty-four patients with bladder carcinoma, carcinoma in situ, and/or dysplasia were injected with hematoporphyrin derivative, Photofrin, 0.35 or 0.5 mg/kg body weight, forty-eight hours prior to the investigation. The ratio between the red sensitizer emission and the bluish tissue autofluorescence provided excellent demarcation between papillary tumors and normal bladder wall. Certain cases of dysplasia also could be differentiated from normal mucosa. Benign exophytic lesions such as malakoplakia appeared different from malignant tumors in fluorescence. Flat suspicious bladder mucosa such as seen in infectious diseases or after radiation therapy appeared normal on fluorescence.

Fluorescence imaging and point measurements of tissue: applications to the demarcation of malignant tumors and atherosclerotic lesions from normal tissue

The possibilities of using laser-induced fluorescence for tissue diagnostics are discussed. The tissue types investigated are malignant tumors and atherosclerotic lesions. Studies with natural autofluorescence as well as with fluorescent tumor markers are included in this paper. Fluorescence emission and decay data are presented for some tissue chromophores contributing to tissue autofluorescence. Optical spectroscopic characteristics of fluorescent malignant tumor markers are analyzed and instrumental designs for clinical applications are discussed. Images recorded with a multicolor fluorescence imaging system developed in Lund are presented.

Time-resolved laser-induced fluorescence spectroscopy for enhanced demarcation of human atherosclerotic plaques

We report on the enhanced demarcation between human atherosclerotic plaques and normal vessel wall obtained using time-resolved detection of laser-induced fluorescence rather than the customary time-integrated monitoring technique. A frequency-doubled mode-locked and cavity-dumped continuous wave dye laser was used for picosecond pulse generation at 320 nm, and photon-counting techniques were employed for the time-resolved signal monitoring from human aorta samples in vitro. Implications for imaging fluorescence angioscopy and spectroscopic guidance in laser ablation of plaque are indicated.

Fluorescence diagnosis and photochemical treatment of diseased tissue using lasers: Part I

Lasers are useful in many applications in medicine and biology. Historically, most laser use has involved heat generated in the interaction of the laser beam with the tissue. Today, however, the spectroscopic aspects of this laser use are playing a more dominant role in a number of applications. In this two-part series, Sune Svanberg and co-workers present illustrations of emerging clinical applications from cooperative work performed by the Lund Institute of Technology and the Lund University Hospital. Part I includes a survey of laser techniques for atomic and molecular analyses of samples of medical interest, spectroscopic analysis of the laser-induced plasma obtained when a high-power pulsed laser beam interacts with tissue, and the use of tumor-seeking agents in combination with laser radiation to provide new possibilities for malignant tumor detection and treatment. Part II, which will appear in the January 1, 1990, issue, describes the use of laser-induced fluorescence for tumor and plaque diagnostics. Different lasers have been used, and research efforts increasingly are being focused on excimer lasers and lasers in the IR region for the ablation of atherosclerotic plaques, cell layer by cell layer.

Fluorescence studies of hematoporphyrin derivative in normal and malignant rat tissue

Laser-induced fluorescence in rat tissue was studied during the uptake and clearing period of i.v.-injected hematoporphyrin derivative. A malignant rat tumor and normal tissue of 20 different kinds from the tumor-bearing animals were investigated. A pulsed nitrogen laser (337 nm) was used in conjunction with an optical multichannel analyzer system, in which the whole fluorescence light distribution was captured for each laser pulse. Several of the organs exhibited an initial and a delayed intensity peak in the characteristic hematoporphyrin derivative laser-induced fluorescence intensity (630 nm) that might be interpreted as due to intracellular transformations of different chemical components of the hematoporphyrin derivative preparation. By dividing the background-free 630-nm signal by the blue fluorescence intensity, a dimensionless quantity is obtained that could have many advantages in practical endoscopic laser-induced fluorescence work. This ratio was also shown to exhibit a larger contrast between tumor and surrounding tissue. The ratio between the two red fluorescence peaks was also found to be useful for discriminating tumor from normal tissue. A combination of the two ratios was shown to be particularly valuable for tumor discrimination.

Multicolor imaging and contrast enhancement in cancer-tumor localization using laser-induced fluorescence in hematoporphyrin-derivative-bearing tissue

Simultaneous imaging of laser-induced fluorescence in three selected wavelength bands from hematoporphyrin-derivative-bearing tissue has been performed, permitting considerable contrast enhancement for cancer-tumor localization.