Evaluation of porfimer sodium fluorescence for measuring tissue transformation

Photodynamic Therapy

Photodynamic therapy is a clinical technique for the treatment of cancers, microbial infections and other medical conditions by means of light-induced generation of reactive oxygen species using photosensitising drugs. The intrinsic fluorescence of many such drugs make them potential theranostic agents for simultaneous diagnosis and therapy. This chapter reviews the basic chemical and biological aspects of photodynamic therapy with an emphasis on its applications in theranostics. The roles of nanotechnology is highlighted, as well as emerging trends such as photoimmunotherapy, image-guided surgery and light- and singlet-oxygen dosimetry.

Autofluorescence and Photofrin-induced fluorescence imaging and spectroscopy in an animal model of oral cancer

Developments in the fluorescence detection of cancer aim either to distinguish tissue autofluorescence from that of injected fluorophores or to exploit differences in autofluorescent spectra of normal versus transforming, premalignant and malignant tissue. This study evaluates the utility of autofluorescence and Photofrin-induced fluorescence imaging and spectroscopy to distinguish tissue transformation associated with early malignant change in the oral cavity. The model of tissue transformation used was that induced by the carcinogen DMBA in the hamster buccal cheek pouch. Fluorescence spectra were obtained using a high-sensitivity fiber optic spectrometer, while imaging was performed using a Multispectral Fluorescence Guidance (MFG) system designed for use in intraoperative fluorescence imaging during photodynamic therapy. The results demonstrate that Photofrin fluorescence can be used to predict the pathologic state of tissue, the fluorescence intensity being directly proportional to the degree of malignant transformation. Autofluorescence detection measured two parameters that are altered by transformation stage: the red/green fluorescence ratio and the total fluorescence intensity. The most striking feature was the change in the latter in malignant tissue. The MFG imaging device performed as well as spectroscopy: the sensitivity and specificity for the imaging system were 65% and 90% for autofluorescence and 87% and 85% with Photofrin. This indicates that either the autofluorescence intensity index of the tissue or the Photofrin-induced fluorescence may provide a good parameter for the "first approximation" characterization of the tissue.

Fluorescence imaging and spectroscopy of ethyl nile blue A in animal models of (pre)malignancies

Discrimination between normal and premalignant tissues by fluorescence imaging and/or spectroscopy may be enhanced by a tumor-localizing fluorescent drug. Ethyl Nile Blue A (EtNBA), a dye with no phototoxic activity, was investigated for this purpose. The pharmacokinetics and tissue-localizing properties were investigated in a rat palate model with chemically induced premalignant mucosal lesions (0.5 mg/kg EtNBA intravenous [i.v.]), a hairless mouse model with UVB-induced premalignant skin lesions (1 mg/kg EtNBA intraperitoneal) and in a rat skin-fold observation chamber model on the back of a rat with a transplanted solid tumor (2.5 mg/kg EtNBA i.v.). Fluorescence images and spectra were recorded in vivo (600 nm excitation, 665-900 nm detection) and in frozen tissue sections at several time points after EtNBA administration. In the rat palate the EtNBA fluorescence was maximum almost immediately after injection, whereas in the mouse skin and the observation chamber the fluorescence maximum was reached between 2 and 3 h after injection. EtNBA cleared from tissues after 8-24 h. EtNBA localizes in the transplantable solid tumor, but is not targeted specifically to the dysplastic location in the rat palate and mouse skin. However, in the rat palate the EtNBA fluorescence increased significantly with increasing dysplasia, apparently due to the increasing thickness of the upper keratinized layer of the epithelium where the dye was found to localize. Localization in this layer occurred both in the rat palate and in hairless mouse skin.

Photodynamic therapy and hyperthermia as an adjuvant modality in preventing tumor recurrence

BACKGROUND AND OBJECTIVE

The objective of this study was to determine the relative efficacy in preventing tumor recurrence by photodynamic therapy (PDT), and by ablative CO2 laser surgery followed by PDT, compared to ablative surgery alone (negative control) or ablative surgery followed by a course of hyperthermia (positive control).

STUDY DESIGN/MATERIALS AND METHODS

The cheek pouches of 36 hamsters were treated with 0.5% 9,10 dimethyl-1,2-benzanthracene in acetone three times a week. After 12 weeks all animals showed tumors of their cheek pouches and were divided into four groups. In groups number I, II, and III, all visible tumors were removed by aid of a CO2 laser. Animals of group I did not receive any further treatment. After tumor resection, the cheek pouches in group II were treated with hyperthermia by aid of a Nd:YAG laser and a temperature of 43 degrees C for 30 minutes. In group III after resection of the tumors, the cheek pouches were treated with PDT (75mW/cm2 175J/cm2--3mg/kg Photofrin i.p./24h). In group IV, the tumors were not excised, instead they were only treated with PDT (as above). All animals were observed for 50 days for any signs of tumor recurrence.

RESULTS

In group I (CO2) all tumors (100%) recurred within 50 days. In group II (CO2 + hyperthermia) 61%, in group III (CO2 + PDT) 27.7%, and in group IV (PDT) 50% of all tumors recurred. The first signs of recurrence could be seen in group I, followed by groups II and IV. Group III was the last one presenting tumor recurrence.

CONCLUSIONS

The combination of CO2 surgery and PDT produced significantly better results than CO2 surgery or PDT alone, and better than the combination of CO2 surgery and hyperthermia.

Promotional effects of CO2 laser on DMBA-induced hamster buccal pouch carcinogenesis as shown by immunohistochemistry of the placental form of glutathione S-transferase

BACKGROUND AND OBJECTIVE

The purpose of the present study was to investigate the kinetics of the expression of the placental form of glutathione S-transferase (GST-P), a useful marker of premalignant lesions, and cell proliferation after CO2 laser surgery on the carcinogen-initiated epithelium.

STUDY DESIGN/MATERIALS AND METHODS

CO2 laser incisions were made on buccal pouch epithelium of 36 hamsters after initiation by 9,10-dimethyl-1,2-benzanthracene (DMBA) (group 1, G1), and scalpel incisions were similarly made on 33 animals (group 2, G2). Twenty animals not treated further after initiation were used as DMBA-treated controls. Incidence of malignant transformation, expression of GST-P, and cell proliferation were examined.

RESULTS

The incidence of malignant transformation in G1 and G2 increased significantly (G1: P < 0.001; G2: P < 0.05) compared with that in DMBA-treated controls. GST-P expression of hyperplasia in G1 and G2 decreased significantly (P < 0.001) compared with that in DMBA-treated controls. In hyperplasia, cell proliferation of the GST-P-negative area was significantly (P < 0.001) higher than that of the GST-P-positive area.

CONCLUSION

The incisions, particularly by the CO2 laser, on the initiated areas made expression of GST-P decrease and cell proliferation increase in the GST-P-negative areas. These incisions may serve to promote malignant transformation.

Distribution and pharmacokinetics of Photofrin in human bile duct cancer

Prognosis of patients with bile duct tumors is mostly poor due to late diagnosis and a lack of adequate curative and palliative treatment modalities. To evaluate the potential of photodynamic therapy (PDT) as a novel and alternative treatment approach, we have investigated the uptake and tumor-specific localization of the photosensitizer Photofrin in human biliary tract neoplasms. We have quantified the distribution and the pharmacokinetics of Photofrin in normal and tumor tissue biopsies of the human bile duct by quantitative fluorescence microscopy and digital image analysis of cryosections. Fluorescence intensities (expressed as a percentage of a standard) are 19.0 +/- 11.4% and 25.2 +/- 12.7% for tumors and 10.9 +/- 2.9% and 13.2 +/- 9.1% (mean +/- SD) for normal bile duct tissue at 24 h (n = 5) and 48 h (n = 8) after Photofrin administration (2 mg kg-1 i.v.), respectively, and decrease afterwards in normal bile duct tissue over the period of investigation (4-35 days). The ratios of fluorescence in tumor versus normal tissue are found to be 1.7 +/- 0.7 and 2.3 +/- 1.2 (mean +/- SD) at days one and two after Photofrin administration, respectively. Thus, Photofrin preferentially accumulates in bile duct neoplasms, reaching peak values during the first two days. These data suggest that laser irradiation should be performed within this period after Photofrin injection to achieve tumor selectivity of PDT for effective treatment of bile duct carcinoma.

Characterization of native fluorescence from DMBA-treated hamster cheek pouch buccal mucosa for measuring tissue transformation

The steady-state native fluorescence spectra of extracts of normal mucosa as well as of different stages of oral lesion of the 7,12-dimethylbenz (a) anthracene (DMBA)-induced hamster cheek pouch carcinogenesis model have been measured and analysed at 405 nm excitation. The emission spectra were scanned from 430 to 700 nm to characterize the native fluorescence of endogenous porphyrin and other fluorophores under various tissue transformation conditions, such as hyperplasia, papilloma, early invasive carcinoma and well-differentiated squamous cell carcinoma. Two ratio parameters, R1 = (I530/I620) and R2 = (I530/I630), are introduced to quantify the diagnostic potentiality. The ratio values were found to decrease as the stage of the cancer increases. The suggested critical values for both R1 and R2 for normal mucosa is above three, and the suggested critical value for tissues with lesion is less than three. It was also found that the values for R1 and R2 for well-differentiated squamous cell carcinoma is less than one. The ratio parameter R2 is selected for discrimination between normal mucosa and oral lesions, as the difference in the R2 value between normal and DMBA-treated tissue is higher than that for R1.

In vivo photo-detection of chemically induced premalignant lesions and squamous cell carcinoma of the rat palatal mucosa

Photo-detection using in vivo fluorescence was studied for different stages of chemically induced premalignant lesions and squamous cell carcinoma (SCC) of the Wistar rat palatal mucosa. It was found that the epithelial dysplasia (numerically expressed in the epithelial atypia index (EAI) of the rat palate, induced by repeated application of the carcinogen 4-nitroquinoline 1-oxide (4NQO), showed an increase approximately proportional to the duration of the application period. Photo-detection of the lesions using Photofrin-induced fluorescence was studied with dual-wavelength excitation and the subtraction of images, in an attempt to reduce the autofluorescence. The Photofrin dose was 2.5 mg kg-1. This was based on a dose-response study for normal tissue damage by photodynamic therapy (PDT) in this animal model, because the underlying rationale was to study photo-detection as a method of locating additional (early) malignancies in patients treated by PDT. Fluorescence intensities 24 and 48 h after injection of Photofrin were shown to increase with the duration of 4NQO application and with increasing EAI. For an EAI greater than 15, there was a statistically significant difference (p < 0.01) between the fluorescence signals obtained with and without the injection of Photofrin. Fluorescence signals of these lesions without the use of Photofrin (autofluorescence) also showed an increase with increasing stages of epithelial dysplasia of the rat palate. However, the fluorescence signals obtained with Photofrin were always higher than those of the autofluorescence. From this study, we conclude that photo-detection with Photofrin has potential in distinguishing chemically induced premalignant lesions and squamous cell carcinomas from the normal rat palatal mucosa. Photofrin (2.5 mg per kg of body weight) certainly adds to the sensitivity of photo-detection, but autofluorescence alone also has promising features for detecting premalignant and malignant lesions of the oral mucosa.

Photodynamic therapy for premalignant lesions in DMBA-treated hamsters: a preliminary study

PURPOSE

Photodynamic therapy (PDT) involves the selective destruction of neoplastic cells through the activation of a photosensitizer by light. We have previously shown that the photosensitizer Photofrin (porfimer sodium) is selectively accumulated in transformed lesions destined to become malignant, but not yet definable histologically as precancers. The aim of this investigation was to determine if this premalignant tissue could be selectively destroyed by systemically administered Photofrin activated by 630 nm red light via an argon dye laser.

MATERIALS AND METHODS

The carcinogenic model used was the DMBA (9, 10 dimethyl 1,2 benzanthracene)-treated hamster cheek pouch. The animals were treated with 0.5% DMBA in acetone thrice weekly for 6 weeks (experiment I, premalignant lesions), or 12 weeks (experiment II, malignant lesions). Ten animals were in experiment I; nine animals were in experiment II. These were divided into experimental and control subgroups. The 6-week experimental group received PDT and CO2 laser incision into the DMBA-treated area. The CO2 laser was used as a promoter of neoplasia in a field that had already undergone initiation from the DMBA treatment. The control groups received either CO2 laser incision alone into the DMBA-treated field or CO2 laser incision and argon pumped dye laser treatment (without Photofrin). The 12-week experimental group received PDT after CO2 laser excision of tumors. The controls received CO2 excision alone, or CO2 excision combined with postoperative hyperthermia.

RESULTS

One hundred percent (three of three) of cheeks in experiment I receiving PDT developed necrosis of the treated area within 24 to 48 hours, but 0% (0 of three) subsequently developed tumors. No necrosis was seen in control cheeks receiving Photofrin without irradiation (0 of four) or irradiation without Photofrin (0 of six), and 56% (five of nine) of cheeks exposed to identical carcinogenic stimulus, without PDT, developed tumors (n = 9). In experiment II, 0% (0 of six) of cheeks receiving postoperative PDT developed tumor recurrence. In experiment II controls, 50% (three of six) of cheeks that underwent excision and hyperthermia developed tumor recurrence. In cheeks treated only with CO2 laser excision of tumors, a recurrence rate of 67% (four of six) was noted. These results were found to be statistically significant by the Student t-test on the binomial distribution (P < .01). One animal was treated with DMBA for 6 weeks, administered Photofrin, and the right cheek was irradiated and the animal was left for 30 weeks. The irradiated cheek epithelium necrosed but no cancer developed, whereas the positive control cheek developed a large cancer.

CONCLUSION

These results suggest that photodynamic therapy possesses significant potential in elimination of premalignant tissue. This could be beneficial in treating potentially premalignant lesions such as oral leukoplakia, and useful as adjunctive therapy in removal of areas of field cancerization adjacent to surgical sites.

Bombesin antagonist prevents CO2 laser-induced promotion of oral cancer

We previously reported that CO2 laser incisions in carcinogen-initiated fields promoted cancer development and caused release of growth factors. Here we examined the quantitative and additive properties of this tumor-promoting event and examined whether this promotion could be nullified by treatment with a bombesin antagonist, which down-regulates epidermal growth factor receptors. The model used for cancer promotion was the hamster buccal cheek pouch that had been treated with a carcinogen (9,10-dimethyl-1,2-benzanthracene) for 6 weeks, producing premalignant lesions. These lesions would evolve into a cancer eventually without further treatment. Promotion was measured both by increased fluorescence in response to systemically administered Photofrin, measured noninvasively using an in vivo fluorescence photometer, and by the timing of appearance of clinical tumors. Laser incisions (0-3) were made into the hamster cheek 1 week apart, or three incisions were done 1 day apart. Another group of animals received bombesin antagonist RC-3095 for 4 weeks during the time incisions were made, again measuring promotion. Laser incisions 1 week apart produced additive promotion, whereas three incisions 1 day apart were not statistically different from the group receiving only one incision. RC-3095 treatment completely eliminated the promoting effects of incision and totally stopped promotion for the 4-week period of treatment. After discontinuing treatment with RC-3095, lesion progression resumed at the untreated control rate. This work confirms that the promoting event of a laser incision follows a comparable time course to release of growth factors after such an incision and that it can be eliminated by treatment with bombesin antagonists.

Photodynamic therapy of oral cancer. A review of basic mechanisms and clinical applications

Photodynamic therapy (PDT) is an experimental cancer treatment modality. PDT is based on the accumulation of a photosensitive dye in premalignant and malignant lesions. A certain period of time after the dye has been administered, tumor tissue may contain more of the sensitizer then the surrounding normal tissues. When tissue containing the sensitizer is exposed to light of a proper wavelength and dose, a photochemical reaction between sensitizer and light will occur. The activated photosensitizer reacts with available oxygen which subsequently damages cells and eventually may cause necrosis of the tumor. Photosensitizers can also be used for fluorescence detection. If a tumor contains more of the photosensitizer than the surrounding normal tissue, its fluorescence can potentially be utilized to detect tumors. Analogous to PDT, this can therefore be referred to as photodynamic detection (PDD). This paper reviews the basic mechanisms and clinical applications of PDT and PDD. Emphasis is placed on PDD and PDT with the photosensitizer Photofrin for detection and treatment of premalignant epithelial lesions and squamous cell carcinomas of the oral mucosa.

In vivo fluorescence kinetics and localisation of aluminum phthalocyanine disulphonate in an autologous tumour model

Sulphonated phthalocyanines are studied as photosensitizers for photodynamic therapy of cancer. Their strong fluorescence and tumour-localising properties make them also potentially useful for detection of cancer by fluorescence. For this purpose, we have studied the fluorescence kinetics and localisation of aluminum phthalocyanine disulphonate (AlPcS2) in 4-nitroquinoline 1-oxide (4NQO)-induced dysplasia and invasive cancer of the oral mucosa of the hard palate in Wistar albino rats. Twenty-two rats were divided into six groups. Five groups were subjected to a 4NQO application period of 8, 12, 16, 20 or 26 weeks and one was a control group. The dysplasia varied from slight to severe and was correlated with the duration of the application period. All animals received a dose of 1 micromol/kg AlPcS2 i.v. Fluorescence images were recorded via a specially designed 'palatoscope' with excitation at 460 +/- 20 nm for autofluorescence, 610 +/- 15 nm for AlPcS2 fluorescence and detection of emission at 675 +/- 15 nm. After subtraction of the two images the specific AlPcS2 fluorescence remained. AlPcS2-mediated fluorescence increased significantly when the severity of dysplasia increased (P<0.04). Also the phenomenon of strong fluorescent spots on the fluorescence images was observed. This always occurred within the first 10 h after injection of AlPcS2. Histological analysis showed a local alteration to a mucosa in 67% of these spots, which was either invasive cancer (29%) or inflammation (38%). These results suggest two different mechanisms of AlPcS2 uptake in tissue, one associated with the presence of generalised dysplasia and another associated with local changes of the epithelial/connective tissue, which is not necessarily specific for tumours.

Localization and treatment of transformed tissues using the photodynamic sensitizer 2-[1-hexyloxyethyl]-2-devinyl pyropheophorbide-a

BACKGROUND AND OBJECTIVE

Photofrin is the photosensitizer currently used in most clinical trials examining the efficacy of photodynamic therapy (PDT) for the treatment and/or palliation of neoplasia. Although this drug has been shown to be efficacious in many of these trials, it possesses less than ideal qualities for use in a systemically administered photosensitizer. A new photosensitizer, 2-[l-hexyloxyethyl]-2-devinyl pyropheophorbide-a (HPPH), was developed for PDT. HPPH possesses more rapid clearance from skin and greater cytotoxicity per drug dose than Photofrin. The aims of this study were to: (1) examine the uptake and retention of HPPH in tissues undergoing malignant transformation using laser-induced fluorescence, and (2) evaluate the efficacy of HPPH and 665 nm light in treating carcinogen-induced tumors of the hamster buccal cheek pouch.

STUDY DESIGN/MATERIALS AND METHODS

The model of tissue transformation was the carcinogen (9,10-dimethyl-1, 2-benzanthracene)-induced premalignant and malignant lesions of the hamster buccal cheek pouch. Following induction of the specific transformation stages, hamsters were injected intraperitoneally with 0.5 mg/kg HPPH. Subsequently, the buccal mucosa was examined for fluorescence at various times up to 72 hours after photosensitizer injection.

RESULTS

Uptake studies of HPPH showed highest fluorescence levels in tissues 48 hours after HPPH injection. Fluorescence levels of tissues increased significantly as follows. Normal < dysplasia < papillomas < squamous cell carcinomas. Carcinogen-induced tumors in 14 hamsters were treated with surface illuminations of red light (665 nm) via fiber optics coupled to an argon-ion pumped dye laser 48 hours after intraperitoneal injection with either 0.5 or 1.0 mg/kg HPPH. Complete necrosis of tumor tissues 7 days following PDT was observed in 57% (4/7) with 0.5 mg/kg and 86% (6/7) with 1.0 mg/kg HPPH.

Detection of squamous neoplasia by fluorescence imaging comparing porfimer sodium fluorescence to tissue autofluorescence in the hamster cheek-pouch model

BACKGROUND

Early neoplastic changes in the oral cavity may be difficult to detect. Fluorescence imaging using porphyrin-derived drugs has been used to enhance detection of neoplasia. Autofluorescence has also been used for this purpose. This paper compares autofluorescence to porfimer sodium-induced fluorescence in the detection of neoplasia in the hamster cheek-pouch model.

MATERIALS AND METHODS

Neoplasia was induced in the hamster cheek pouch by the application of 9,10-dimethyl-1,2-benzanthracene. Animals were imaged either with injection of drug (porfimer sodium) or without drug (autofluorescence). Imaging was carried out using a laser-induced fluorescence detection system. Biopsies were performed on imaged sections and histologic grades were assigned.

RESULTS

Porfimer sodium fluorescence provided 100% sensitivity and specificity in detection of neoplasia. The sensitivity and specificity with autofluorescence was 76% and 83%, respectively.

CONCLUSIONS

Autofluorescence provides an accurate means of detecting early neoplastic changes in the hamster cheek-pouch model; however, porfimer sodium imaging does improve detection rates.