Tumor oxygen tension during photodynamic therapy

Photodynamic therapy, priming and optical imaging: Potential co-conspirators in treatment design and optimization - a Thomas Dougherty Award for Excellence in PDT paper

Photodynamic therapy is a photochemistry-based approach, approved for the treatment of several malignant and non-malignant pathologies. It relies on the use of a non-toxic, light activatable chemical, photosensitizer, which preferentially accumulates in tissues/cells and, upon irradiation with the appropriate wavelength of light, confers cytotoxicity by generation of reactive molecular species. The preferential accumulation however is not universal and, depending on the anatomical site, the ratio of tumor to normal tissue may be reversed in favor of normal tissue. Under such circumstances, control of the volume of light illumination provides a second handle of selectivity. Singlet oxygen is the putative favorite reactive molecular species although other entities such as nitric oxide have been credibly implicated. Typically, most photosensitizers in current clinical use have a finite quantum yield of fluorescence which is exploited for surgery guidance and can also be incorporated for monitoring and treatment design. In addition, the photodynamic process alters the cellular, stromal, and/or vascular microenvironment transiently in a process termed photodynamic priming, making it more receptive to subsequent additional therapies including chemo- and immunotherapy. Thus, photodynamic priming may be considered as an enabling technology for the more commonly used frontline treatments. Recently, there has been an increase in the exploitation of the theranostic potential of photodynamic therapy in different preclinical and clinical settings with the use of new photosensitizer formulations and combinatorial therapeutic options. The emergence of nanomedicine has further added to the repertoire of photodynamic therapy's potential and the convergence and co-evolution of these two exciting tools is expected to push the barriers of smart therapies, where such optical approaches might have a special niche. This review provides a perspective on current status of photodynamic therapy in anti-cancer and anti-microbial therapies and it suggests how evolving technologies combined with photochemically-initiated molecular processes may be exploited to become co-conspirators in optimization of treatment outcomes. We also project, at least for the short term, the direction that this modality may be taking in the near future.

DFT Case Study of the Mechanism of a Metal-Free Oxygen Atom Insertion into a p-Quinone Methide C(sp3)-C(sp2) Bond

The site-selective introduction of an oxygen atom into an organic molecule, without the assistance of metals, is a useful transformation, though understanding the mechanistic underpinning of such a process is oftentimes a challenging task. In exploring this chemical space and in building upon experimental precedents, we have utilized computational tools to delineate the mechanistic details of site-selective oxygen atom insertion into a p-quinone methide C(sp³)-C(sp²) bond. To this end, several different reaction pathways for oxygen atom insertion were explored-each encompassing a unique element qualifying the respective pathway as being more or less feasible. The findings of these investigations revealed several features that were vital to this reactivity, including the formation of a dimeric intermediate, interconversion between ground- and excited-state species, and strain. Notably, the latter finding adds to the portfolio of strain-release-driven reactions that have emerged as popular methods to achieve otherwise difficult chemical transformations.

Modulating tumor hypoxia by nanomedicine for effective cancer therapy

Hypoxia, a characteristic feature of tumors, is indispensable to tumor angiogenesis, metastasis, and multi drug resistance. Hypoxic avascular regions, deeply embedded inside the tumors significantly hinder delivery of therapeutic agents. The low oxygen tension results in resistance to the current applied anti-cancer therapeutics including radiotherapy, chemotherapy, and photodynamic therapy, the efficacy of which is firmly tied to the level of tumor oxygen supply. However, emerging data indicate that nanocarriers/nanodrugs can offer substantial benefits to improve the efficacy of current therapeutics, through modulation of tumor hypoxia. This review aims to introduce the most recent advances made in nanocarrier mediated targeting of tumor hypoxia. The first part is dedicated to the approaches by which nanocarriers could be designed to target/leverage hypoxia. These approaches include i) inhibiting Hypoxia Inducer Factor (HIF-1α); ii) hypoxia activated prodrugs/linkers; and iii) obligate anaerobe mediated targeting of tumor hypoxia. The second part, details novel nanosystems proposed to modulate tumor hypoxia through tumor oxygenation. These methods seek to lessen tumor hypoxia through vascular normalization, or reoxygenation therapy. The reoxygenation of tumor could be accomplished by: i) generation of oxygen filled nanocarriers; ii) natural/artificial oxygen nanocarriers; and iii) oxygen generators. The efficacy of each approach and their potential in cancer therapy is further discussed.

Intramolecular Transfer of Singlet Oxygen

The intramolecular transfer of energy (FRET) and electrons (Dexter) are of great interest for the scientific community and are well-understood. In contrast, the intramolecular transfer of singlet oxygen ((1)O2), a reactive and short-lived oxygen species, has until now been unknown. This process would be very interesting because (1)O2 plays an important role in photodynamic therapy (PDT). Herein, we present the first successful intramolecular transfer of (1)O2 from a donor to acceptor. Also, we found a dependence of conformation and temperature comparable with those of FRET. We provide several pieces of evidence for the intramolecular character of this transfer, including competition experiments. Our studies should be interesting not only from the theoretical and mechanistic point of view but also for the design of new (1)O2 donors and applications in PDT.

Monitoring photodynamic therapy of head and neck malignancies with optical spectroscopies

In recent years there has been significant developments in photosensitizers (PSs), light sources and light delivery systems that have allowed decreasing the treatment time and skin phototoxicity resulting in more frequent use of photodynamic therapy (PDT) in the clinical settings. Compared to standard treatment approaches such as chemo-radiation and surgery, PDT has much reduced morbidity for head and neck malignancies and is becoming an alternative treatment option. It can be used as an adjunct therapy to other treatment modalities without any additive cumulative side effects. Surface illumination can be an option for pre-malignant and early-stage malignancies while interstitial treatment is for debulking of thick tumors in the head and neck region. PDT can achieve equivalent or greater efficacy in treating head and neck malignancies, suggesting that it may be considered as a first line therapy in the future. Despite progressive development, clinical PDT needs improvement in several topics for wider acceptance including standardization of protocols that involve the same administrated light and PS doses and establishing quantitative tools for PDT dosimetry planning and response monitoring. Quantitative measures such as optical parameters, PS concentration, tissue oxygenation and blood flow are essential for accurate PDT dosimetry as well as PDT response monitoring and assessing therapy outcome. Unlike conventional imaging modalities like magnetic resonance imaging, novel optical imaging techniques can quantify PDT-related parameters without any contrast agent administration and enable real-time assessment during PDT for providing fast feedback to clinicians. Ongoing developments in optical imaging offer the promise of optimization of PDT protocols with improved outcomes.

Light delivery over extended time periods enhances the effectiveness of photodynamic therapy

PURPOSE

The rate of energy delivery is a principal factor determining the biological consequences of photodynamic therapy (PDT). In contrast to conventional high-irradiance treatments, recent preclinical and clinical studies have focused on low-irradiance schemes. The objective of this study was to investigate the relationship between irradiance, photosensitizer dose, and PDT dose with regard to treatment outcome and tumor oxygenation in a rat tumor model.

EXPERIMENTAL DESIGN

Using the photosensitizer HPPH (2-[1-hexyloxyethyl]-2-devinyl pyropheophorbide), a wide range of PDT doses that included clinically relevant photosensitizer concentrations was evaluated. Magnetic resonance imaging and oxygen tension measurements were done along with the Evans blue exclusion assay to assess vascular response, oxygenation status, and tumor necrosis.

RESULTS

In contrast to high-incident laser power (150 mW), low-power regimens (7 mW) yielded effective tumor destruction. This was largely independent of PDT dose (drug-light product), with up to 30-fold differences in photosensitizer dose and 15-fold differences in drug-light product. For all drug-light products, the duration of light treatment positively influenced tumor response. Regimens using treatment times of 120 to 240 min showed marked reduction in signal intensity in T2-weighted magnetic resonance images at both low (0.1 mg/kg) and high (3 mg/kg) drug doses compared with short-duration (6-11 min) regimens. Significantly greater reductions in pO(2) were observed with extended exposures, which persisted after completion of treatment.

CONCLUSIONS

These results confirm the benefit of prolonged light exposure, identify vascular response as a major contributor, and suggest that duration of light treatment (time) may be an important new treatment variable.

Real-time in situ monitoring of human prostate photodynamic therapy with diffuse light

Photodynamic therapy (PDT) requires oxygen to cause cellular and vascular tumor damage. Tissue oxygen concentration, in turn, is influenced by blood flow and blood oxygenation. Real-time clinical measurement of these hemodynamic quantities, however, is rare. This paper reports the development and application of a probe, combining diffuse reflectance spectroscopy (DRS) for measurement of tumor blood oxygenation and diffuse correlation spectroscopy (DCS) for measurement of tumor blood flow. The instrument was adapted for clinical use during interstitial prostate PDT. Three patients with locally recurrent prostate cancer received 2 mg/ kg motexafin lutetium (MLu) 3 h before illumination and a total light dose of 100 J/cm(2) at 150 mW/cm. Prostrate blood oxygen saturation (StO2) decreased only slightly (approximately 3%) after treatment. On the other hand, prostate blood flow and total hemoglobin concentration over the course of PDT decreased by 50% and 15%, respectively, suggesting MLu-mediated PDT has an anti-vascular effect. While it is certainly impossible to draw definite conclusions from measurements of only three patients, the observed differences in tumor blood flow and blood oxygenation responses during PDT can, in principle, be used to choose among tissue oxygen consumption models and therefore emphasize the potential clinical value for simultaneous monitoring of both parameters.

Photodynamic therapy for pancreatic and biliary tract carcinoma

The prognosis of patients with pancreatic and biliary tract cancer treated with conventional therapies such as stent insertion or chemotherapy is often poor, and new approaches are urgently needed. Surgery is the only curative treatment but is appropriate in less than 20% of cases, and even then it is associated with a 5-yr survival of less than 30% in selected series. Photodynamic therapy represents a novel treatment for pancreaticobiliary malignancy. It is a way of producing localized tissue necrosis with light, most conveniently from a low-power, red laser, after prior administration of a photosensitizing agent, thereby initiating a non-thermal cytotoxic effect and tissue necrosis. This review outlines the mechanisms of action of photodynamic therapy including direct cell death, vascular injury, and immune system activation, and summarizes the results of preclinical and clinical studies of photodynamic therapy for pancreaticobiliary malignancy.

Choice of Optimal Wavelength for PDT: The Significance of Oxygen Depletion

We have investigated the role of tissue oxygenation on light penetration into tissue at different wavelengths. As a field of application we have chosen aminolevulinic acid-photodynamic therapy (ALA-PDT). To calculate efficiency spectra of PDT on human skin one needs to know the excitation spectrum of the photosensitizer of interest and the relative fluence rate as a function of depth in the tissue. We measured the former and computed the latter with an accurate radiative transfer algorithm. In this way we determined the efficiency spectra as functions of depth for different types of basal cell carcinomas (BCC). Our results suggest that ALA-PDT works best for nodular BCC at a wavelength of 630 nm, whereas it works best for pigmented superficial BCC at a wavelength of 390 nm. At 630 nm the light penetration into a tumor depends strongly on the oxygenation of the blood. Below a 2 mm thick, well-oxygenated, nodular BCC, we find the efficiency to be an order of magnitude larger than below a poorly oxygenated tumor. At 390 nm, the light penetration into a tumor does not depend on the oxygenation of the blood.

Perspectives of photodynamic therapy for skin diseases

Photodynamic therapy (PDT) is largely an experimental modality for the treatment of neoplastic and selected nonneoplastic diseases. This therapeutic procedure, through a cascade of events, leads to cell killing. In the past few years, dermatology has taken advantage of PDT for the treatment of skin cancer and other skin diseases. The skin has considerable attributes over many other organs for the application of PDT. These include the accessibility to all three PDT essential requirements; the drug (photosensitizing agent), visible light and oxygen. The major benefit of experimental PDT in dermatology is the ability to assess the clinical response visually and the relative ease in obtaining biopsies for precise biochemical and histological analysis. Currently, PDT has received approval worldwide for the ablation of various tumor types. In the United States, the Food and Drug Administration has approved PDT for the treatment of advanced esophageal cancer and selected patients with lung cancer. Clinical trials, employing several types of photosensitizers for PDT, are ongoing for a variety of dermatological lesions. This review summarizes current knowledge of PDT in dermatology and highlights future perspectives of this modality for effective management of skin diseases.

The role of oxygen in cutaneous photodynamic therapy

Photodynamic therapy (PDT) is based on the dye-sensitized photooxidation of biological matter in the target tissue, and utilizes light activated drugs for the treatment of a wide variety of malignancies. Skin is a target organ for PDT, because of the increasing incidence of skin cancers and the easy accessibility to photosensitizing drugs and light. Skin oxygen tension changes dramatically during and after PDT and seems to be an important treatment parameter. Experimental approaches to modulate oxygen tension (e.g., hyperbaric oxygenation, hyperthermia, or perfluorocarbons) have been studied mainly in animals, and some of these techniques may have the potential to be applied in humans to improve the efficacy and safety of PDT. The main purpose of this review is to provide the reader with current information on cutaneous oxygen physiology and oximetry, the role of oxygen and singlet oxygen (1O2) in PDT, and approaches to modulate skin oxygen tension. The literature indicates that it may be possible to utilize transcutaneous oxygen measurements as a valuable measure of the clinical effectiveness of PDT and as an in situ predictor of the energy required to elicit a biological response. Consequently the effectiveness of PDT can be manipulated by modulating skin oxygen tension.

Tumour destruction and proliferation kinetics following periodic, low power light, haematoporphyrin oligomers mediated photodynamic therapy in the mouse tongue

Photodynamic therapy (PDT) is an experimental modality in the treatment of cancer. It involves photochemical reactions that require the interaction of a photosensitising drug, light and oxygen. The development of an efficient protocol based on assuring oxygen availability through modulation of the incident light power density and its mode of delivery was addressed in this study. An estimated energy dose of 180 J/cm2 of 630 nm light from pulsed Nd:YAG dye laser was delivered 24 h after injection of 10 mg/kg haematoporphyrin oligomers in C3H/HeNCrj mice bearing the transplantable squamous cell carcinoma NR-S1, by either of these light regimens: (1) 5 mJ/cm2/pulse for 30 min, 1 h dark interval, followed by another 30 min exposure to the same power (low power, periodic light regimen) or (2) 15 mJ/cm2/pulse for 20 min (high power, continuous light regimen). Results showed a higher mean percentage area of tumour destruction with the low power, periodic light regimen at 54.34% in contrast to 12.44% of the high power, continuous light regimen 2 days after PDT. Furthermore, the mean bromodeoxyuridine labelling indices of the remaining viable-appearing cancer cells were 27.90 and 42.41, respectively, indicating a smaller tumour growth fraction with the former regimen. These results suggest that use of low power, periodically delivered light increases the antitumour efficacy of PDT.

Relation of early Photofrin uptake to photodynamically induced phototoxicity and changes of cell volume in different cell lines

For efficacy of photodynamic therapy, selective uptake and retention of photoactive substances has been postulated. Therefore, measurements were performed to find out whether the photosensitiser Photofrin is taken up differently in malignant and non-malignant cells in vitro. In addition, the sensitivity of malignant cells and non-malignant cells to photodynamic exposure was investigated, by quantifying viability and volume alterations of the cells. Bovine aortic endothelial cells, mouse fibroblasts and amelanotic hamster melanoma cells were suspended in a specially designed incubation chamber under controlled conditions (e.g. pH, pO2, pCO2 and temperature). After establishing constant baseline conditions, the cellular fluorescence intensity per cell volume, indicative of the uptake of Photofrin, and cell volume were assessed by flow cytometry, and cell viability was quantified by the trypan blue exclusion test. Photodynamic exposure of cells was performed using an argon-pumped dye laser system via a 600 microns optical fibre at energy density of 4 Joules at the cell surface (40 mW/cm2, 100 s). In comparison to endothelial and fibroblast cells, the melanoma cells exhibited no increased uptake of Photofrin, and no enhanced sensitivity to photodynamic therapy (PDT). However, the fluorescence intensity/volume of endothelial cells was two to three times higher at each concentration of the photosensitiser. Following PDT, reduction in cell viability was dependent on the concentration of Photofrin, and directly correlated with fluorescence intensity per cell volume. In addition, the cells of all three lines, treated by PDT, revealed dose-dependent changes in cell volume. Melanoma cells exhibited the most excessive increase. It is suggested that selective uptake of photosensitiser in vitro is not characteristic for tumour cells. The high uptake of Photofrin by endothelial cells may indicate that the vascular endothelium is a major target for PDT, leading to cessation of tumour blood flow and subsequent destruction of tumour tissue. In addition, PDT-induced swelling of tumour cells might represent and effect synergistically impairing tumour perfusion, and thereby promoting tumour death.

Non-invasive monitoring of photodynamic therapy with 99technetium HMPAO scintigraphy

The effect of photodynamic therapy (PDT) on tumour perfusion in both anaplastic (R3327-AT) and well differentiated (R3327-H) Dunning prostatic tumours was studied using the radiopharmaceutical 99Technetium hexamethylpropyleneamine oxime (99mTc-HMPAO). Tumours in the left flanks of rats (Copenhage x Fischer, F1 hybrids) were treated with interstitial PDT when their volumes reached 2-3 cm3. Qualitative and quantitative data from pre- and post-PDT scintigraphy revealed a light-dose-dependent shut-down of tumour perfusion which was also time-dependent. Maximal shut-down, following a 1,600 J light-dose, occurred about 8 h post-PDT. Light exposure 2 h after the intravenous administration of the photosensitiser (Photofrin II) produced a greater vascular shut-down than did light exposure 24 h after the administration of the drug. Regional differences in perfusion within treated and non-treated tumours were measured by tomographic procedures. Light-dose-dependent volumes of perfusion shut-down were demonstrated in addition to the naturally occurring regional differences in tumour perfusion. This radiopharmaceutical may have future utility for monitoring the clinical treatment of solid tumours with PDT.

Tumor hypoxia, reoxygenation and oxygenation strategies: possible role in photodynamic therapy

The concept of hypoxia and its role in tumor therapy are currently under re-evaluation. Poor oxygenation is no longer visualized as an independent feature promoting necrosis and resistance to treatments, but rather as one of the several interdependent microenvironmental parameters associated with impaired blood perfusion. Tumor cells display several survival strategies and remain clonogenic for long periods in nutrient-deprived situations. Reoxygenation may cause lethal damage, improve the response to therapy, or else allow the cell variants adapted to hypoxia to resume proliferation with enhanced aggressiveness and resistance to treatment. The blood supply parameters, oxygenation status and metabolism of malignant cells are discussed here from the standpoint of tumor photodynamic therapy. The role of the tumor interstitial fluid as oxygen- and sensitizer-carrier is discussed. Techniques for assessing tumor oxygenation and for mapping hypoxic territories are described. Strategies for locally improving the oxygenation levels or for selectively destroying the hypoxic populations are outlined.

Temperature effects on photosensitized processes

The singlet-oxygen-mediated reaction of meso-tetraphenylporphine tetrasulphonate (TPPS4) with different chemical acceptors in buffered aqueous solution was studied as a function of temperature. Imidazole, tryptophan, dimethyl p-nitrosoaniline, (RNO) and furfuryl alcohol served as acceptors. The measurements were performed in real time by spectroscopic or electrochemical monitoring of the consumption of the various reagents, acceptors or dissolved oxygen as a function of the absorbed energy. The results show the following increases in the reaction rate over the temperature range 15-45 degrees C: tryptophan (86%), RNO (90%), furfuryl alcohol (150%) and imidazole (210%). The influence of temperature-correlated changes in the initial oxygen concentration and pH was investigated. Possible implications of the present results for the synergistic influence of hyperthermia and photodynamic therapy are discussed.