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da Cruz Rodrigues A, Bilha JK, Pereira PRM, de Souza CWO, Passarini MRZ, Uliana MP. Photoinactivation of microorganisms using bacteriochlorins as photosensitizers. Braz J Microbiol 2024; 55:1139-1150. [PMID: 38378880 PMCID: PMC11153405 DOI: 10.1007/s42770-024-01278-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Accepted: 02/04/2024] [Indexed: 02/22/2024] Open
Abstract
In recent years, some microorganisms have shown resistance to conventional treatments. Considering this increase in resistant pathogens, treatment alternatives are needed to promote greater treatment efficiency. In this sense, antimicrobial photodynamic therapy (aPDT) has been an alternative treatment. This technique uses a photosensitizer that is activated by light with a specific wavelength producing reactive species, leading to the death of pathogenic microorganisms. In this study, bacteriochlorophyll derivatives such as bacteriochlorin metoxi (Bchl-M) and bacteriochlorin trizma (Bchl-T) obtained from purple bacterium (Rhodopseudomonas faecalis), were evaluated as photosensitizers in the aPDT. Photodynamic inactivation (PDI) of the microorganisms Staphylococcus aureus, Micrococcus luteus, Candida albicans and Pseudomonas aeruginosa was investigated with both bacteriochlorins (Bchl-M and Bchl-T) at different concentrations (1, 15 and 30 µM for S. aureus; 1, 15, 30, 45, 60 and 75 µM for M. luteus; 30, 60, 90, 105, 120 and 150 µM for C. albicans; and 200 µM for P. aeruginosa) and different doses of light (20 and 30 J/cm2 for S. aureus and M. luteus; 30 and 45 J/cm2 for C. albicans; and 45 J/cm2 for P. aeruginosa) to inactivate them. Both photosensitizers showed good activation against S. aureus and for M. luteus, we observed the inactivation of these microorganisms at approximately 3 log, showing to be a good photosensitizers for these microorganisms.
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Affiliation(s)
- Andréia da Cruz Rodrigues
- Universidade Federal da Integração Latino-Americana, Caixa Postal 2044, Foz Do Iguaçu, PR, CEP 85866-000, Brazil
| | - Juliana Kafka Bilha
- Universidade Federal da Integração Latino-Americana, Caixa Postal 2044, Foz Do Iguaçu, PR, CEP 85866-000, Brazil
| | | | | | | | - Marciana Pierina Uliana
- Universidade Federal da Integração Latino-Americana, Caixa Postal 2044, Foz Do Iguaçu, PR, CEP 85866-000, Brazil.
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Li Y, Li Y, Song Y, Liu S. Advances in research and application of photodynamic therapy in cholangiocarcinoma (Review). Oncol Rep 2024; 51:53. [PMID: 38334150 DOI: 10.3892/or.2024.8712] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2023] [Accepted: 01/18/2024] [Indexed: 02/10/2024] Open
Abstract
Cholangiocarcinoma (CCA) is a disease characterized by insidious clinical manifestations and challenging to diagnose. Patients are usually diagnosed at an advanced stage and miss the opportunity for radical surgery. Therefore, effective palliative therapy is the main treatment approach for unresectable CCA. Current common palliative treatments include biliary drainage, chemotherapy, radiotherapy, targeted therapy and immunotherapy. However, these treatments only offer limited improvement in quality of life and survival. Photodynamic therapy (PDT) is a novel local treatment method that is considered a safe tumor ablation method for numerous cancers. It has shown good efficacy in various studies of CCA and is expected to become an important treatment for CCA. In the present study, the mechanisms of PDT in the treatment of CCA were systematically explored and the progress in the research of photosensitizers was discussed. The current study focused on the various PDT protocols and their therapeutic effects in CCA, with the objective of providing a new horizon for future research and clinical applications of PDT in the treatment of CCA.
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Affiliation(s)
- Yufeng Li
- Department of Hepatobiliary Surgery, The First Affiliated Hospital of Hunan Normal University, Changsha, Hunan 410005, P.R. China
| | - Yuhang Li
- Department of Hepatobiliary Surgery, The First Affiliated Hospital of Hunan Normal University, Changsha, Hunan 410005, P.R. China
| | - Yinghui Song
- Central Laboratory of Hunan Provincial People's Hospital (The First Affiliated Hospital of Hunan Normal University), Changsha, Hunan 410005, P.R. China
| | - Sulai Liu
- Department of Hepatobiliary Surgery, The First Affiliated Hospital of Hunan Normal University, Changsha, Hunan 410005, P.R. China
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Kim HI, Lee SH, Shin SJ, Park JH, Yu JE, Lee SW, Yang SH, Pires L, Wilson BC. Phonozen-mediated photodynamic therapy comparing two wavelengths in a mouse model of peritoneal carcinomatosis. Photochem Photobiol Sci 2023; 22:2563-2572. [PMID: 37632684 DOI: 10.1007/s43630-023-00470-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Accepted: 08/14/2023] [Indexed: 08/28/2023]
Abstract
BACKGROUND This study assessed the therapeutic efficacy of intraperitoneal photodynamic therapy (PDT) using photosensitizer activation at two different wavelengths, 405 and 664 nm, in a mouse model of peritoneal carcinomatosis. METHODS The dark and light cytotoxicity of chlorin e6-polyvinylpyrrolidone (Phonozen) were measured in vitro under 402 ± 14 and 670 ± 18 nm LED activation in bioluminescent human gastric cancer cells, MKN45-luc. Cell viability was measured at 6 h after irradiation using the PrestoBlue assay. Corresponding in vivo studies were performed in athymic nude mice by intraperitoneal injection of 1 × 106 MKN45-luc cells. PDT was performed 10 d after tumor induction and comprised intraperitoneal injection of Phonozen followed by light irradiation at 3 h, delivered by a diffusing-tip optical fiber placed in the peritoneal cavity and coupled to a 405 or 664 nm diode laser to deliver a total energy of 50 J (20 mice per cohort). Whole-body bioluminescence imaging was used to track the tumor burden after PDT out to 130 days, and 5 mice in each cohort were sacrificed at 4 h post treatment to measure the acute tumor necrosis. RESULTS Photosensitizer dose-dependent photocytotoxicity was higher in vitro at 405 than 664 nm. In vivo, PDT reduced the tumor growth rate at both wavelengths, with no statistically significant difference. There was substantial necrosis, and median survival was significantly prolonged at both wavelengths compared with controls (46 and 46 vs. 34 days). CONCLUSIONS Phonozen-mediated PDT results in significant cytotoxicity in vitro as well as tumor necrosis and prolonged survival in vivo following intraperitoneal light irradiation. Blue light was more photocytotoxic than red in vitro and had marginally higher efficacy in vivo.
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Affiliation(s)
- Hyoung-Il Kim
- Princess Margaret Cancer Research Tower, University Health Network, 15-314, 101 College Street, Toronto, ON, M5G 1L7, Canada
- Department of Surgery, Yonsei University College of Medicine, Seoul, South Korea
- Division of Upper Gastrointestinal Surgery, Gastric Cancer Center, Yonsei Cancer Center, Seoul, South Korea
- Yonsei-Dongsung Photodynamic Therapy Research Center, Avison Biomedical Research Center, Yonsei University College of Medicine, Seoul, South Korea
| | - Sung-Ho Lee
- Yonsei-Dongsung Photodynamic Therapy Research Center, Avison Biomedical Research Center, Yonsei University College of Medicine, Seoul, South Korea
| | - Su-Jin Shin
- Department of Pathology, Yonsei University College of Medicine, Seoul, South Korea
| | - Jong-Hyun Park
- Yonsei-Dongsung Photodynamic Therapy Research Center, Avison Biomedical Research Center, Yonsei University College of Medicine, Seoul, South Korea
- Department of Nano-Science and Technology, Graduate School of Convergence Science and Technology of Seoul National University, Seoul, South Korea
| | - Jae Eun Yu
- Yonsei-Dongsung Photodynamic Therapy Research Center, Avison Biomedical Research Center, Yonsei University College of Medicine, Seoul, South Korea
| | - Sang Won Lee
- Yonsei-Dongsung Photodynamic Therapy Research Center, Avison Biomedical Research Center, Yonsei University College of Medicine, Seoul, South Korea
| | - Seung Hee Yang
- Yonsei-Dongsung Photodynamic Therapy Research Center, Avison Biomedical Research Center, Yonsei University College of Medicine, Seoul, South Korea
| | - Layla Pires
- Princess Margaret Cancer Research Tower, University Health Network, 15-314, 101 College Street, Toronto, ON, M5G 1L7, Canada
| | - Brian C Wilson
- Princess Margaret Cancer Research Tower, University Health Network, 15-314, 101 College Street, Toronto, ON, M5G 1L7, Canada.
- Department of Medical Biophysics, Faculty of Medicine, University of Toronto, Toronto, ON, Canada.
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Sobhani N, Samadani AA. Implications of photodynamic cancer therapy: an overview of PDT mechanisms basically and practically. J Egypt Natl Canc Inst 2021; 33:34. [PMID: 34778919 DOI: 10.1186/s43046-021-00093-1] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Accepted: 09/24/2021] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND Tumor eradication is one of the most important challengeable categories in oncological studies. In this account, besides the molecular genetics methods including cell therapy, gene therapy, immunotherapy, and general cancer therapy procedures like surgery, radiotherapy, and chemotherapy, photodynamic adjuvant therapy is of great importance. Photodynamic therapy (PDT) as a relatively noninvasive therapeutic method utilizes the irradiation of an appropriate wavelength which is absorbed by a photosensitizing agent in the presence of oxygen. In this procedure, a series of events lead to the direct death of malignant cells such as damage to the microvasculature and also the induction of a local inflammatory function. PDT has participated with other treatment modalities especially in the early stage of malignant tumors and has resulted in decreasing morbidity besides improving survival rate and quality of life. High spatial resolution of PDT has attracted considerable attention in the field of image-guided photodynamic therapy combined with chemotherapy of multidrug resistance cancers. Although PDT outcomes vary across the different tumor types, minimal natural tissue toxicity, minor systemic effects, significant reduction in long-term disease, lack of innate or acquired resistance mechanisms, and excellent cosmetic effects, as well as limb function, make it a valuable treatment option for combination therapies. SHORT CONCLUSION In this review article, we tried to discuss the potential of PDT in the treatment of some dermatologic and solid tumors, particularly all its important mechanisms.
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Affiliation(s)
- Nafiseh Sobhani
- Department of Basic Medical Sciences, Neyshabur University of Medical Sciences, Neyshabur, Iran
| | - Ali Akbar Samadani
- Healthy Ageing Research Center, Neyshabur University of Medical Sciences, Neyshabur, Iran. .,Clinical Research Development Unit of Poursina Hospital, Guilan University of Medical Sciences, Rasht, Iran.
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Recent Advances in Photodynamic Imaging and Therapy in Hepatobiliary Malignancies: Clinical and Experimental Aspects. Curr Oncol 2021; 28:4067-4079. [PMID: 34677263 PMCID: PMC8534451 DOI: 10.3390/curroncol28050345] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2021] [Revised: 09/27/2021] [Accepted: 09/28/2021] [Indexed: 01/10/2023] Open
Abstract
The therapeutic and diagnostic modalities of light are well known, and derivative photodynamic reactions with photosensitizers (PSs), specific wavelengths of light exposure and the existence of tissue oxygen have been developed since the 20th century. Photodynamic therapy (PDT) is an effective local treatment for cancer-specific laser ablation in malignancies of some organs, including the bile duct. Although curability for extrahepatic cholangiocarcinoma is expected with surgery alone, patients with unresectable or remnant biliary cancer need other effective palliative therapies, including PDT. The effectiveness of PDT for cholangiocarcinoma has been reported experimentally or clinically, but it is not the standard option now due to problems with accompanied photosensitivity, limited access routes of irradiation, tumor hypoxia, etc. Novel derivative treatments such as photoimmunotherapy have not been applied in the field hepatobiliary system. Photodynamic diagnosis (PDD) has been more widely applied in the clinical diagnoses of liver malignancies or liver vascularization. At present, 5-aminolevulinic acid (ALA) and indocyanine green (ICG) dyes are mainly used as PSs in PDD, and ICG has been applied for detecting liver malignancies or vascularization. However, no ideal tools for combining both PDD and PDT for solid tumors, including hepatobiliary malignancies, have been clinically developed. To proceed with experimental and clinical trials, it is necessary to clarify the effective photosensitive drugs that are feasible for photochemical diagnosis and local treatment.
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Ströbl S, Wäger F, Domke M, Rühm A, Sroka R. Homogeneously Emitting, Mechanically Stable, and Efficient fs-Laser-Machined Fiber Diffusers for Medical Applications. Lasers Surg Med 2020; 54:588-599. [PMID: 33616996 DOI: 10.1002/lsm.23365] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2020] [Revised: 11/12/2020] [Accepted: 11/12/2020] [Indexed: 11/06/2022]
Abstract
BACKGROUND AND OBJECTIVES Light delivery is an essential part of therapy forms like photodynamic therapy (PDT), laser-induced thermotherapy, and endovenous laser therapy. While there are approaches to the light application for all three therapies, there is no diffuser that can be used for all three approaches. This diffuser must meet the following criteria: Homogeneous radiation profile over a length of 40 mm, efficient light extraction in the diffuser area, mechanical breakage resistance as well as thermal stability when applying high power. STUDY DESIGN/MATERIALS AND METHODS An ultrashort pulse laser was used to inscribe inhomogeneities into the core of a fused-silica fiber core while scanning the laser focus within a linear arrangement of cuboids centered around the fiber axis. The manufactured diffuser was optically and mechanically characterized and examined to determine the maximum power that can be applied in a tissue environment. RESULTS Based on the analysis of all examined diffusers, the manufactured diffuser exhibits an emission efficiency ε = (81.5 ± 5.9)%, an intensity variability of (19 ± 5)% between distal and proximal diffuser end, and a minimum bending radius Rb = (15.4 ± 1.5) mm. It was taken advantage of the fact that the outer areas of the fiber core do not undergo any structural changes due to the machining and therefore do not suffer a major loss of stability. Tissue experiments revealed that a maximal power of 15 W was deliverable from the diffuser without harming the diffuser itself. CONCLUSIONS It could be shown that a diffuser manufactured by ultrafast-laser processing can be used for low power applications as well as for high power applications. Further tests have to show whether the mechanical stability is still maintained after the application of high power in a tissue environment. Lasers Surg. Med. © 2020 Wiley Periodicals LLC.
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Affiliation(s)
- Stephan Ströbl
- Research Centre for Microtechnology, FH Vorarlberg, Hochschulstr. 1, Dornbirn, Vorarlberg, 6850, Austria.,Laser Research Laboratory, LIFE-Centre, Fraunhoferstr. 20, Planegg, Bavaria, 82152, Germany.,Ludwig-Maximilians-Universität München affiliation
| | - Felix Wäger
- Research Centre for Microtechnology, FH Vorarlberg, Hochschulstr. 1, Dornbirn, Vorarlberg, 6850, Austria
| | - Matthias Domke
- Research Centre for Microtechnology, FH Vorarlberg, Hochschulstr. 1, Dornbirn, Vorarlberg, 6850, Austria
| | - Adrian Rühm
- Laser Research Laboratory, LIFE-Centre, Fraunhoferstr. 20, Planegg, Bavaria, 82152, Germany.,Department of Urology, University Hospital Großhadern, Marchioninistr. 15, Munich, Bavaria, 81377, Germany
| | - Ronald Sroka
- Laser Research Laboratory, LIFE-Centre, Fraunhoferstr. 20, Planegg, Bavaria, 82152, Germany.,Department of Urology, University Hospital Großhadern, Marchioninistr. 15, Munich, Bavaria, 81377, Germany
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Seidensticker M, Schütte K, Seidensticker R, Mühlmann M, Schulz C. Multi-modal and sequential treatment of liver cancer and its impact on the gastrointestinal tract. Best Pract Res Clin Gastroenterol 2020; 48-49:101709. [PMID: 33317790 DOI: 10.1016/j.bpg.2020.101709] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2020] [Revised: 11/02/2020] [Accepted: 11/06/2020] [Indexed: 01/31/2023]
Abstract
Hepatic tumors include hepatocellular cancer (HCC) and cholangiocarcinoma (CC), a small subgroup of tumors (approx. 1%) are classified as combined hepatocellularcholangiocellular carcinomas. Different stage-dependent therapeutic approaches comprise resection, local ablative techniques, locoregional therapies, systemic treatment, liver transplantation in selected cases and possible combination of these treatment modalities. This review summarizes current knowledge on multi-modal treatment strategies for liver cancer focusing on gastrointestinal side effects.
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Affiliation(s)
- Max Seidensticker
- Klinik und Poliklinik für Radiologie, Klinikum der Universität München, Munich, Germany.
| | - Kerstin Schütte
- Department of Internal Medicine and Gastroenterology, Niels-Stensen-Kliniken, Marienhospital, Osnabrück, Germany
| | - Ricarda Seidensticker
- Klinik und Poliklinik für Radiologie, Klinikum der Universität München, Munich, Germany
| | - Marc Mühlmann
- Klinik und Poliklinik für Radiologie, Klinikum der Universität München, Munich, Germany
| | - Christian Schulz
- Medical Department II, University Hospital, LMU, Munich, Germany
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Long-term results of ERCP- or PTCS-directed photodynamic therapy for unresectable hilar cholangiocarcinoma. Surg Endosc 2020; 35:5655-5664. [PMID: 33104917 PMCID: PMC8437910 DOI: 10.1007/s00464-020-08095-1] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2020] [Accepted: 10/13/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND Photodynamic therapy (PDT) can be performed as palliative therapy for cholangiocarcinoma, while there is currently insufficient evidence for the efficacy. The aim of this study was to explore the clinical efficacy and safety of endoscopic retrograde cholangiopancreatography (ERCP)- or percutaneous transhepatic cholangioscopy (PTCS)-directed PDT combined with stent placement for unresectable hilar cholangiocarcinoma. METHODS A retrospective analysis was conducted on 62 patients with unresectable hilar cholangiocarcinoma. Thirty patients received PDT using hematoporphyrin combined with biliary stent placement (PDT+stent group), including 22 receiving ERCP-directed PDT and 8 receiving PTCS-directed PDT. Survival time, quality of life, and postoperative adverse events were compared to 32 patients receiving biliary stent placement alone (Stent-only group). RESULTS After 42 months of follow-up, median survival time was significantly longer in the PDT+stent group than the Stent-only group (14.2 vs. 9.8 months, P = 0.003). In the PDT+stent group, the median survival time was longer in the 6 patients with recurrence after surgical resection than the 24 patients without prior surgical resection (20.0 vs. 13.0 months, P = 0.017). The QOL total scores was significantly higher in the PDT+stent group than the Stent-only group at postoperative 6, 9, and 12 months (P<0.05). There was no significant difference in the incidence of postoperative adverse events between the two groups (24 [38.7%] vs. 20 [29.0%], P = 0.239). CONCLUSION ERCP- or PTCS-directed PDT + stent placement can prolong the survival of patients with unresectable hilar cholangiocarcinoma, especially those with recurrence and improve quality of life without increasing adverse events.
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Kim MM, Darafsheh A. Light Sources and Dosimetry Techniques for Photodynamic Therapy. Photochem Photobiol 2020; 96:280-294. [PMID: 32003006 DOI: 10.1111/php.13219] [Citation(s) in RCA: 181] [Impact Index Per Article: 45.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2019] [Accepted: 11/29/2019] [Indexed: 12/19/2022]
Abstract
Effective treatment delivery in photodynamic therapy (PDT) requires coordination of the light source, the photosensitizer, and the delivery device appropriate to the target tissue. Lasers, light-emitting diodes (LEDs), and lamps are the main types of light sources utilized for PDT applications. The choice of light source depends on the target location, photosensitizer used, and light dose to be delivered. Geometry of minimally accessible areas also plays a role in deciding light applicator type. Typically, optical fiber-based devices are used to deliver the treatment light close to the target. The optical properties of tissue also affect the distribution of the treatment light. Treatment light undergoes scattering and absorption in tissue. Most tissue will scatter light, but highly pigmented areas will absorb light, especially at short wavelengths. This review will summarize the basic physics of light sources, and describe methods for determining the dose delivered to the patient.
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Affiliation(s)
- Michele M Kim
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, PA
| | - Arash Darafsheh
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, MO
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Buerlein RCD, Wang AY. Endoscopic Retrograde Cholangiopancreatography-Guided Ablation for Cholangiocarcinoma. Gastrointest Endosc Clin N Am 2019; 29:351-367. [PMID: 30846158 DOI: 10.1016/j.giec.2018.11.006] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Most patients with perihilar cholangiocarcinoma present with surgically unresectable disease owing to the insidious nature of this malignancy. Relief of malignant perihilar biliary obstruction is a key aspect of cholangiocarcinoma. Although palliative stenting using uncovered metal stents has been advocated in patients with unresectable malignant perihilar biliary strictures, several endoscopic retrograde cholangiopancreatography-guided ablative modalities have emerged. Palliative photodynamic therapy, radiofrequency ablation, and intraluminal brachytherapy have been associated with improved stent patency and survival, although the ideal treatment approach remains unclear. This article reviews the published evidence for using each of these endobiliary ablative modalities in this difficult-to-treat patient population.
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Affiliation(s)
- Ross C D Buerlein
- Division of Gastroenterology and Hepatology, University of Virginia, PO Box 800708, Charlottesville, VA 22908, USA
| | - Andrew Y Wang
- Division of Gastroenterology and Hepatology, University of Virginia, PO Box 800708, Charlottesville, VA 22908, USA.
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Wang AY, Yachimski PS. Endoscopic Management of Pancreatobiliary Neoplasms. Gastroenterology 2018; 154:1947-1963. [PMID: 29458151 DOI: 10.1053/j.gastro.2017.11.295] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2017] [Revised: 11/16/2017] [Accepted: 11/17/2017] [Indexed: 12/14/2022]
Abstract
Endoscopic ultrasound (EUS) and endoscopic retrograde cholangiopancreatography (ERCP) are the mainstays of interventional endoscopic practice. EUS occupies a central role in the diagnosis of pancreatobiliary neoplasms and offers a platform for a wide range of direct tumor therapies. Initial steps have demonstrated the feasibility of such applications in animal models and pilot studies. Larger clinical trials and incorporation of EUS-based therapies into cooperative cancer studies might demonstrate an impact in the clinical prognosis of patients with pancreatic cancer. ERCP plays an important role in elucidating indeterminate biliary strictures and in treating patients with malignant biliary obstruction who are symptomatic or have borderline-resectable or unresectable disease. ERCP-directed ablative therapies enable neoadjuvant and palliative intervention in patients with malignant biliary obstruction, in particular perihilar cholangiocarcinoma. Additional comparative, multicenter studies are needed to better understand the safety and efficacy of endobiliary brachytherapy, photodynamic therapy, and radiofrequency ablation in patients with pancreatobiliary malignancies.
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Affiliation(s)
- Andrew Y Wang
- Division of Gastroenterology and Hepatology, University of Virginia Health System, Charlottesville, Virginia.
| | - Patrick S Yachimski
- Division of Gastroenterology, Hepatology & Nutrition, Vanderbilt University Medical Center, Nashville, Tennessee
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Synthesis and biological evaluation of new water-soluble photoactive chlorin conjugate for targeted delivery. Eur J Med Chem 2018; 144:740-750. [DOI: 10.1016/j.ejmech.2017.12.062] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2017] [Revised: 12/15/2017] [Accepted: 12/16/2017] [Indexed: 11/19/2022]
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Evens KK, Splan KE. Spectroscopic characterization of free-base hydroxy(arylethynyl)porphyrins in acidic and basic media. J PORPHYR PHTHALOCYA 2017. [DOI: 10.1142/s1088424617500675] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
The addition of arylethynyl groups to the porphyrin macrocycle represents an effective strategy with which to enhance the light-harvesting properties of porphyrins. We now extend this modification to arylethynyl porphyrins with two or four [Formula: see text]-hydroxyphenyl substituents. Arylethynyl porphyrins bearing four, but not two, [Formula: see text]-hydroxyphenyl substituents show evidence of aggregation under acidic conditions. Under basic conditions, deprotonation of the peripheral hydroxyphenyl substituents results in substantially red-shifted spectral features and enhanced absorption in the Q-band region. When the hydroxyphenyl groups are appended to the porphyrin macrocylce via the ethynyl spacers, the spectral shifts observed upon deprotonation are significantly enhanced relative to those observed for hydroxyphenylporphyrins, highlighting the role of expanded conjugation in altering porphyrin photophysics.
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Affiliation(s)
- Kaarin K. Evens
- Department of Chemistry, Macalester College, 1600 Grand Avenue, Saint Paul, MN 55105, USA
| | - Kathryn E. Splan
- Department of Chemistry, Macalester College, 1600 Grand Avenue, Saint Paul, MN 55105, USA
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Li L, Wang H, Wang H, Li L, Wang P, Wang X, Liu Q. Interaction and oxidative damage of DVDMS to BSA: a study on the mechanism of photodynamic therapy-induced cell death. Sci Rep 2017; 7:43324. [PMID: 28252029 PMCID: PMC5333107 DOI: 10.1038/srep43324] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2016] [Accepted: 01/25/2017] [Indexed: 12/22/2022] Open
Abstract
Photodynamic therapy (PDT) is a promising method for neoplastic and nonneoplastic diseases. In this study, we utilized sinoporphyrin sodium (DVDMS) as a sensitizer combined with light to investigate its cytotoxic effect on different cell lines. For this purpose, we chose bovine serum albumin (BSA) as a model to explore the mechanism of PDT-induced cell death at a molecular level. Our findings indicated that the combined treatment significantly suppressed cell survival. Fluorescence spectroscopy revealed a strong interaction between DVDMS and BSA molecules in aqueous solution, affecting DVDMS’ targeting distribution and metabolism. Spectroscopic analysis and carbonyl content detection indicated that DVDMS-PDT significantly enhanced the damage of BSA at a higher extent than Photofrin II-PDT under similar experimental conditions. Our observations were consistent with the cytotoxicity results. Excessive reactive oxygen species (ROS) were induced by the synergy effect of the sensitizer and light, which played an important role in damaging BSA and tumor cells. These results suggested that the interaction and oxidative damage of protein molecules by DVDMS were the main reasons to cell death and constitute a valuable reference for future DVDMS-PDT investigations.
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Affiliation(s)
- Li Li
- Key Laboratory of Medicinal Resources and Natural Pharmaceutical Chemistry, Ministry of Education, National Engineering Laboratory for Resource Developing of Endangered Chinese Crude Drugs in Northwest of China, College of Life Sciences, Shaanxi Normal University, Xi'an 710119, Shaanxi, China
| | - Huiyu Wang
- Department of Ultrasound, Beijing Shijitan Hospital Affiliated to the Capital Medical University, 100038, Beijing, China
| | - Haiping Wang
- Key Laboratory of Medicinal Resources and Natural Pharmaceutical Chemistry, Ministry of Education, National Engineering Laboratory for Resource Developing of Endangered Chinese Crude Drugs in Northwest of China, College of Life Sciences, Shaanxi Normal University, Xi'an 710119, Shaanxi, China
| | - Lijun Li
- Department of Surgical Oncology, Beijing Shijitan Hospital Affiliated to the Capital Medical University, 100038, Beijing, China
| | - Pan Wang
- Key Laboratory of Medicinal Resources and Natural Pharmaceutical Chemistry, Ministry of Education, National Engineering Laboratory for Resource Developing of Endangered Chinese Crude Drugs in Northwest of China, College of Life Sciences, Shaanxi Normal University, Xi'an 710119, Shaanxi, China
| | - Xiaobing Wang
- Key Laboratory of Medicinal Resources and Natural Pharmaceutical Chemistry, Ministry of Education, National Engineering Laboratory for Resource Developing of Endangered Chinese Crude Drugs in Northwest of China, College of Life Sciences, Shaanxi Normal University, Xi'an 710119, Shaanxi, China
| | - Quanhong Liu
- Key Laboratory of Medicinal Resources and Natural Pharmaceutical Chemistry, Ministry of Education, National Engineering Laboratory for Resource Developing of Endangered Chinese Crude Drugs in Northwest of China, College of Life Sciences, Shaanxi Normal University, Xi'an 710119, Shaanxi, China
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van Straten D, Mashayekhi V, de Bruijn HS, Oliveira S, Robinson DJ. Oncologic Photodynamic Therapy: Basic Principles, Current Clinical Status and Future Directions. Cancers (Basel) 2017; 9:cancers9020019. [PMID: 28218708 PMCID: PMC5332942 DOI: 10.3390/cancers9020019] [Citation(s) in RCA: 571] [Impact Index Per Article: 81.6] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2016] [Revised: 02/10/2017] [Accepted: 02/12/2017] [Indexed: 12/12/2022] Open
Abstract
Photodynamic therapy (PDT) is a clinically approved cancer therapy, based on a photochemical reaction between a light activatable molecule or photosensitizer, light, and molecular oxygen. When these three harmless components are present together, reactive oxygen species are formed. These can directly damage cells and/or vasculature, and induce inflammatory and immune responses. PDT is a two-stage procedure, which starts with photosensitizer administration followed by a locally directed light exposure, with the aim of confined tumor destruction. Since its regulatory approval, over 30 years ago, PDT has been the subject of numerous studies and has proven to be an effective form of cancer therapy. This review provides an overview of the clinical trials conducted over the last 10 years, illustrating how PDT is applied in the clinic today. Furthermore, examples from ongoing clinical trials and the most recent preclinical studies are presented, to show the directions, in which PDT is headed, in the near and distant future. Despite the clinical success reported, PDT is still currently underutilized in the clinic. We also discuss the factors that hamper the exploration of this effective therapy and what should be changed to render it a more effective and more widely available option for patients.
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Affiliation(s)
- Demian van Straten
- Cell Biology, Department of Biology, Science Faculty, Utrecht University, Utrecht 3584 CH, The Netherlands.
| | - Vida Mashayekhi
- Cell Biology, Department of Biology, Science Faculty, Utrecht University, Utrecht 3584 CH, The Netherlands.
| | - Henriette S de Bruijn
- Center for Optical Diagnostics and Therapy, Department of Otolaryngology-Head and Neck Surgery, Erasmus Medical Center, Postbox 204, Rotterdam 3000 CA, The Netherlands.
| | - Sabrina Oliveira
- Cell Biology, Department of Biology, Science Faculty, Utrecht University, Utrecht 3584 CH, The Netherlands.
- Pharmaceutics, Department of Pharmaceutical Sciences, Science Faculty, Utrecht University, Utrecht 3584 CG, The Netherlands.
| | - Dominic J Robinson
- Center for Optical Diagnostics and Therapy, Department of Otolaryngology-Head and Neck Surgery, Erasmus Medical Center, Postbox 204, Rotterdam 3000 CA, The Netherlands.
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Yang J, Shen H, Jin H, Lou Q, Zhang X. Treatment of unresectable extrahepatic cholangiocarcinoma using hematoporphyrin photodynamic therapy: A prospective study. Photodiagnosis Photodyn Ther 2016; 16:110-118. [PMID: 27720942 DOI: 10.1016/j.pdpdt.2016.10.001] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2016] [Revised: 09/25/2016] [Accepted: 10/04/2016] [Indexed: 02/06/2023]
Abstract
BACKGROUND The available evidence of Photodynamic therapy (PDT) combined with stent placement treatment for unresectable extrahepatic cholangiocarcinoma (EHCC) is still insufficient. It also remains unclear whether PDT influences systemic inflammatory response. AIM To explore the clinical efficacy and safety of the combination treatment and the systemic inflammatory response in patients with EHCC. METHODS Patients with unresectable EHCC underwent either the combined treatment using Hematoporphyrin PDT and stent placement (PDT+stent group, n=12) or stent-only (stent group, n=27). The primary end-point was overall survival. Tumor necrosis factor (TNF)-α and interleukin (IL)-6 levels were measured. Quality of life was assessed using the Karnofsky performance scale (KPS) every 3 months. RESULTS Average survival time (13.8 vs. 9.6 months), and 6-month (91.7% vs. 74.1%), and 1-year (58.3% vs. 3.7%) survival rates of PDT+stent group were significantly increased compared with the stent group. KPS scores in the PDT+stent group were significantly improved. TNF-α and IL-6 levels were significantly increased in the PDT+stent group. CONCLUSION Hematoporphyrin-PDT combined with stent placement is an effective and safe treatment for EHCC. The treatment might promote systemic inflammatory response.
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Affiliation(s)
- Jianfeng Yang
- Department of Gastroenterology, Hangzhou First People's Hospital, Nanjing Medical University, Hangzhou, Zhejiang Province, China
| | - Hongzhang Shen
- Department of Gastroenterology, Hangzhou First People's Hospital, Nanjing Medical University, Hangzhou, Zhejiang Province, China
| | - Hangbin Jin
- Department of Gastroenterology, Hangzhou First People's Hospital, Nanjing Medical University, Hangzhou, Zhejiang Province, China
| | - Qifeng Lou
- Department of Gastroenterology, Hangzhou First People's Hospital, Nanjing Medical University, Hangzhou, Zhejiang Province, China
| | - Xiaofeng Zhang
- Department of Gastroenterology, Hangzhou First People's Hospital, Nanjing Medical University, Hangzhou, Zhejiang Province, China.
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Hinger D, Gräfe S, Navarro F, Spingler B, Pandiarajan D, Walt H, Couffin AC, Maake C. Lipid nanoemulsions and liposomes improve photodynamic treatment efficacy and tolerance in CAL-33 tumor bearing nude mice. J Nanobiotechnology 2016; 14:71. [PMID: 27716314 PMCID: PMC5048629 DOI: 10.1186/s12951-016-0223-8] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2016] [Accepted: 09/27/2016] [Indexed: 11/15/2022] Open
Abstract
Background Photodynamic therapy (PDT) as promising alternative to conventional cancer treatments works by irradiation of a photosensitizer (PS) with light, which creates reactive oxygen species and singlet oxygen (1O2), that damage the tumor. However, a routine use is hindered by the PS’s poor water solubility and extended cutaneous photosensitivity of patients after treatment. In our study we sought to overcome these limitations by encapsulation of the PS m-tetrahydroxyphenylchlorin (mTHPC) into a biocompatible nanoemulsion (Lipidots). Results In CAL-33 tumor bearing nude mice we compared the Lipidots to the existing liposomal mTHPC nanoformulation Foslip and the approved mTHPC formulation Foscan. We established biodistribution profiles via fluorescence measurements in vivo and high performance liquid chromatography (HPLC) analysis. All formulations accumulated in the tumors and we could determine the optimum treatment time point for each substance (8 h for mTHPC, 24 h for Foslip and 72 h for the Lipidots). We used two different light doses (10 and 20 J/cm2) and evaluated immediate PDT effects 48 h after treatment and long term effects 14 days later. We also analyzed tumors by histological analysis and performing reverse transcription real-time PCR with RNA extracts. Concerning tumor destruction Foslip was superior to Lipidots and Foscan while with regard to tolerance and side effects Lipidots were giving the best results. Conclusions We could demonstrate in our study that nanoformulations are superior to the free PS mTHPC. The development of a potent nanoformulation is of major importance because the free PS is related to several issues such as poor bioavailability, solubility and increased photosensibility of patients. We could show in this study that Foslip is very potent in destroying the tumors itself. However, because the Lipidots' biocompatibility is outstanding and superior to the liposomes we plan to carry out further investigations and protocol optimization. Both nanoformulations show great potential to revolutionize PDT in the future. Electronic supplementary material The online version of this article (doi:10.1186/s12951-016-0223-8) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Doris Hinger
- Institute of Anatomy, University of Zurich, Winterthurerstrasse 190, Zurich, 8057, Switzerland.
| | - Susanna Gräfe
- Biolitec Research GmbH, Otto-Schott-Str. 15, 07745, Jena, Germany
| | - Fabrice Navarro
- CEA, LETI, MINATEC Campus, Commissariat à l'Énergie Atomique et aux Énergies Alternatives (CEA), Technologies for Biology and Healthcare Division, 38054, Grenoble, France.,Université Grenoble Alpes, Grenoble, 38000, France
| | - Bernhard Spingler
- Department of Inorganic Chemistry, University of Zurich, Winterthurerstrasse 190, Zurich, 8057, Switzerland
| | - Devaraj Pandiarajan
- Department of Inorganic Chemistry, University of Zurich, Winterthurerstrasse 190, Zurich, 8057, Switzerland
| | - Heinrich Walt
- Department of Cranio-Maxillofacial Surgery, University Hospital Zurich, Frauenklinikstrasse 24, Zurich, 8091, Switzerland
| | - Anne-Claude Couffin
- CEA, LETI, MINATEC Campus, Commissariat à l'Énergie Atomique et aux Énergies Alternatives (CEA), Technologies for Biology and Healthcare Division, 38054, Grenoble, France.,Université Grenoble Alpes, Grenoble, 38000, France
| | - Caroline Maake
- Institute of Anatomy, University of Zurich, Winterthurerstrasse 190, Zurich, 8057, Switzerland
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Hauge T, Hauge P, Warloe T, Drolsum A, Johansen C, Viktil E, Aabakken L, Buanes T, Konopski Z. Randomised controlled trial of temoporfin photodynamic therapy plus chemotherapy in nonresectable biliary carcinoma—PCS Nordic study. Photodiagnosis Photodyn Ther 2016; 13:330-333. [DOI: 10.1016/j.pdpdt.2015.09.004] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2015] [Revised: 08/17/2015] [Accepted: 09/22/2015] [Indexed: 01/04/2023]
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Moghissi K, Dixon K, Gibbins S. A Surgical View of Photodynamic Therapy in Oncology: A Review. Surg J (N Y) 2015; 1:e1-e15. [PMID: 28824964 PMCID: PMC5530619 DOI: 10.1055/s-0035-1565246] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2015] [Accepted: 08/25/2015] [Indexed: 12/18/2022] Open
Abstract
Clinical photodynamic therapy (PDT) has existed for over 30 years, and its scientific basis has been known and investigated for well over 100 years. The scientific foundation of PDT is solid and its application to cancer treatment for many common neoplastic lesions has been the subject of a huge number of clinical trials and observational studies. Yet its acceptance by many clinicians has suffered from its absence from the undergraduate and/or postgraduate education curricula of surgeons, physicians, and oncologists. Surgeons in a variety of specialties many with years of experience who are familiar with PDT bear witness in many thousands of publications to its safety and efficacy as well as to the unique role that it can play in the treatment of cancer with its targeting precision, its lack of collateral damage to healthy structures surrounding the treated lesions, and its usage within minimal access therapy. PDT is closely related to the fluorescence phenomenon used in photodiagnosis. This review aspires both to inform and to present the clinical aspect of PDT as seen by a surgeon.
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Affiliation(s)
- K. Moghissi
- The Yorkshire Laser Centre, Goole and District Hospital, Goole, East Yorkshire, United Kingdom
| | - Kate Dixon
- The Yorkshire Laser Centre, Goole and District Hospital, Goole, East Yorkshire, United Kingdom
| | - Sally Gibbins
- The Yorkshire Laser Centre, Goole and District Hospital, Goole, East Yorkshire, United Kingdom
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21
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Grünebaum J, Söbbing J, Mulac D, Langer K. Nanoparticulate carriers for photodynamic therapy of cholangiocarcinoma: In vitro comparison of various polymer-based nanoparticles. Int J Pharm 2015; 496:942-52. [DOI: 10.1016/j.ijpharm.2015.10.023] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2015] [Revised: 09/28/2015] [Accepted: 10/04/2015] [Indexed: 10/22/2022]
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Kumta NA, DeRoche K, Kahaleh M. Temoporfin photodynamic therapy in advanced hilar ductal carcinoma: A promising endoscopic modality. Hepatology 2015; 62:1342-3. [PMID: 26235213 DOI: 10.1002/hep.28021] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2015] [Accepted: 07/30/2015] [Indexed: 12/25/2022]
Affiliation(s)
- Nikhil A Kumta
- Division of Gastroenterology and Hepatology, Weil Cornell Medical College, Cornell University, New York, NY
| | - Ketisha DeRoche
- Division of Gastroenterology and Hepatology, Weil Cornell Medical College, Cornell University, New York, NY
| | - Michel Kahaleh
- Division of Gastroenterology and Hepatology, Weil Cornell Medical College, Cornell University, New York, NY
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Smith I, Kahaleh M. Biliary Tumor Ablation with Photodynamic Therapy and Radiofrequency Ablation. Gastrointest Endosc Clin N Am 2015; 25:793-804. [PMID: 26431605 DOI: 10.1016/j.giec.2015.06.013] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Within the past two decades, major progress has been made in biliary endoscopy both with stenting and with ablative therapy. A primary goal in patients with malignant biliary lesions who are not candidates for surgery is to provide localized and efficient necrosis of the lesions. This article summarizes the current literature on biliary tumor ablation with photodynamic therapy and radiofrequency ablation. Prognosis, treatment technique, potential complications, treatment efficacy, and controversies are discussed.
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Affiliation(s)
- Ioana Smith
- Division of Gastroenterology and Hepatology, University of Alabama at Birmingham, 1720 2nd Avenue South BDB 380, Birmingham, AL 35294, USA
| | - Michel Kahaleh
- Division of Gastroenterology and Hepatology, Weill Cornell Medical College, 1305 York Avenue 4th floor, New York, NY 10021, USA.
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Uppal DS, Wang AY. Advances in endoscopic retrograde cholangiopancreatography for the treatment of cholangiocarcinoma. World J Gastrointest Endosc 2015; 7:675-687. [PMID: 26140095 PMCID: PMC4482827 DOI: 10.4253/wjge.v7.i7.675] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2014] [Revised: 01/22/2015] [Accepted: 02/11/2015] [Indexed: 02/05/2023] Open
Abstract
Cholangiocarcinoma (CCA) is a malignancy of the bile ducts that carries high morbidity and mortality. Patients with CCA typically present with obstructive jaundice, and associated complications of CCA include cholangitis and biliary sepsis. Endoscopic retrograde cholangiopancreatography (ERCP) is a valuable treatment modality for patients with CCA, as it enables internal drainage of blocked bile ducts and hepatic segments by using plastic or metal stents. While there remains debate as to if bilateral (or multi-segmental) hepatic drainage is required and/or superior to unilateral drainage, the underlying tenant of draining any persistently opacified bile ducts is paramount to good ERCP practice and good clinical outcomes. Endoscopic therapy for malignant biliary strictures from CCA has advanced to include ablative therapies via ERCP-directed photodynamic therapy (PDT) or radiofrequency ablation (RFA). While ERCP techniques cannot cure CCA, advancements in the field of ERCP have enabled us to improve upon the quality of life of patients with inoperable and incurable disease. ERCP-directed PDT has been used in lieu of brachytherapy to provide neoadjuvant local tumor control in patients with CCA who are awaiting liver transplantation. Lastly, mounting evidence suggests that palliative ERCP-directed PDT, and probably ERCP-directed RFA as well, offer a survival advantage to patients with this difficult-to-treat malignancy.
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Patel J, Rizk N, Kahaleh M. Role of photodynamic therapy and intraductal radiofrequency ablation in cholangiocarcinoma. Best Pract Res Clin Gastroenterol 2015; 29:309-18. [PMID: 25966430 DOI: 10.1016/j.bpg.2015.02.008] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2014] [Revised: 01/15/2015] [Accepted: 02/07/2015] [Indexed: 02/07/2023]
Abstract
Cholangiocarcinoma comprises 3% of all gastrointestinal malignancies. Prognosis is poor as the disease is locally advanced at the time of its presentation. Biliary endoprosthesis are widely used for biliary decompression, however, they only provides temporary relief. Photodynamic therapy and Radiofrequency ablation are two innovative approaches performed endoscopically to locally destruct the malignant tissue. This chapter focuses on their application and appropriate use along with their benefits and complications.
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Affiliation(s)
- Janaki Patel
- Division of Gastroenterology and Hepatology, Weill Cornell Medical College, NY, USA
| | - Nada Rizk
- Division of Gastroenterology and Hepatology, Weill Cornell Medical College, NY, USA
| | - Michel Kahaleh
- Division of Gastroenterology and Hepatology, Weill Cornell Medical College, NY, USA.
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