Increased tumour dihydroceramide production after Photofrin-PDT alone and improved tumour response after the combination with the ceramide analogue LCL29. Evidence from mouse squamous cell carcinomas.

Photodynamic therapy (PDT) has been proven effective for treatment of several types of cancer. Photodynamic therapy alone, however, attains limited cures with some tumours and there is need for its improved efficacy in such cases. Sphingolipid (SL) analogues can promote tumour response in combination with anticancer drugs. In this study, we used mouse SCCVII squamous cell carcinoma tumours to determine the impact of Photofrin-PDT on the in vivo SL profile and the effect of LCL29, a C6-pyridinium ceramide, on PDT tumour response. Following PDT, the levels of dihydroceramides (DHceramides), in particular C20-DHceramide, were elevated in tumours. Similarly, increases in DHceramides, in addition to C20:1-ceramide, were found in PDT-treated SCCVII cells. These findings indicate the importance of the de novo ceramide pathway in Photofrin-PDT response not only in cells but also in vivo. Notably, co-exposure of SCCVII tumours to Photofrin-PDT and LCL29 led to enhanced tumour response compared with PDT alone. Thus, we show for the first time that Photofrin-PDT has a distinct signature effect on the SL profile in vitro and in vivo, and that the combined treatment advances PDT therapeutic gain, implying translational significance of the combination.

Photodynamic therapy.

Photodynamic therapy involves administration of a tumor-localizing photosensitizing agent, which may require metabolic synthesis (i.e., a prodrug), followed by activation of the agent by light of a specific wavelength. This therapy results in a sequence of photochemical and photobiologic processes that cause irreversible photodamage to tumor tissues. Results from preclinical and clinical studies conducted worldwide over a 25-year period have established photodynamic therapy as a useful treatment approach for some cancers. Since 1993, regulatory approval for photodynamic therapy involving use of a partially purified, commercially available hematoporphyrin derivative compound (Photofrin) in patients with early and advanced stage cancer of the lung, digestive tract, and genitourinary tract has been obtained in Canada, The Netherlands, France, Germany, Japan, and the United States. We have attempted to conduct and present a comprehensive review of this rapidly expanding field. Mechanisms of subcellular and tumor localization of photosensitizing agents, as well as of molecular, cellular, and tumor responses associated with photodynamic therapy, are discussed. Technical issues regarding light dosimetry are also considered.

Photodynamic therapy-mediated immune response against subcutaneous mouse tumors.

The curative ability of photodynamic therapy (PDT) is severely compromised if treated tumors are growing in immunodeficient hosts. Reconstitution of severe combined immunodeficient (scid) mice with splenocytes from naive immunologically intact BALB/c mice did not improve the response to Photofrin-based PDT of EMT6 tumors growing in these animals. In contrast, adoptive transfer of BALB/c splenocytes containing EMT6 tumor-sensitized immune cells had a dramatic effect on tumor regrowth after PDT. For instance, full restoration of the curative effect of PDT was achieved with scid mice that received splenocytes from BALB/c donors that were cured of EMT6 tumors by PDT 5 weeks before adoptive transfer. Splenocytes obtained from donors cured of EMT6 tumors using X-rays were much less effective. Selective in vitro depletion of specific T-cell populations from engrafting splenocytes indicated that CTLs are the main immune effector cells responsible for conferring the curative outcome to PDT in this experimental model, whereas helper T lymphocytes play a supportive role. The immune specificity of these T-cell populations was demonstrated by the absence of cross-reactivity between the EMT6 and Meth-A tumor models (mismatch between tumors growing in splenocyte donors and recipients). The immunocompetent BALB/c mice that received adoptively transferred splenocytes containing PDT-generated, tumor-sensitized immune cells also benefited from the improved outcome of PDT of tumors they were bearing. This was demonstrated not only with the fairly immunogenic EMT6 tumor model but also with weakly immunogenic Line 1 carcinomas. The results of this study indicate that PDT is a highly effective means of generating tumor-sensitized immune cells that can be recovered from lymphoid sites distant to the treated tumor at protracted time intervals after PDT, which asserts their immune memory character. It is also shown that the treatment of tumors by PDT creates the conditions necessary for converting the inactive adoptively transferred pre-effector, tumor-sensitized immune cells into fully functional antitumor effector cells. An additional finding of this study is the evidence of NK cell activation in PDT-treated Meth-A sarcomas.

The role of host lymphoid populations in the response of mouse EMT6 tumor to photodynamic therapy.

Photodynamic therapy (PDT) treatment of murine EMT6 mammary sarcoma using Photofrin (10 mg/kg) and light (110 J/cm2) cured all these lesions growing in syngeneic BALB/c mice. In contrast, the same treatment produced initial ablation but no long-term cures of EMT6 tumors growing in either scid or nude mice, the immunodeficient strains sharing the same genetic background with BALB/c mice. No difference was detected in either the level of Photofrin accumulated per g of tumor tissue or the extent of tumor cell killing during the first 24 h after PDT of EMT6 tumors growing in BALB/c or scid mice. The assumption that the difference in tumor cures could be ascribed to the absence of functional lymphoid cells in scid and nude mice was supported by the results of experiments involving the adoptive T-cell transfer into scid mice or bone marrow transfer between BALB/c and scid mice. The adoptive transfer of splenic virgin T lymphocytes from BALB/c mice into scid mice performed 9 days before PDT of EMT6 tumors growing in the recipients was successful in delaying the recurrence of treated tumors. Adoptive transfer done immediately after PDT or 7 days after PDT had no obvious benefit. Even better improvement and a high cure rate of PDT-treated tumors was obtained with scid mice reconstituted with BALB/c bone marrow. In contrast, a marked drop in tumor cure rate was observed with BALB/c mice reconstituted with scid bone marrow. These results suggest that the activity of host lymphoid populations was essential for preventing the recurrence of EMT6 tumors following the PDT treatment used in this study. The contribution of PDT-induced immune reaction may, therefore, be of critical importance for the cure with at least some tumors.

Potentiation of photodynamic therapy-elicited antitumor response by localized treatment with granulocyte-macrophage colony-stimulating factor.

Murine squamous cell carcinoma (SCCVII) cells were genetically engineered to produce marine granulocyte-macrophage colony-stimulating factor (GM-CSF). GM-CSF immunotherapy, based on the peritumoral injection of lethally irradiated GM-CSF-producing SCCVII cells, was examined as adjuvant to photodynamic therapy (PDT) treatment of this tumor. The GM-CSF immunotherapy administered three times in 48-h intervals, starting 2 days before the light treatment, substantially improved the curative effect of Photofrin-mediated PDT. A comparable effect of GM-CSF immunotherapy was observed in the combination with benzoporphyrin derivative-mediated PDT. The tumor-localized GM-CSF immunotherapy alone had no obvious effect on the growth of parental SCCVII tumors. This treatment did not significantly alter the differential peripheral WBC count and appeared not to affect tumor leukocyte infiltration. However, GM-CSF treatment did increase the cytotoxic activity of tumor-associated macrophages against SCCVII tumor cells. It appears, therefore, that tumor-localized immune stimulation by GM-CSF amplifies a PDT-induced antitumor immune reaction, which has a potentiating effect on tumor control.

Photofrin uptake by murine macrophages.

The uptake of Photofrin by murine peritoneal macrophages in vivo and in vitro was examined. Cellular Photofrin content was measured either by performing a fluorometric assay or by using 14C-labeled drug. For comparison, the uptake of Photofrin by murine SCCVII tumor cells (squamous cell carcinoma) was also examined under the same conditions. The data demonstrate that macrophages have a much greater capacity for Photofrin uptake than SCCVII tumor cells. Photofrin contents at 24 h after drug administration (25 mg/kg) measured 420 +/- 90 (SD), 74 +/- 15, and 15 +/- 2 ng/micrograms of cell protein for peritoneal macrophages, tumor-associated macrophages, and SCCVII tumor cells, respectively. Factors that modify macrophage activity also influence the uptake of the drug by macrophages. The results support the assumption that Photofrin uptake by macrophages is dominated by phagocytosis of highly aggregated components of the drug. In vivo accumulated Photofrin material in peritoneal macrophages, tumor-associated macrophages, and tumor cells has shown very similar in vitro clearance from all three cell types. Only 20-30% of Photofrin was lost from the cells during the initial 24 h, mainly between 1 and 4 h of clearance incubation.

Misonidazole and potentially lethal damage.

The existence of potentially lethal damage (PLD) is demonstrated in exponentially growing CHO cells exposed to misonidazole in hypoxia. The method of hypertonic post-treatment of cells was used in these studies. Misonidazole-induced PLD differs in many characteristics from radiation-induced PLD. The repair kinetics of misonidazole-induced PLD are much slower than for the repair of radiation-induced PLD (hours vs. minutes). No significant repair of misonidazole-induced PLD took place at 25 degrees C. Other differences are discussed. Hypertonic post-treatment of irradiated cells which had been pre-incubated with misonidazole to non-toxic levels, gave survival data consistent with the interpretation that no radiation PLD can be induced in such cells.

The interaction of trans-DDP [PtCl2(NH3)2] with low doses of radiation in mammalian cells.

Trans-DDP, a less toxic isomer of cisplatin, was examined for its radiosensitizing activity at high and low doses of ionizing radiation. Cells were exposed to the drug to produce low toxicity before exposure to X rays. A sensitive assay using the DMIPS Cell Analyzer was employed to measure cell survival response in low dose region (0-4 Gy) and conventional assay was used for high doses (4-25 Gy). The results show that trans-DDP is a much more effective radiosensitizer at low doses than at high doses, whether or not cytotoxicity was pronounced. This is in contrast to any other sensitizer studied to date, including oxygen, misonidazole, SR-2508 and Ro-03-8799, regardless of prior incubation and/or cytotoxicity.

Energy and misonidazole toxicity: the effects of 5-thio-D-glucose.

Cell inactivation and DNA damage (single-strand breaks) were used to study the effects of inhibitors of anaerobic glucose oxidation on the toxicity of misonidazole to hypoxic Chinese hamster cells. Citrate and 2-deoxyglucose produced no effects on the toxicity. 5-thio-D-glucose (5-TG) protected cells of the CH2B2 line to some extent (SSB decreased by about 30%). In the CHO lines used (wild, and ethylmethanesulfonate-sensitive mutants), 5-TG had varied effects. Non-protein sulfhydryl (NPSH) levels were measured in all lines. Cells with lower NPSH levels are more sensitive to misonidazole; these are the cells which are protected by 5-TG. Cell line variations must be considered when studying interactions between a drug and other forms of treatment as possible treatments of cancer.

The influence of cathepsin B and leupeptin on potentially lethal damage repair in mammalian cells.

Cell response to irradiation depends on many micro-environmental and intracellular factors. It is known that proteinases control many physiological functions and are also involved in progression of the cell cycle. They also could be involved in cell response to irradiation. In this work the influence of cathepsin B, which is one of the important lysosomal proteinases, and one of its inhibitors, leupeptin, on the potentially lethal damage repair (PLDR) was studied. Chinese hamster V79 cells were irradiated with gamma rays in the plateau-phase of growth. Immediately after irradiation cathepsin B or leupeptin were added to the growth medium. Four hours later, a determined sufficient period of time for maximal PLDR, the cells were replated to assess survival and mutation induction. Mutation frequency was determined at the hypoxanthine-guanine phosphoribosyltransferase (HGPRT) locus using resistance to 6-thioguanine (6-TG). Simultaneously, the activity of cysteine, aspartic and serine proteinases were determined at different postirradiation intervals. The results show that when plateau-phase cells were incubated with cathepsin B during the postirradiation interval strong inhibition of PLDR was observed, accompanied with a reduced number of 6-TG resistant mutants. If leupeptin was added, more modest inhibition of PLDR was observed, accompanied with only slight reduction in the mutation frequency. The addition of cathepsin B or leupeptin to irradiated cells modified the activities of intracellular proteinases. As the highest alterations in proteinase activities were observed at the time when maximum repair of DNA lesions occurred, the biological consequences could involve a series of sequential steps in intracellular proteinase activities.

Accumulation of benzoporphyrin derivative in malignant and host cell populations of the murine RIF tumor.

The accumulation of benzoporphyrin derivative (BPD) in malignant and host cell populations of the mouse RIF tumor was studied by flow cytometry analysis of cells dissociated from the tumor tissue. The highest cellular BPD levels were found in a subpopulation of tumor associated macrophages (TAMs) characterized by a highly elevated expression of interleukin 2 receptor (F4/80+CD25++), but this selectivity was less pronounced than with photofrin. The BPD levels in tumor associated immune cells other than TAMs were lower than in malignant cells. No significant difference in cellular distribution of BPD was observed with the photosensitizer delivered in liposomes compared to the aqueous solution.

Potentiation of photodynamic therapy by immunotherapy: the effect of schizophyllan (SPG).

Treatment of squamous cell carcinoma (SCCVII) bearing mice with the immunostimulant schizophyllan (SPG) raised the relative content of Mac-1 positive host cells infiltrating the tumor and increased photofrin retention in these tumors. In vitro colony formation assay following photofrin-based photodynamic therapy (PDT) in vivo revealed a greater killing of tumor cells in the SPG pre-treated group, particularly pronounced when the tumor excision was delayed for 8 h after PDT. The tumor cure rate increased approximately three times when PDT was preceded by the SPG therapy. In contrast, the administration of SPG after PDT was of no benefit for tumor control.

Contribution of myeloid and lymphoid host cells to the curative outcome of mouse sarcoma treatment by photodynamic therapy.

Selective depletion or inactivation of specific myeloid populations (neutrophils, macrophages) and lymphoid populations (helper T cells, cytolytic T cells) in EMT6 sarcoma-bearing mice was used to determine the contribution of each of these host immune cell types to the curative outcome of Photofrin-based photodynamic therapy (PDT). Immunodepletion of neutrophils and cytolytic T cells initiated immediately after PDT resulted in a marked reduction in PDT-mediated tumor cures. Significant reduction in the cures of EMT6 tumors was also achieved by immunodepletion of helper T cells and inactivation of macrophages by silica treatment. The initial tumor ablation by PDT was not affected by any of the above depletion treatments. These results provide direct evidence that the contribution of neutrophils, macrophages and T lymphocytes is essential for the maintenance of long-term control of PDT-treated tumors.

Detection of early lung cancer using low dose Photofrin II.

Fluorescence imaging using hematoporphyrin derivative (HpD) or Photofrin II as a tumor marker has been used for localization of early bronchogenic carcinoma. Wider clinical application of HpD or Photofrin II as a cancer imaging agent has been hampered by the potentially serious and prolonged skin photosensitivity. Using a sensitive fluorescence bronchoscope system with a ratio fluorometer probe, carcinoma in situ was detected in four patients with low dose Photofrin II (0.25 mg/kg) with no apparent skin phototoxicity to 30 J/cm2 visible light on skin photosensitivity test.

Inactivation of hypoxic cells by cisplatin and radiation at clinically relevant doses.

We have examined the effects of exposure to cisplatin (cis-diamminedichloroplatinum(II] on the response of exponentially growing V79 cells to low (0-4 Gy) and high (up to 30 Gy) doses of X rays under hypoxic and aerobic conditions. Survival in both dose regions was assessed by clonogenic assays; the low-dose studies were facilitated by a Cell Analyser (B. Palcic and B. Jaggi, Int. J. Radiat. Biol. 50, 345-352 (1986]. The results show that cisplatin, like its isomer trans-DDP, exhibits greater interaction with low than with high radiation doses in hypoxic cells. This increased interaction could be seen even with subtoxic exposures to cisplatin as low as 1 mumol dm-3. In contrast, with cells irradiated in air in the presence of either complex, the interaction seen with high doses of radiation is completely lost or greatly diminished in the low radiation dose region. Further experiments showed that enhanced interaction of hypoxic cells with low doses of radiation could be equally effective with cisplatin pretreatments in air or in hypoxia, even if the cells are exposed to cisplatin only after irradiation. In experiments with nonproliferating plateau-phase cultures, the same enhanced interaction was observed in the low-dose region. These results, for example enhancement ratios of 2.3 and 1.2 at low- and high-dose regions, respectively, for 5 mumol dm-3 cisplatin, are contrasted with those for nitroimidazoles which are better sensitizers in the high-dose region.

Oxygen enhancement ratio of fractionated regimens in vitro.

The oxygen enhancement ratio (OER) of proliferating and nonproliferating cells grown in vitro was measured using accelerated fractionated regimens. Irradiations were performed either twice daily or three times per day, with a minimum of 6 h between the consecutive fractions. The dose delivered was 2.3 Gy per fraction. Two significant observations were made: (i) the OER of accelerated fractionation regimens for proliferating cells is lower than that obtained from single-exposure experiments at 2.3 Gy (approximately 1.4 vs 2.4, respectively), while for nonproliferating cells it is approximately the same (2.3); (ii) the fractionated regimen does not spare proliferating cells irradiated under hypoxic conditions, and thus the fractionated survival curve lies below the single-exposure curve. For cells irradiated under aerobic conditions or for nonproliferating cells, irradiated under either hypoxic or aerobic conditions, the fractionated survival curve lies above the single-exposure curves as expected.

Cellular delivery and retention of photofrin: II. The effects of human versus mouse and bovine serum.

The effects of human serum (HS), mouse serum (MS) and fetal bovine serum (FBS) on cellular delivery and retention of Photofrin were examined using human lung tumor cells (A549) cultured in vitro. The results show that these three kinds of sera exhibit substantial differences in: (i) degree of inhibition of Photofrin cellular uptake, (ii) retention capacity of Photofrin delivered to the cells in their presence and (iii) efficacy of promoting the clearance of Photofrin from the cells. It is suggested that these differences originate from unequal interaction of each of the sera with Photofrin material, which in turn is the consequence of variability in composition and in the levels of serum proteins in HS, MS and FBS. The highest degree of Photofrin disaggregation and and competitive binding of its constituents was attributed to HS. The lowest degree of Photofrin disaggregation, and the competitive binding limited mostly to monomeric porphyrin forms was implicated for FBS. For MS, the spectroscopic and cellular data indicated a lesser degree of Photofrin disaggregation than with HS, with little if any consequence in Photofrin retention characteristics. The implication of this comparative analysis is that in vitro studies using FBS may underestimate the extent of interaction of Photofrin with serum proteins in humans, and overestimate the retention capacity of the photosensitizer in human tissues. Studies in vivo using a mouse model may also underestimate the degree of disaggregation of Photofrin in human circulation, and give different photosensitizer tissue retention levels than in humans.

Cellular delivery and retention of photofrin: III. Role of plasma proteins in photosensitizer clearance from cells.

Human plasma proteins, albumin, globulins and low density (LDL), high density (HDL) and very low density (VLDL) lipoproteins were tested for their effects on retention of Photofrin and three other photosensitizers in cultured cells. This was assessed by incubating the cells, subsequent to the exposure to Photofrin, in the photosensitizer-free medium containing various concentrations of different plasma proteins. Photofrin clearance levels differed with individual plasma proteins and also were dependent on concentration of these proteins in the incubation medium. All of the proteins except VLDL promoted clearance of Photofrin taken up by the cells in the presence of 5% human serum. Subsequent to some Photofrin exposure conditions (in the presence of 5% fetal bovine serum, or in protein-free medium), albumin, in contrast to LDL, HDL and globulins, exhibited decreased capacity for promoting the photosensitizer clearance from the cells. The VLDL showed very little or no effect in promoting cellular clearance of Photofrin, tetraphenyl porphine tetrasulfonate (TPPS4), and di- and tetrasulfonated chloroaluminum phthalocyanine (AlPcS2 and AlPcS4, respectively). The LDL seem to be particularly effective in promoting clearance of Photofrin and AlPcS2 from the cells, whereas albumin and globulins were shown to be more effective than LDL and HDL in promoting the cellular clearance of TPPS4.

Cellular delivery and retention of Photofrin II: the effects of interaction with human plasma proteins.

The absorbance and fluorescence spectra of Photofrin II (PII) in the presence of albumin, globulins and lipoproteins from human plasma show that all of these proteins induce a degree of disaggregation of PII material. In addition, there are substantial rearrangements in the distribution of different fractions contained in PII and their binding to the protein. It is shown that these rearrangements have considerable impact on the uptake of PII by cultured cells and the ensuing retention of the drug in the cells. The information on the contribution of fluorescing and non-fluorescing components of PII in the cells was obtained by measuring first the PII fluorescence in suspensions of live cells, followed by chemical extraction of porphyrin material from the same cells. The interaction of PII with low density lipoproteins resulted in markedly lower levels of PII material retained in the cells, compared to protein-free drug exposure. Somewhat better but still inferior PII retention was observed with high density lipoproteins. The samples with very low density lipoproteins showed increased uptake of PII, but the subsequent retention of the drug was low, so that the remaining amount of the drug was not much different than in protein-free samples. The strongest inhibition of PII uptake was seen with albumin, with ensuing retention of PII not significantly different than in protein-free samples. The best retention of PII was observed with globulins, with approx. 25% higher total drug content retained in the cells after long-term clearance relative to protein-free samples.

Photofrin accumulation in malignant and host cell populations of a murine fibrosarcoma.

Photofrin (25 mg/kg) was administered to the FsaR fibrosarcoma-bearing mice (either syngeneic or severe combined immunodeficient [SCID]) and the tumors were excised 24 h later. The photosensitizer content in the cells dissociated from tumor tissue was analyzed using flow cytometry. Staining the cell suspensions with the monoclonal antibodies against specific membrane markers served to identify the malignant cells and various types of host immune cells infiltrating the tumor. Photofrin content was also examined in the cells from normal tissues of the tumor-bearing mice (spleen, heart muscle, peritoneal macrophages). The results show a marked heterogeneity in the Photofrin cellular content of FsaR tumor, particularly within the population of tumor-associated macrophages (TAM). The Photofrin levels in some TAM were lower or similar to those in the malignant cells. In contrast, a subpopulation of TAM accumulated very high levels of the photosensitizer, which exceeded by far the levels found in the other tumor cell populations. This TAM fraction was characterized by particularly high expression of interleukin-2 receptors and increased cell size and granularity when compared to the other TAM, which suggests that these macrophages are in the activated state. Their average Photofrin content was almost 13 times higher than in the malignant cells. The lowest photosensitizer levels in the tumor were found in tumor-infiltrating leukocytes other than TAM. In FsaR tumors growing in SCID mice, the pattern of Photofrin distribution in TAM and other cellular populations was similar to that found in tumors growing in syngeneic mice.(ABSTRACT TRUNCATED AT 250 WORDS)