Photoradiation in the treatment of recurrent breast carcinoma.

Photoradiation, with the use of hematoporphyrin derivative (Hpd) activated by visible light in the red region of the spectrum, was an effective treatment for controlling local and regional chest wall recurrences of breast carcinoma. With sufficient time between iv injection of the drug and local activation with red light, cutaneous and subcutaneous masses were treated effectively without undue damage to overlying and adjacent skin. This high therapeutic ratio resulted from the ability to Hpd to accumulate and/or to be retained to a higher degree in malignant tissue than in many normal tissues. This technique can be used as a primary treatment or upon tumor recurrence following conventional modalities such as surgery, chemotherapy, and radiation therapy.

Photoradiation therapy. II. Cure of animal tumors with hematoporphyrin and light.

Exposure of mouse and rat tumors of various types to more than 600 nm light 24 or 48 hours after an injection of hematoporphyrin resulted in a substantial number of long-term cures. Since hematoporphyrin is preferentially retained in tumor tissue, selective tumor destruction could be obtained. Light penetration studies and the high efficiency of this technique indicated its applicability even to certain deep-seated human tumors.

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.

Determination of [3H]- and [14C]hematoporphyrin derivative distribution in malignant and normal tissue.

The synthesis and tissue-localizing ability of [14C]- and [3H]hematoporphyrin derivative (HPD) in mice have been described. Tissue levels and distributions were the same for both radioactive compounds, indicating that in vivo tritium exchange did not occur with [3H]HPD. The amount of [14C]HPD or [3H]HPD which localized in the transplanted tumor tissue of mice at various times following i.p. injection (10 mg/kg) was higher than in skin or muscle tissue but was less than in liver, kidney, or spleen tissue. These results tend to disprove the generalization that HPD accumulates in malignant tissue to a higher degree than in all normal tissue. It is also reported that gross visualization of porphyrin fluorescence cannot be correlated with actual tissue concentrations of the dye.

Syntheses and photosensitizing activity of porphyrins joined with ester linkages.

In order to investigate the structure of hematoporphyrin derivative and its purified version, Photofrin-II, porphyrin dimers with ester linkage were synthesized. 2,4-Diacetyldeuteroporphyrin dimethyl ester and protoporphyrin IX dimethyl ester were used as starting materials. The methyl esters were replaced by trimethylsilylethyl esters to protect the carboxylic groups. Deprotection using tetra-n-butylammonium fluoride in tetrahydrofuran regenerated the carboxylic functions. Reversed phase high performance liquid chromatography was used to compare the synthetic dimers with components of Photofrin-II. Our data indicate that these dimers are not components of Photofrin-II. During the synthesis of a 13C-labeled dimer with an ester linkage, a small amount of trimer was also isolated. The structures of these compounds were confirmed by nuclear magnetic resonance and mass spectroscopy. Using a standard screening system with DBA/2 mice bearing transplanted SMT-F tumors, these dimers were found not to be as active as Photofrin-II.

Energetics and efficiency of photoinactivation of murine tumor cells containing hematoporphyrin.

Hematoporphryrin derivative at an intracellular concentration in TA-3 mouse mammary carcinoma cells of 0.6 or 0.9 mM required input of 3.0 X 3.6 X 10(9) quanta/cell of red light (620 nm) to achieve a 90% kill. At an intracellular concentration of 1.2 mM, this light requirement drops to 1.5 X 10(9)quanta/cell. The energy for this photodynamic process is about 100 times higher than that required for ionizing radiation to achieve the same level of kill for these cells. The quantum yield for singlet oxygen formation (the cytotoxic agent in most photodynamic processes) from hematoporphyrin derivative is 0.75 +/- 0.07 in ethanol but only 0.16 +/- 0.07 within TA-3 cells, indicating possible intracellular complexing and quenching.

Identification of singlet oxygen as the cytotoxic agent in photoinactivation of a murine tumor.

Singlet oxygen, a metastable state of normal triplet oxygen, has been identified as the cytotoxic agent that is probably responsible for in vitro inactivation of TA-3 mouse mammary carcinoma cells following incorporation of hematoporphyrin and exposure to red light. This photodynamic inactivation can be completely inhibited by intracellular 1,3-diphenylisobenzofuran. This very efficient singlet oxygen trap is not toxic to the cells nor does it absorb the light responsible for hematoporphyrin activation. We have found that the singlet oxygen-trapping product, o-dibenzoylbenzene, is formed nearly quantitatively intracellularly when both the furan and hematoporphyrin are present during illumination but not when only the furan is present during illumination. The protective effect against photodynamic inactivation of the TA-3 cells afforded by 1,3-diphenylisobenzofuran coupled with the nearly quantitative formation of the singlet oxygen-trapping product indicates that singlet oxygen is the probable agent responsible for toxicity in this system.

Autoradiographic distribution of hematoporphyrin derivative in normal and tumor tissue of the mouse.

The distribution of isotopically labeled hematoporphyrin derivative (HPD) has been studied in mice bearing the spontaneous mammary tumor (fast growing). In stomach, liver, spleen, and pancreas, 3 hr after i.p. injection of [3H]HPD, grains were uniformly distributed over the tissue sections. After 24 hr, the grain density overlying parenchymous areas of these tissues was lower than that over the stromal or reticuloendothelial areas. In the spontaneous mammary tumor (fast growing), higher grain densities were seen over pseudocapsule, stromal septa, and necrotic areas at 3, 6, 12, 24, and 48 hr after injection. At 168 hr postinjection, only isolated stomal cells, presumably macrophages, showed high grain densities. From the temporal changes observed in the distributions of HPD in normal tissues and the relative stability of the distribution seen in the spontaneous mammary tumor (fast growing), we speculate that tissue factors such as vascular permeability, lack of an adequate lymphatic drainage, and nonspecific binding of serum proteins to stromal elements may be responsible for or contribute to the preferential uptake and/or retention of HPD observed in both human and animal tumors.

Interaction of photodynamic therapy and hyperthermia: tumor response and cell survival studies after treatment of mice in vivo.

The interaction of photodynamic therapy (PDT) and hyperthermia was studied in the radiation-induced-fibrosarcoma experimental mouse tumor system by tumor regrowth experiments as well as in vivo to in vitro cloning assays. In vivo, PDT (Photofrin II, 10 mg/kg i.p.), followed 24 h later by light (135 J/cm2, 630 nm) and/or heat (44 degrees C, 30 min) caused severe vascular damage (congestion of tumor vessels and hemorrhage) and subsequent disappearance of palpable tumor mass. While heat-treated tumors always started to regrow within 2 days of treatment, regrowth if it occurred was delayed to 4-5 days after PDT and 6-7 days following combined treatments. Only PDT followed by heat cured a considerable number of animals (45%), while PDT alone and heat followed by PDT cured less than 10% of animals, and heat alone caused no tumor cures. The various treatments differed in their immediate as well as their delayed effects on tumor clonogenicity when observed over a 24-h period. Tumors treated with PDT showed no immediate changes in clonogenicity, but progressive delayed cell death occurred if tumors remained in situ. Heat alone led to an immediate reduction in the number of clonogenic tumor cells, followed by some additional cell death for 4 h and subsequent recovery of clonogenicity. PDT followed by heat caused markedly potentiated immediate reduction in cell survival which may be the result of direct interaction of heat and PDT damage affecting the tumor cells. Some tumors rapidly progressed to total eradication, whereas others showed delayed survival values similar to those for tumor having received PDT only. In the reverse sequence, heat before PDT, the tumor cell survival kinetics resembled those following heat treatment alone. The comparative lack of effectiveness of this treatment regimen can be explained by the severe tumor hemorrhage caused by the initial heat treatment which reduces the transmission of light essential for the subsequent PDT treatment. This study shows that despite pronounced similarities in the microscopic and macroscopic appearance shortly after treatment by PDT or hyperthermia, these two modalities lead to tumor destruction by different mechanisms. Furthermore the combination of these two modalities in the proper sequence leads to potentiated cytocidal effects on the tumor cells in vivo.

Interstitial photoradiation therapy for primary solid tumors in pet cats and dogs.

Photoradiation therapy, a new method for treatment of solid malignant tumors, depends upon the tumor localization and retention of hematoporphyrin derivative, which is activated in vivo by light in the red region of the spectrum. As currently applied to cutaneous and s.c. lesions, the light dose is limited by both normal tissue reactions and the effective penetration of the light through the tissues. In this report, primary solid malignant lesions in pet cats and dogs have been treated by interstitial photoradiation therapy by applying the activating light from a laser [635 +/- 5 (S. D.) nm] directly into the tumor masses thrugh a 200-micrometer quartz fiber optic. Twelve of 14 lesions (four osteosarcomas, two squamous cell carcinomas, two malignant melanomas, one mast cell sarcoma, one fibrosarcoma, one sebaceous gland sarcoma, and a metastatic prostatic carcinoma) responded to treatment, and three are currently considered permanently controlled at 1 year or more following treatment. This method has not only allowed photoradiation therapy to be applied to some remote lesions but has also nearly eliminated normal tissue effects, thus greatly extending the applicability of this treatment to a wide range of human tumors.

Photoradiation therapy for the treatment of malignant tumors.

Administration of hematoporphyrin derivative i.v. followed by local exposure to red light has resulted in complete or partial response in 111 of 113 cutaneous or s.c. malignant lesions. Tumors treated have included carcinomas of the breast, colon, prostate, squamous cell, basal cell, and endometrium; malignant melanoma; mycosis fungoides; chondrosarcoma; and angiosarcoma. No type has been found to be unresponsive. In several cases complete clearing of chest wall metastatis has been achieved in treated areas. Deep-seated and pigmented tumors required a higher dose of drug for effective treatment than did the more superficial and nonpigmented lesions. A high therapeutic ratio between tumor and skin response has been obtained by allowing at least 3 days between drug injection and exposure to the therapeutic light for 2,5-mg/kg doses and at least a 4-day interval for 5.0-mg/kg doses.

Protoporphyrin IX occurs naturally in colorectal cancers and their metastases.

Colorectal cancers exhibit a red fluorescence. The nature of the responsible fluorophore and its eventual diagnostic potential were investigated. Thirty-three consecutive colorectal resection specimen, 32 of which with histologically confirmed cancer, and a total of 1053 palpable mesenteric nodes were fluorimetrically characterized ex vivo. Furthermore, frozen material from 28 patients was analyzed, selected for the availability of primary tumor material and metastatic tissue, e.g., lymphatic and liver metastases from the same patient. Biochemical characterization was carried out through chemical extraction and reversed phase high-performance liquid chromatography. The fluorescence spectra of tissues, tissue extracts, and standard solutions of porphyrins were determined using a pulsed solid-state laser system for excitation and an imaging polychromator, together with an intensified CCD camera for time-delayed observation. Protoporphyrin IX (PpIX) was identified as the predominant fluorophore in primary tumors and their metastases. The fluorophore occurred in the absence of necrosis and in sterile locations. In untreated cases (n = 24), PpIX fluorescence discriminates metastatically involved lymph nodes from all other palpable nodes with a sensitivity of 62% at a specificity of 78% (P < 0.0001). After neoadjuvant treatment of rectal cancer, the PpIX fluorescence level of the primary tumors was reduced and a discrimination of lymph nodes based on PpIX-fluorescence was impossible. We conclude that colorectal cancer metastases accumulate diagnostic levels of endogenous PpIX as a result of a tumor-specific metabolic alteration.

Tumor destruction and kinetics of tumor cell death in two experimental mouse tumors following photodynamic therapy.

The effect of photodynamic therapy (PDT) on tumor growth as well as on tumor cell survival in vitro and in vivo was studied in the EMT-6 and RIF experimental mouse tumor systems. In vitro, RIF cells were more sensitive towards PDT than were EMT-6 cells when incubated with porphyrin (25 micrograms/ml, dihematoporphyrin ether) and subsequently given graded doses of light. In vivo, both tumor types responded to PDT (EMT-6, dihematoporphyrin ether, 7.5 mg/kg; RIF, dihematoporphyrin ether, 10 mg/kg; both followed 24 hr later by 135 J of light at 630 nm/sq cm) with severe vascular disruption and subsequent disappearance of tumor bulk. However, whereas the cure rate for EMT-6 tumors was 90%, it was 0% for RIF tumors. Raising the light dose to 200 J/sq cm resulted in 100% cures for EMT-6 tumors accompanied by damage to the surrounding tissues and 13% cures for RIF tumors. Tumor cell clonogenicity following PDT in vivo was assessed using the in vitro colony formation assay. In both tumors, it was found to be nearly unaffected by PDT if the tumor tissue was excised and explanted immediately following completion of treatment. This indicates that the effect of PDT on tumor cells directly was not sufficient to decrease tumor clonogenicity even at doses which led to total macroscopic tumor destruction. Where the tumors remained in situ following PDT and explantation was delayed for varying lengths of time (1 to 24 hr), tumor cell death occurred rapidly and progressively, indicating that tumor cell damage was expressed only if the cells remained exposed to the in situ environment after treatment. The kinetics and extent of tumor cell death were very similar for both tumor types despite their difference in cure rates. The reduction in tumor clonogenicity at 4 hr post-PDT closely matched that of tumor deprived of oxygen for the same period of time, implying that one of the major factors contributing to tumor destruction may be damage of the tumor circulation and the consequences of treatment-induced changes in tumor physiology.

An in vivo quantitative structure-activity relationship for a congeneric series of pyropheophorbide derivatives as photosensitizers for photodynamic therapy.

An in vivo quantitative structure-activity relationship (QSAR) study was carried out on a congeneric series of pyropheophorbide photosensitizers to identify structural features critical for their antitumor activity in photodynamic therapy (PDT). The structural elements evaluated in this study include the length and shape (alkyl, alkenyl, cyclic, and secondary analogs) of the ether side chain. C3H mice, harboring the radiation-induced fibrosarcoma tumor model, were used to study three biological response endpoints: tumor growth delay, tumor cell lethality, and vascular perfusion. All three endpoints revealed highly similar QSAR patterns that constituted a function of the alkyl ether chain length and drug lipophilicity, which is defined as the log of the octanol:water partition coefficient (log P). When the illumination of tumor, tumor cells, or cutaneous vasculature occurred 24 h after sensitizer administration, activities were minimal with analogs of log P < or = 5, increased dramatically between log P of 5-6, and peaked between log P of 5.6-6.6. Activities declined gradually with higher log P. The lack of activity of the least-lipophilic analogs was explained in large part by their poor biodistribution characteristics, which yielded negligible tumor and plasma drug levels at the time of treatment with light. The progressively lower potencies of the most lipophilic analogs cannot be explained through the overall tumor and plasma pharmacokinetics of photosensitizer because tumor and plasma concentrations progressively increased with lipophilicity. When compensated for differences in tumor photosensitizer concentration, the 1-hexyl derivative (optimal lipophilicity) was 5-fold more potent than the 1-dodecyl derivative (more lipophilic) and 3-fold more potent than the 1-pentyl analog (less lipophilic), indicating that, in addition to the overall tumor pharmacokinetics, pharmacodynamic factors may influence PDT activity. Drug lipophilicity was highly predictive for photodynamic activity. QSAR modeling revealed that direct antitumor effects and vascular PDT effects may be governed by common mechanisms, and that the mere association of high levels of photosensitizer in the tumor tissue is not sufficient for optimal PDT efficiency.

Photodynamic therapy for palliation of locally recurrent breast carcinoma.

Fourteen women with locally recurrent breast carcinoma on the chest wall following mastectomy were given 30 courses of photodynamic therapy (PDT). All patients had been heavily pretreated with conventional modes of therapy (radiation therapy, chemotherapy, hormonal therapy, surgical resection). Twenty-two courses yielded a partial response; two courses yielded a complete response; four courses showed no response; one patient was treated as an adjunct to surgery; and one patient was lost to follow-up. Duration to response was variable, ranging from 6 weeks to 8 months. Several women had chest wall disease controlled for prolonged periods of time using repeated courses of PDT. Two women had re-epithelialization of ulcerated lesions. Complications were minimal and included pain (two patients), sunburn (two), and infection (one). These results suggest that treatment with PDT can aid in local control of chest wall recurrence following mastectomy in selected patients.

Preferential binding and aggregation of rabbit C-reactive protein with arginine-rich proteins.

Human and rabbit C-reactive proteins (CRP) are similar in mol. wt, structure and amino acid sequence. In addition to the characteristic phosphoryline (PC)-binding specificity, both CRP molecules bind arginine- and lysine-rich proteins. The human CRP-cationic protein reactivity has been reported to be inhibited by calcium and promoted by PC in the presence of calcium. The present study compares binding and precipitation reactions of rabbit CRP (raCRP) with arginine- and lysine-rich proteins, and demonstrates the differential modulation of these interactions by calcium and acidic pH. Rabbit CRP shows preferential binding and precipitation reactivities with arginine-rich cationic molecules. Binding of raCRP to poly-L-arginine (PLA) and arginine-rich histone (ARH) occurs at pH 6.0, in the presence of calcium and is inhibitable by phosphorylcholine (PC) suggesting an interaction at or near the calcium-modulated PC binding site. The in vitro precipitation of raCRP and arginine-rich cationic molecules is significantly inhibited at pH 6.0, by the non-precipitating lysine-rich ligand PLL, and by physiological levels of calcium, and may reflect the participation of distinct "self-aggregation" sites on CRP in the precipitation response. The significance of the preferential arginine reactivity of raCRP to in vivo functions as a scavenger of chromatin during cell death and/or as a modulator of lipoprotein metabolism during the acute phase response is discussed.

Photofrin photodynamic therapy for treatment of AIDS-related cutaneous Kaposi's sarcoma.

OBJECTIVE: Kaposi's sarcoma, the most common malignancy in AIDS patients, often presents with painful cutaneous lesions that are difficult to treat effectively despite a wide variety of therapeutic approaches. We used photodynamic therapy in an attempt to provide effective palliative treatment for this disease. METHODS: Photodynamic therapy utilizes the activation by light of a photosensitizing drug that preferentially accumulates in tumor tissue such as Kaposi's sarcoma. We enrolled 25 patients who received 1.0 mg/kg of Photofrin 48 h before exposure to 100-400 J/cm2 of 630 nm light. RESULTS: Of the 348 lesions treated, 289 were evaluable: 32.5% had complete clinical response, 63.3% had partial clinical response and 4.2% were clinical failures. There was a strong correlation between response and light dose: 54% of lesions achieved a complete clinical response at optimum light dose (> 250 J/cm2). There was no correlation of response with CD4 cell count nor was there a change in CD4 cell count post-treatment. At 400 J/cm2 full field scabbing and necrosis occurred in 90% of the treated fields. Thus, the maximum tolerated dose was determined to be 300 J/cm2. At light doses of 250 J/cm2 and below the toxicities were limited to erythema and edema in the treatment field. Forty-three biopsies were taken 0.5 h to 4 months post-treatment. These showed little change in the B and T cell infiltrates identified. Kaposi's sarcoma cells disappeared post-treatment in certain lesions. CONCLUSION: Photofrin is effective palliative treatment for HIV-associated Kaposi's sarcoma.

Photoradiation therapy for cutaneous and subcutaneous malignancies.

Photoradiation therapy (PRT) using hematoporphyrin derivative (Hpd) as the photosensitizing agent is being developed for local treatment of a wide variety of malignant lesions including those involving the skin. The largest group of patients in this category are those with metastatic breast carcinoma in which 34/35 showed response to PRT. Other patients showing response to PRT are those with basal cell carcinoma, malignant melanoma, and squamous cell carcinoma.

Photodynamic therapy (PDT) of malignant tumors.

Photodynamic therapy (PDT) is finding increasing application to a number of malignant tumors. It is based on the specific photosensitization of malignant tissue by a particular porphyrin derived from hematoporphyrin, known as Photofrin II. The exact structure at present is unknown. However this material, following systemic injection, is retained longer in malignant tissue than in many normal tissues and can be activated by visible light, usually red, to initiate a lethal phototoxic effect on the tumor. It is a particularly useful treatment when specificity is necessary in treatment, for example in treatment of widespread chest wall metastasis, bladder cancer and early lesions of the bronchus, trachea and esophagus, including CIS.

Photodynamic therapy.

Photodynamic therapy (PDT) has been developed over the past decade into a useful treatment for several types of solid cancers in man. This unique therapy requires a photosensitiser accumulated in tumours and local activation by visible light generally delivered from lasers and delivered to the patient through various types of fibers and endoscopes. PDT appears to be most effective in treating certain superficial, difficult to treat cancers such as carcinoma in situ of the urinary bladder (here complete control is the intent), but also is effectively used in bulkier tumours obstructing bronchi or the oesophagus where palliation can be achieved. The primary mechanism of action is the in situ generation of an active form of molecular oxygen (singlet oxygen) which causes the rapid, local onset of vascular stasis and eventual vascular haemorrhage and tumour wall destruction. This process appears to be mediated through various cytokines such as prostaglandin, lymphokines and thromboxanes. The ultimate clinical value of PDT will be seen over the next few years following health agency approval worldwide.