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Photodynamic therapy (PDT), a treatment approach that makes use of a photosensitizer to generate a localized toxic species in diseased tissue, has recently become an approved treatment modality. So far, however, only a handful of photosensitizers have received regulatory approval and for a small number of diseases. This chapter outlines the major limitations of PDT and speculates on the possible improvements that are required in order to advance PDT to a front line therapy. Seven areas of improvements are discussed: drug selectivity, drug delivery, light delivery, combination therapies, pigmented tumors, other potential uses, and protocol optimization. For each area, current limitations are discussed, and further required studies are recommended.

A fluorescence imaging prototype for skin lesion detection and diagnosis using aminolaevulinic acid (ALA) induced protoporphyrin IX (PpIX) was tested in vivo and in the clinic. The prototype was designed as an affordable, portable device to allow contrast enhanced imaging of skin lesions using either the dual excitation wavelength method or the dual emission wavelength method or both. In this study the prototype was tested first on an animal model. Topical application of ALA on defined spots on mouse skin gave PpIX fluorescence after about 3 hours of application. After successful in vivo testing the instrument was tested on basal cell carcinoma patients before ALA-PpIX photodynamic therapy. The patients were topically applied with ALA. After three hours the device was tested (immediately before treatment). The prototype showed good results in terms of contrast enhancement (elimination of unwanted background signals, e.g. autofluorescence) using either contrast enhancement method, both methods achieving similar results. The results achieved in this study, combined with the affordable design of the device, seem to allow cost-effective, contrast-enhanced imaging of skin lesions before or during photodynamic therapy using ALA induced PpIX.

Steady-state fluorescence imaging can be used in conjunction with selective exogenous or endogenous fluorescent compounds for the diagnosis of skin lesions, for example cancerous lesions. Depending on the excitation and emission properties of the fluorescent compound used, various excitation and/or emission wavelengths can be chosen in order to allow fluorescence imaging. Unwanted background signals like autofluorescence and scattering can decrease the image quality and hence the diagnosis potential of this imaging method. A method involving two excitation and/or emission wavelengths was used in order to suppress the unwanted background signal and allow contrast enhanced fluorescence imaging. A fluorescence imaging device prototype was assembled using both the two wavelength excitation method and the two wavelength emission method. Additionally, a white light source was included to allow the collection of images as seen with the naked eye. The prototype was designed to be affordable and portable and was laid out towards the diagnosis of skin lesions using aminolaevulinic acid-induced protoporphyrin IX (PpIX). This paper describes the excitation and detection characteristics of a fluorescence imaging device prototype. This includes spectral and spatial characteristics of the various light sources included in the device as well as specifications of the image detector used. Furthermore, the image analysis procedure used for the dual wavelength excitation/emission is described.

The method of surface-detected fluorescence has been used to monitor the emission intensity from 5-aminolaevulinic acid (ALA)-induced protoporphyrin IX (PpIX) in lesions and corresponding adjacent normal skin. Three types of lesions were examined: psoriatic plaques, actinic keratosis and basal cell carcinoma. This study included a total of 14 human volunteers on whom ALA-induced PpIX formation and clearance was monitored for a total of 48 h post-ALA application. Both an ALA dose-ranging study, as well as a comparison of results between normal and lesional tissue at a fixed ALA dose, were carried out. For the dose range examined (10-30%), there was no ALA dose dependency of the PpIX fluorescence for any of the lesions tested. Although all three lesions tested did show enhanced PpIX fluorescence as compared with normal skin, there was considerable lesion-to-lesion variability. Thick psoriatic plaques seem to give longer PpIX retention times than those of thin lesions. Limitations of the surface-detected fluorescence methodology are discussed.

Many different types of mammalian cells accumulate fluorescing and photosensitizing concentrations of protoporphyrin IX (PpIX) when exposed to exogenous 5-aminolevulinic acid (ALA) in vivo or in vitro. Most types of malignant cells accumulate substantially more ALA-induced PpIX than do the normal cells from which they arose. Most types of malignant cells also are less differentiated than their normal counterparts. We therefore considered the possibility that malignant cells demonstrate a malignant ALA phenotype (accumulate abnormally large amounts of PpIX when exposed to exogenous ALA) as a direct consequence of their less differentiated state. Human promyelocyte cell line HL-60 and mouse preadipocyte cell line 3T3 L1 were induced to differentiate by exposing them to inducing agents in vitro. The HL-60 cells accumulated less ALA-induced PpIX when differentiated, but the 3T3 L1 cells accumulated more. It appears then that changes in the ALA phenotype with changes in the state of differentiation are cell-type specific. The decreased accumulation of ALA-induced PpIX that accompanied differentiation of the promyelocytic leukemia cells may have clinical application for rapid quantitation of the response of myelocytic leukemia patients to differentiation therapy.

Objectives: To determine the in vivo dose-response relation between administered 5-aminolevulinic acid (ALA) and the concentration of protoporphyrin IX (PpIX) produced in rat uterine tissue, to determine the effect of estrogen on ALA-induced PpIX production in the rat endometrium and myometrium, and to determine the selectivity of ALA-induced PpIX production in uterine tissue., Methods: Ovary-intact female rats (n = 53) received a subcutaneous estradiol-17 beta (E2) implant. Three days later, ALA dissolved in saline (0, 1, 2.5, 10, 25, or 50 mg/100 microL) was injected into one uterine horn. Three hours after ALA administration, the uterus was removed and the endometrium was scraped from the myometrium. In a second study, rats (n = 35) were ovariectomized and 8 days later given either an E2 or sham implant. After 3 days of hormonal or sham priming, ALA (10 or 25 mg) was injected into the uterine horn 3 hours before hysterectomy. In both studies, PpIX was extracted in a methanol/ perchloric acid (1:1) solution and quantified spectrofluorometrically., Results: Five-aminolevulinic acid increased PpIX concentrations in the endometrium and myometrium in a dose-dependent fashion. Twenty-five milligrams of ALA produced maximum PpIX concentrations in both the endometrium and myometrium. In the second study, sham-implanted ovariectomized rats had endometrial PpIX concentrations approximately two times higher than those in the estrogen-primed rats after doses of either 10 or 25 mg ALA. In the third study, the endometrium had two to three times higher PpIX concentrations than the myometrium at 1, 10, 25, and 50 mg of ALA., Conclusions: An in vivo dose-response relation was demonstrated between ALA and uterine production of PpIX, with maximum PpIX concentrations occurring after 25 mg of intrauterine ALA. Because estrogen was not required to convert ALA to PpIX, complete endometrial ablation may best be achieved with an unstimulated endometrium.

5-Aminolevulinic acid (ALA), when added to many tissues, results in the accumulation of sufficient quantities of the endogenous photosensitizer protoporphyrin IX (PpIX) via the heme biosynthetic pathway, to produce a photodynamic effect when exposed to activating light. Therefore, ALA is the only photodynamic therapy (PDT) agent in current clinical development that is a biochemical precursor of a photosensitizer. Topical ALA application, followed by exposure to activating light (ALA PDT), has been reported effective for the treatment of a variety of dermatologic diseases including cutaneous superficial and nodular basal cell carcinoma, Bowen's disease, and actinic (solar) keratoses. Local internal application of ALA has also been used for selective endometrial ablation in animal model systems and in human clinical studies has shown selective formation of PpIX within the endometrium. PpIX induced by ALA application has also been used as a fluorescence detection marker for photodiagnosis (PD) of cancer and dysplastic conditions of the urinary bladder and other organs. Systemic, oral administration of ALA has been used for ALA PDT of superficial head and neck cancer, various gastrointestinal cancers, and the condition known as Barrett's esophagus. The current state of knowledge of the mechanisms of endogenous topical and systemic photosensitization using ALA, the results of published clinical trials, and possible methods of increasing the efficacy of endogenous photosensitization for ALA PDT are reviewed in this paper.

Administration of the heme precursor 5-aminolevulinic acid (ALA) leads to the selective accumulation of the photosensitizer protoporphyrin IX (PpIX) in certain types of normal and abnormal tissues. This phenomenon has been exploited clinically for detection and treatment of a variety of malignant and nonmalignant lesions. The present preclinical study examined the specificity of ALA-induced porphyrin fluorescence in chemically induced murine lung tumors in vivo. During the early stages of tumorigenesis, ALA-induced PpIX fluorescence developed in hyperplastic tissues in the lung and later in early lung tumor foci. In early tumor foci, maximum PpIX fluorescence occurred 2 h after the administration of ALA and returned to background levels after 4 h. There was approximately a 20-fold difference in PpIX fluorescence intensity between tumor foci and the adjacent normal tissue. The specificity of ALA-induced fluorescence for hyperplastic tissues and benign tumors in lung during tumorigenesis suggests a possible use for this fluorochrome in the detection of premalignant alterations in the lung by fluorescence endoscopy. Two non-small cell lung cancer cell lines developed ALA-induced PpIX fluorescence in vitro. These lines exhibited a light-dose-dependent phototoxic response to ALA photodynamic therapy (PDT) in vitro. Because PpIX is a clinically effective photosensitizer for a wide variety of malignancies, these results support the possible use of ALA-induced PpIX PDT for lung cancer.

Transcutaneous detection of fluorescence from an injection of the pH-sensitive probe biscarboxyethyl carboxyfluorescein (BCECF) has been used to monitor plasma pH in conscious animals. The fluorescence signal must be calibrated with reference to a standard curve. This standard, calibration curve has been achieved using in vitro methods. Here it is shown that temperature influences the calibration curve determination in vitro and hence influences the pH determined from transcutaneous measurements. Two calibration curves have been obtained, one at room temperature (approximately 25 degrees C) and the other at 37 degrees C. At pH 7.01 the calibration curves intersect, so that, at more alkaline pH values, use of room temperature calibration data will lead to an overestimate of plasma pH. Below pH 7.01, plasma pH will be underestimated. Transcutaneous fluorescence spectra recorded from a mouse injected with BCECF are shown, indicating that baseline plasma pH was estimated about 0.3 pH units too high using room temperature calibration, and that the extent of acidification when the animal was allowed to breathe an atmosphere containing 15% CO2 was overestimated by 0.7 pH units. Additionally, it is shown that in vitro bovine serum albumin at concentrations comparable with albumin concentrations in vivo shifts the absorption, fluorescence excitation and emission spectra of BCECF. However, fluorescence spectra recorded in vivo show no such shift. The results indicate that in vitro calibration for transcutaneous fluorescence measurements in vivo can be misleading, and that in the case of pH measurement inattention to temperature can lead to spurious results.

Surface-detected fluorescence spectroscopy can be used to monitor the pharmacokinetics of uptake and clearance of red-absorbing fluorophores such as zinc(II) phthalocyanine (ZnPc) in vivo. When this technique is applied to mice that have been fed on a normal chlorophyll-based diet, and particularly when measurements are performed in the abdominal region, oscillations are sometimes observed superimposed on the pharmacokinetic curve of the ZnPc. An oscillatory signal has also been observed arising from the abdominal region of control mice fed a normal diet but not injected with the ZnPc photosensitizer; this oscillatory component to the signal is reduced when mice are fed a chlorophyll-free diet. The oscillatory signal component has been attributed to fluorescence arising from chlorophyll derivatives (pheophorbide/pheophytin) contained in the rodent food, whose concentration in the measured abdominal region changes substantially with time, presumably due to digestive processes. Thus it is important to be aware of the possibility of such artifactual contributions to in vivo fluorescence pharmacokinetic measurements.

Extracellular pH was measured continuously and noninvasively in hairless mice using a transcutaneous spectrofluorometric technique and a fluorescent pH probe, bis-carboxyethyl carboxyfluorescein (BCECF). The acid form of BCECF was injected intravenously. An optical fiber system excited the fluorescent probe at 450 and 500 nm alternately, using one branch of a bifurcated, fiber optic bundle. The other branch of the bundle collected the emitted fluorescence which was measured by a photomultiplier tube. The ratio of fluorescence intensities from the two excitation wavelengths was pH dependent. Measurements could be obtained for approximately 60 min following a single injection. Mice exposed to elevated partial pressures of CO2 demonstrated changes in the fluorescence ratio indicative of a dramatic decrease in extracellular pH. If the exposure was brief, the fluorescence signal recovered within 20 min. The fluorescence intensity ratio was calibrated against aqueous BCECF samples in vitro. Fluorescence pH values determined using the in vitro calibration were compared with measurements made on blood samples taken from seven mice. Extracellular pH in hairless mice was found to be approximately 7.5, within the expected physiological range. The variability of the pH signal derived from the fluorescence signal was approximately 0.05 units.

The tissue photosensitizer protoporphyrin IX (PpIX) is an immediate precursor of heme in the biosynthetic pathway for heme. In certain types of cells and tissues, the rate of synthesis of PpIX is determined by the rate of synthesis of 5-aminolevulinic acid (ALA), which in turn is regulated via a feedback control mechanism governed by the concentration of free heme. The presence of exogenous ALA bypasses the feedback control, and thus may induce the intracellular accumulation of photosensitizing concentrations of PpIX. However, this occurs only in certain types of cells and tissues. The resulting tissue-specific photosensitization provides a basis for using ALA-induced PpIX for photodynamic therapy. The topical application of ALA to certain malignant and non-malignant lesions of the skin can induce a clinically useful degree of lesion-specific photosensitization. Superficial basal cell carcinomas showed a complete response rate of approximately 79% following a single exposure to light. Recent preclinical studies in experimental animals and human volunteers indicate that ALA can induce a localized tissue-specific photosensitization if administered by intradermal injection. A generalized but still quite tissue-specific photosensitization may be induced if ALA is administered by either subcutaneous or intraperitoneal injection or by mouth. This opens the possibility of using ALA-induced PpIX to treat tumors that are too thick or that lie too deep to be accessible to either topical or locally injected ALA.

The clearance times of 17 different porphyrin derivatives from SKH:HR-1 mice have been measured using the technique of in vivo fluorescence spectroscopy. This technique monitors the in vivo porphyrin fluorescence observed from the external skin surface. Most hydrophilic porphyrin derivatives show relatively short clearance times, in the order of 2.5-6 h. The dicarboxylic acid porphyrins, proto-, hydroxyethylvinyldeutero- and hematoporphyrin IX have clearance times of 7.8, 12.2 and 14.7 h respectively. The mixture hematoporphyrin derivative has an intermediate clearance time of 12.6 h. N-methylated porphyrins show clearance times in the vicinity of 15-22 h. Monoaspartyl chlorin e6 shows the longest clearance time of all porphyrin derivatives measured (30.3 h).

Volumetric titration of aqueous solutions of haematoporphyrin IX (HP) yields two inflexion points, whereas four pK values can be obtained via mathematical fitting of the experimental data. Assignment of all pK protonation sites is made. A zwitterion is proposed as the neutral species of HP. Evaluation of the pK values of HP in the presence of sodium dodecyl sulphate (SDS) leads to a drastically altered ionic species distribution. On the basis of the distribution diagrams obtained, a pH-sensitive twofold mechanism is proposed for the selective biodistribution of porphyrin-type photochemotherapeutic agents, one involving tissue distribution and the other involving cell membrane penetration by the neutral zwitterion.

5-Aminolaevulinic acid (ALA) is a precursor of protoporphyrin IX (Pp IX) in the biosynthetic pathway for haem. Certain types of cells have a large capacity to synthesize Pp IX when exposed to an adequate concentration of exogenous ALA. Since the conversion of Pp IX into haem is relatively slow, such cells tend to accumulate photosensitizing concentrations of Pp IX. Pp IX photosensitization can be induced in cells of the epidermis and its appendages, but not in the dermis. Moreover, since ALA in aqueous solution passes readily through abnormal keratin, but not through normal keratin, the topical application of ALA in aqueous solution to actinic keratoses or superficial basal cell or squamous cell carcinomas induces Pp IX photosensitization that is restricted primarily to the abnormal epithelium. Subsequent exposure to photoactivating light selectively destroys such lesions. In our ongoing clinical trial of ALA-induced Pp IX photodynamic therapy, the response rate for basal cell carcinomas following a single treatment has been 90% complete response and 7.5% partial response for the first 80 lesions treated. The cosmetic results have been excellent, and patient acceptance has been very good.

The skin of albino mice given 5-aminolevulinic acid (ALA) by intraperitoneal injection rapidly developed the characteristic red fluorescence of protoporphyrin IX. Fluorescence microscopy of frozen tissue sections revealed intense red fluorescence within the sebaceous glands and a much weaker fluorescence within the epidermis and hair follicles. Little or no fluorescence was detected in the dermis, blood vessels, or cartilage of the ear. Light microscopy of skin taken at intervals after whole-body exposure of ALA-injected mice to photoactivating light revealed destruction of sebaceous cells, focal epidermal necrosis with a transient acute inflammation, and diffuse reactive changes in the keratinocytes. The dermis showed transient secondary edema and inflammation. The location and severity of the phototoxic damage correlated well with the location and intensity of the red fluorescence. The light-exposed skin appeared to recover completely except for a persistent reduction in the number of hair follicles.

A fiber optic spectrophotometric system was used to monitor the in vivo oxygenation of leghemoglobin in intact, attached soybean root nodules (Glycine max L. Merr. x USDA 16 Bradyrhizobium japonicum) which were flattened during development by growth in narrow, glass-walled cuvettes. When equilibrated at an external pO(2) of 20 kilopascals, leghemoglobin was 36.6 +/- 5.4% oxygenated, a value estimated to represent an infected cell O(2) concentration of 21.5 nanomolar. Increasing the external pO(2) from 20 to 25 kilopascals caused a rapid increase in leghemoglobin oxygenation, followed by a recovery to the initial level, all within 7.5 minutes. At 25 kilopascals O(2), the rates of H(2) and CO(2) evolution were similar to those at 20 kilopascals. Since respiration had not increased, the results support the proposal that nodules adapt to increased external pO(2) by regulating their resistance to O(2) diffusion.