Photodynamic therapy on rat urinary bladder with intravesical instillation of 5-aminolevulinic acid: light diffusion and histological changes

PURPOSE: Photodynamic therapy (PDT) has the potential to treat extensive premalignant lesions and microinvasive tumors in the bladder, but its use has been hampered by the risk of detrusor muscle damage and prolonged skin photosensitivity. We have shown that the rat urothelium can be sensitized by selectively using a 10% solution of 5-aminolevulinic acid (ALA) at pH 5.5 administered intravesically. This paper evaluates the photodynamic effects on sensitized bladders. MATERIALS AND METHODS: The bladders ofs Wistar rats were instilled with ALA solutions of different concentrations at pH 5.5 and subsequently treated with laser light at 630 nm. Bladders were harvested 1 to 7 days after PDT for histological assessment. RESULTS: Under optimum conditions (10% intralipid diffusion medium, light dose 50J) uniform urothelial necrosis was seen after 1 to 2 days; it healed in 7 days without damage to the underlying muscle layer although some increase in collagen was seen in the lamina propria. Overtreatment or poor light distribution resulted in muscle necrosis and scarring. CONCLUSIONS: Selective urothelial necrosis is possible with PDT using intravesical ALA. There is now sufficient data for pilot clinical trials to start photodynamic therapy for management of superficial bladder cancer or carcinoma in situ.     

Clinical photodynamic therapy for superficial cancer in the oesophagus and the bronchi: 514 nm compared with 630 nm light irradiation after sensitization with Photofrin II

Photodynamic therapy (PDT) for cancer in the oesophagus and bronchi with red (630 nm) light may occasionally lead to wall perforation and fistula. Therefore, we investigated the clinical use of a less penetrating wavelength (514 nm) for the curative treatment of nine superficial carcinomas in the oesophagus and bronchi after photosensitization with Photofrin II. Tumours without infiltration beyond the submucosa in the oesophagus and beyond the lamina propria in the bronchi were considered as superficial cancers. The outcome and complications were compared with those of 13 superficial cancers treated with PDT and 630 nm light. In addition, we evaluated histologically the extent of the long-term tissue damage and scarring following treatment of six oesophageal cancers with either green or red light. At first endoscopic control, 7-10 days after PDT, tissue necrosis simply matched the illuminated area, without evidence of selective tumour damage. Six of nine tumours treated with 514 nm light had a complete response compared with nine of 13 after 630 nm irradiation. No perforation or fistula occurred in either treatment group. However, severe chest pain and fever with or without pleural effusion, consistent with occult perforation, were observed in three patients after 630 nm illumination in the oesophagus. Histologically, fibrous scarring in the three distinct sites treated with green light was limited to the superficial layers of the oesophagus. After red light treatment, transmural fibrosis with marked thinning of the oesophageal wall was evident in two of the three specimens available for inspection. These results indicate that PDT with 514 nm light has the potential to cure superficial cancer in the oesophagus and bronchi with essentially the same probability of success as red light. In the oesophagus, green light prevents deep tissue damage, thus reducing the risk of perforation.     

Diagnosis, management, and outcome of late duodenal complications in portal-enteric pancreas transplantation: case reports

BACKGROUND: Enteric drainage (ED) of pancreas allografts is an alternative to the bladder drainage (BD) technique and eliminates unique metabolic complications seen in the BD pancreas transplant recipients. Little longterm data has been reported in ED pancreas transplants. STUDY DESIGN: Of 53 patients who underwent pancreas transplantations performed with ED drainage of the exocrine secretion to a Roux-en-Y limb, who had more than 6 months graft function, four patients were identified with late duodenal segment complications (more than 6 months after transplantation) and are presented as case reports. RESULTS: The duodenal segment complications occurred between 8 and 48 months after simultaneous pancreas-kidney transplantation. Three patients were diagnosed with leakage from the duodenal segment. All were managed operatively. The fourth patient developed a distal stricture of the transplant duodenum occluding the anastomosis between the duodenum and the Roux-en-Y limb and also had a pancreatic pseudocyst. Drainage via a cyst-jejunostomy resulted in graft salvage. The mean followup after operative management of the duodenal-related complications was 15 months (range, 3-24 months). The patient, pancreas and kidney graft survival are 100%. CONCLUSIONS: Late duodenal complications occurred in 8% of pancreas transplant recipients with ED. Operative intervention in all four patients resulted in excellent graft and patient outcome and is recommended for these complications.     

Intra-operative laser-induced photodynamic therapy in the treatment of experimental hepatic tumours

OBJECTIVE: To examine the effect of photodynamic therapy (PDT) on experimental liver tumours in rats. DESIGN: An experimental liver tumour model was used. Each of a group of rats had two tumours simultaneously inoculated into its liver. The tumour located in the left hepatic lobe was used for PDT, and the other one, in the median lobe, as a control. The haem precursor delta-amino laevulinic acid (ALA), at a dose of 30 mg/kg body weight, was injected 60 min before laser irradiation. Rats in group I received ALA through a femoral vein. Those in group II received ALA through the portal vein. Group III had an injection of ALA solution through the portal vein plus hepatic inflow occlusion. Three and 6 days after the treatment, the rats were killed, and the tumours were measured, and ultrastructural changes were examined using scanning electron microscopy. SETTING: Lund University Medical Laser Centre, Lund, Sweden. RESULTS: The mean tumour volume of the treated tumours increased by factors of 1.9, 1.5 and 1.7 in groups I, II and III, respectively, compared with the pretreatment baseline value. However, the mean tumour volume in the control tumours increased by factors of 9.5, 4.3 and 4.8 in the respective groups. Under the light microscope, marked necrosis of the treated tumour and the surrounding liver tissue was observed. Scanning electron microscopy revealed heavy damage to the cells and vessels in the treated tumour. CONCLUSION: PDT with ALA is an effective treatment modality for rat liver tumours.     

Treatment of ovarian cancer with photodynamic therapy and immunoconjugates in a murine ovarian cancer model

In photodynamic therapy (PDT), photosensitisers accumulate somewhat preferentially in malignant tissues; photoactivation with appropriate wavelength of light release toxic molecular species which lead to tumour tissue death. In order to target ovarian cancer with increased specificity, a chlorin-based photosensitiser (chlorin e6 monoethylendiamine monoamide) was conjugated to OC125, a monoclonal antibody recognising an antigen expressed in 80% of non-mucinous ovarian cancers. In previous work, this immunoconjugate (IC) was shown to be selectively phototoxic to cancer cells from ovarian cancer patients ex vivo and to localise preferentially in ovarian cancer tissue in vivo. In this study we report results from in vivo phototoxicology and photodynamic treatment studies using this IC in a murine model for ovarian cancer. A comparison of single vs multiple treatments was also made. For in vivo experimentation, Balb C nude mice were injected with 30 x 10(6) NIH:OVCAR 3 cancer cells to create an ascitic tumour model. Animals were then given intraperitoneal injections of the immunoconjugate (0.5 mg kg-1). Twenty-four hours later the intraperitoneal surfaces were exposed to 656 nm light from an argon-ion pumped-dye laser (50 mW, 656 nm), using a cylindrical diffusing tip fibre. The overall treatment was given either once or multiply. No animals died from treatment complications. Twenty-four hours following one and three PDT treatments, the percentage of viable tumour cells in the ascites of the treated animals analysed ex vivo was 34% and 5% of control for one and three treatments respectively. With respect to survival, all control mice (n = 18) died between 30 and 50 days. However, for those treated three times (n = 10), 40% were still alive after 50 days, and for those treated four times (n = 12) 58% were alive after 50 days. Evaluation with log-rank test revealed a significant survival with intraperitoneal PDT compared with controls (P = 0.0006). These preliminary results suggest that PDT with an OC125 immunoconjugate may be an effective therapy for the management of advanced ovarian cancer. Clinical application of this therapy needs to be further optimised and may require multiple treatments, similar to fractionated radiation therapy and cyclic chemotherapy, in order to control malignant disease with acceptable toxicity to normal tissue.     

Modified duodenum-preserving resection of the head of the pancreas

A modified procedure of duodenum-preserving resection of the head of the pancreas was used in treating three patients with benign lesions in the head of the pancreas. Compared with Beger's procedure, the modified procedure was simpler, and pancreaticojejunostomy on duodenal side was not necessary because of less remaining pancreas attached to the conjunction of the pancreatobiliary duct. The patients, recovered and ate food from 4 to 6 days after operation without symptoms of duodenal obstruction. The patient's digestive function was normal, and the pre- and postoperative pancreatic endocrine function was almost identical. This procedure can be used as the first-choice surgical procedure for benign lesions in the head of the pancreas. Problems in how to protect blood supply of the duodenum were also discussed.     

An unusual case of clear-cell carcinoma of the pancreas

This case of clear-cell carcinoma of the pancreas was a rare for three reasons: a) discovery: the investigation was indicated after sudden digestive hemorrhage revealed by melena and anaemia; b) morphology: the tumour began in the head with a spheric tumoural bud and a pediculated extension into the duodenum; c) pathology a clear-cell tumour similar to the type seen in renal localizations. Only one other case of such a primitive tumour was found reported in the literature.     

Photodynamic laser therapy of basal-cell carcinoma of the lid

Photodynamic therapy (PDT) remains an experimental approach for the treatment of small, mainly superficial malignant tumors. When given intravenously, hematoporphyrin derivative (HpD) selectively photosensitizes tumor tissue. Activated by light of 630 nm wave-length, HpD leads to tumor necrosis. This paper presents the results of PDT to eyelid basal-cell carcinomas in 21 patients. All lesions primarily responded to the treatment and became necrotic. A generalized photosensitization lasting for more than 4 weeks was seen in all patients. In five patients, lid malformations due to scar formation were noted, being marked in three cases. Ten patients showed a recurrence of tumor after 3-12 months. At present, PDT has no advantage over well-established therapies for basal-cell carcinomas of the eyelid.     

The presence of antibodies against HIV peptides in the sera of alloimmune mice and thalassemic patients is due to a polyclonal activation mechanism

The effect of Photofrin-based photodynamic therapy (PDT) and adjuvant treatment with serum vitamin D3-binding protein-derived macrophage-activating factor (DBPMAF) was examined using a mouse SCCVII tumour model (squamous cell carcinoma). The results show that DBPMAF can markedly enhance the curative effect of PDT. The most effective DBPMAF therapy consisted of a combination of intraperitoneal and peritumoral injections (50 and 0.5 ng kg-1 respectively) administered on days 0, 4, 8 and 12 after PDT. Used with a PDT treatment curative to 25% of the treated tumours, this DBPMAF regimen boosted the cures to 100%. The DBPMAF therapy alone showed no notable effect on the growth of SCCVII tumour. The PDT-induced immunosuppression, assessed by the evaluation of delayed-type contact hypersensitivity response in treated mice, was greatly reduced with the combined DBPMAF treatment. These observations suggest that the activation of macrophages in PDT-treated mice by adjuvant immunotherapy has a synergistic effect on tumour cures. As PDT not only reduces tumour burden but also induces inflammation, it is proposed that recruitment of the activated macrophages to the inflamed tumour lesions is the major factor for the complete eradication of tumours.     

The diagnosis of chronic cholecystitis and pancreatitis

Results are submitted of ultrasonic monitoring of gallbladder, pancreas and duodenum during the I, II, III phases of digestion in 186 patients who ranged from 30 to 60 years old. The form was studied of the gallbladder as was its size and location together with the volume, thickness of walls, presence of deformities; echogenicity of pancreas, outline, state of the main duct. Interdigestive duodenal motility and intracavitary pressure were recorded. Relationship has been established of the gallbladder and pancreas contraction phases to the condition of the intracavitary pressure in the duodenum.     

The influence of smoking on pancreatic function in man

A combination secretin-Lundh test was performed on 14 healthy established smokers to determine if smoking inhibited pancreatic secretion and therefore might contribute to the production of a duodenal ulcer. Seven of the patients studied smoked more than 20 cigarettes per day and were classified "heavy smokers". The remaining seven patients smoked less than 20 cigarettes per day and were classified "light to moderate smokers". The volume and bicarbonate output of the pancreas were lowered in both groups of patients after smoking one cigarette. This apparent side effect of nicotine may possibly play an important role in the production of duodenal ulcers in smokers by producing an acid milieu in the duodenum. Tryptic activity was unaffected by smoking.     

A ghost in the closet]

The authors share their experiences with observations of profuse bleedings from the tumour of the pancreas head into the duodenum lumen. The clinical picture of this complication and surgical methods of treatment are described. Both patients recovered.     

Heterogeneity of motilin receptors in the gastrointestinal tract of the rabbit

Motilin, a 22-amino acid peptide synthesized in endocrine cells of intestinal mucosa, stimulates GI smooth muscle contractility. To elucidate the mode of action of motilin, we attempted to determine whether motilin receptors are localized on nerve cells or on smooth muscle cells of the GI tract. Mucosa-free tissues from rabbit antrum and duodenum were homogenized separately with a Polytron prior to differential centrifugation to obtain synaptosome or plasma membrane-enriched fractions, as determined by the distribution of [3H]saxitoxin (SAX) binding (neural membranes) and 5' nucleotidase (5'N) activity (smooth muscle plasma membranes). Motilin binding was evaluated by the displacement of [125I]motilin by motilin (1-22) on the various membrane fractions. In the antrum, motilin binding was highly correlated with SAX binding (r = 0.81, p < 0.0005), and also significantly with 5'N activity (r = 0.54, p < 0.05). In the duodenum, motilin binding correlated significantly with 5'N activity (r = 0.67, p < 0.005), but not with SAX binding (r = -0.11, NS). Receptor affinity, for the motilin antagonist MOT(1-12)[CH2NH]10-11, for motilin(1-22), and for the motilin agonist erythromycin lactobionate was significantly (p < 0.001, p < 0.001, and p < 0.05, respectively) higher in SAX-enriched fractions from the antrum than in 5'N-enriched fractions from the duodenum. Therefore, in the rabbit: 1) motilin receptors appear to be predominantly located on nerve tissues in the antrum and restricted to smooth muscle cells in the duodenum, and 2) antral receptors and duodenal receptors displayed different pharmacological characteristics, probably corresponding to two specific and heterogeneous motilin receptor subtypes.     

Photodynamic therapy: applications in bladder cancer and other malignancies

Photodynamic therapy (PDT) has gained popularity in the past 10 years because of advances in laser and pharmacokinetic technologies and the development of new photosensitizers. Early studies on PDT with focal illumination for papillary bladder cancer obtained reasonable response rates for small tumors but recurrence was common. Whole bladder irradiation, once a suitable light-delivery system had been developed, gave promising outcomes with acceptable rates of complications. PDT for prostate cancer is still at the experimental stage but initial results have been promising. Clinical trials of PDT for brain tumors have shown no significant complications but no improvement in survival rate compared with other treatment modalities. PDT is particularly useful for early superficial lung cancers that are localized to one or a few discrete sites; it is also safe to use in patients who are too sick to be treated with conventional therapies. Preoperative PDT has reduced the extent of surgery necessary in some patients. Clinical experience with PDT for gynecological cancer is limited and prospective studies are needed. In head and neck oncology, PDT should prove a useful option, but methodological problems need to be overcome. Good responses of esophageal cancer to PDT have led to governmental approval of Photofrin, a photosensitizer, in several countries for either palliative use or treatment of inoperable or recurrent cancer. The use of PDT for early gastric cancer has great potential but several technical problems remain. PDT has proven generally effective for skin cancer when hematoporphyrin derivative or Photofrin is used but more long-term follow-up data are required for PDT with 5-aminolevulinic acid. Overall, PDT is changing from a scientific curiousity into an accepted modality for the treatment of cancer, with an improved likelihood of finding further clinical applications.     

Reduction of tumour oxygenation during and after photodynamic therapy in vivo: effects of fluence rate

It has been proposed that the generation of O2 during photodynamic therapy (PDT) may lead to photochemical depletion of ambient tumour oxygen, thus causing acute hypoxia and limiting treatment effectiveness. We have studied the effects of fluence rate on pO2, in the murine RIF tumour during and after PDT using 5 mg kg(-1) Photofrin and fluence rates of 30, 75 or 150 mW cm(-2). Median pO2 before PDT ranged from 2.9 to 5.2 mmHg in three treatment groups. Within the first minute of illumination, median tumour pO2 decreased with all fluence rates to values between 0.7 and 1.1 mmHg. These effects were rapidly and completely reversible if illumination was interrupted. During prolonged illumination (20-50 J cm(-2)) pO2 recovered at the 30 mW cm(-2) fluence rate to a median value of 7.4 mmHg, but remained low at the 150 mW cm(-2) fluence rate (median pO2 1.7 mmHg). Fluence rate effects were not found after PDT, and at both 30 and 150 mW cm(-2) median tumour pO2 fell from control levels to 1.0-1.8 mmHg within 1-3 h after treatment conclusion. PDT with 100 J cm(-2) at 30 mW cm(-2) caused significantly (P = 0.0004) longer median tumour regrowth times than PDT at 150 mW cm(-2), indicating that lower fluence rate can improve PDT response. Vascular perfusion studies uncovered significant fluence rate-dependent differences in the responses of the normal and tumour vasculature. These data establish a direct relationship between tumour pO2, the fluence rate applied during PDT and treatment outcome. The findings are of immediate clinical relevance.     

Enhancement of the efficiency of photodynamic therapy of tumours by t-butyl-4-hydroxyanisole

The effects of photodynamic therapy (PDT) alone and in combination with 3(2)-t-butyl-4-hydroxyanisole (BHA) on Ehrlich ascites carcinoma (EAC) cells have been investigated. BHA, a widely used food antioxidant, administered to the cells prior to light exposure is found to cause concentration-dependent alterations of the haematoporphyrin derivative (HpD)-based PDT. BHA (0.15 mM) causes a small (about 10%) inhibition in the rate of HpD-photosensitized injury of EAC cells. In contrast, upon increasing the concentration of BHA from 0.15 to 0.5 mM, a 1.3-fold enhancement in HpD-PDT efficiency is achieved. The cytotoxic effect on the cells treated with HpD-PDT and a higher concentration of BHA (0.5 mM) is additive. When BHA (0.5 mM) is given immediately after HpD-PDT, the combination is found to be three to four times more effective than when BHA is added to EAC cells before phototherapy. In this treatment regimen BHA acts synergistically with HpD-PDT. Such a difference in the action of BHA on the efficiency of HpD-PDT might be explained by the ability of BHA to inhibit the HpD-photosensitized destruction of some biomolecules. An enhancing action of BHA on the intensity of HpD-photosensitized death of tumour cells is also observed in vivo. Even a single dose of BHA (0.6 mM kg-1, 15 min after irradiation) causes (in an additive manner) an approximately two-fold increase in the efficiency of HpD-PDT of mice bearing Ehrlich ascites tumour (intraperitoneal transplantation). The results obtained indicate that the potentiating effect of BHA on the HpD-PDT could be caused by the impairment of the mitochondrial respiration, since there is a good correspondence between the concentration of BHA that increases the efficiency of PDT and the concentration that inhibits the oxygen consumption and dehydrogenase activity of EAC cells. The influence of BHA on the efficiency of PDT does not depend on the nature of the photosensitizer used; the effects with chlorin-e6 trimethyl ester are similar to that seen for HpD.     

Photochemotherapy of experimental colonic tumours with intra-tumorally applied methylene blue

INTRODUCTION: Phototoxicity of intra-tumoral injected methylene blue (MB+) was studied in 48 experimental colonic tumours in comparison with photosan-3, Zn-phthalocyanine and tetrasulphanated ClAl-phthalocyanine. METHODS: In mice. xenotransplanted subcutaneous tumours about 1 cm in diameter were treated photodynamically twice, with different sensitisers. The irradiation was performed at the sensitiser-specific wavelength, and a density of 100 mW/cm2 and a dose of 100 J/cm2. RESULTS: Light alone without sensitiser did not induce any effect in mice tumours. Surprisingly, Al-phthalocyanine could only be used for intratumoral injections because of toxic effects after intravenous applications in nude mice. Using MB+ (1%), 75% of the tumours were destroyed by a single photodynamic treatment (PDT). In addition, toxicity of MB+ was most intense when compared with Zn-phthalocyanine and photosan-3. However, after the second PDT, there was no statistically significant difference among these sensitisers. Dark toxicity of MB+ (1%) could be well demonstrated by sufficient sensitiser incorporation without irradiation, which led to a stationary tumour volume up to 3 weeks after injection. CONCLUSION: Intra-tumoral MB+ PDT is a potential treatment for inducing necrosis in vivo. With regard to tumour tissue, the selectivity of MB+ is high and depends on a precise local injection of the dye.     

Sorbin in the porcine gastrointestinal tract and pancreas: an immunocytochemical analysis

Sorbin is a 153-amino acid peptide that was initially discovered in the porcine duodenum. We have reported previously that this peptide regulates intestinal electrolyte transport and have described accumulation sites in the rat digestive tract. In the present study, we investigated the anatomical distribution and the site(s) of sorbin production in the porcine digestive tract using immunocytochemistry. The use of polyclonal antisera, which by cross-reaction studies were shown to be specific for different regions of the molecule, revealed a diversified distribution. Sorbin predominated in endocrine cells preferentially localized in the pyloric glands, duodenal crypts of Lieberkühn, and pancreatic islets; in the gastrointestinal tract, sorbin coexisted with Met-enkephalin or with substance P in a small fraction of serotonin-storing [enterochromaffin (ED)] cells, i.e. EC2 cells and EC1 cells, respectively; in the pancreas, sorbin coexisted with insulin in the beta-cells, also considered as serotonin-storing cells in the pig, and with EC cells in the exocrine pancreas. An enteric neuronal system containing sorbin was also reported. Our results demonstrate that sorbin is a component of the serotonin-storing cell type in the porcine gastrointestinal tract and pancreas, and suggest potential directions to investigate the functions of this new regulatory peptide.     

Duodenal somatostatinomas associated with von Recklinghausen disease

A case of von Recklinghausen's disease with double somatostatin producing neuroendocrine tumour of the ampulla and duodenum is reported. A search of the world's literature revealed 28 patients with immunohistologically proven duodenal somatostatinoma associated with type I neurofibromatosis. These tumours are seldom associated with a recognizable "somatostatin syndrome", but often present with obstructive jaundice, duodenal obstruction, weight loss or gastrointestinal bleeding. Histologically, psammoma bodies are frequently encountered in the glandular lumina of duodenal somatostatinomas (66%), whereas their presence in other neuroendocrine tumours of the gastrointestinal tract is very rare. Metastatization is rare (27%) and mainly confined to lymph nodes (88%). In the world literature duodenal somatostatinoma is associated with von Recklinghausen's disease in 50%.     

The coexistence of 2 different neuroendocrine tumors of the upper gastrointestinal tract and pancreas

HISTORY AND CLINICAL FINDINGS: A 41-year-old obese patient presented with cramp-like abdominal pain, watery diarrhoea with partly digested food particles, projectile vomiting and newly diagnosed diabetes mellitus. For the preceding 6 years he had been treated for recurrent gastric and duodenal ulcers. Although the fasting gastrin level was raised and Zollinger-Ellison syndrome suspected, computed tomography (CT), magnetic resonance imaging (MRI) and coeliac angiography at another hospital had failed to discover a tumor. INVESTIGATIONS: Biochemical tests were unremarkable except for an increased GPT concentration, slight fasting hyperglycemia and hypertriglyceridemia. The gastrin and chromogranin A levels were markedly elevated (15,590 pg/ml and 584.2 U/l, respectively). Gastroscopy revealed, in addition to multiple small duodenal ulcers, a round polypoid mass (diameter of 0.7 cm) lateral to the papilla of Vater, histologically an APUDoma. Endoscopic retrograde cholangiopancreatography (ERCP) revealed a 0.5 cm long compression of the duct of Wirsung in the region of the head of the pancreas. Liver metastases were excluded by magnetic resonance imaging and computed tomography. Endosonography showed a ca. 4 mm space-occupying lesion in the region of the body of the pancreas. Octreotide scintigraphy demarcated two foci at the level of the head of the pancreas (somatostatin-receptor positive). TREATMENT AND COURSE: After a pylorus-preserving partial duodenopancreatectomy with lymph node dissection N1/N2, histology confirmed a gastrinoma of the duodenum and a glucagonoma of the pancreas (pT3pN1pMx). Postoperatively the patient became symptom-free and both the blood sugar level and the tumor marker were normal. CONCLUSION: Combined ERCP, endosonography and scintigraphy are more sensitive than other radiological examinations (CT and MRI) in diagnosing and localizing neuroendocrine tumours of the gastrointestinal tract. Despite the low incidence of such tumours, the possible synchronous occurrence of several such tumour should not be ignored.