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

The known optical properties (absorption, scattering, total attenuation, effective attenuation, and/or anisotropy coefficients) of various biological tissues at a variety of wavelengths are reviewed. The theoretical foundations for most experimental approaches are outlined. Relations between Kubelka-Munk parameters and transport coefficients are listed. The optical properties of aorta, liver, and muscle at 633 nm are discussed in detail. An extensive bibliography is provided. >

A review of the optical properties of biological tissues

The absorption, scattering, and anisotropy coefficients of the fat emulsion lntralipid-10% have been measured at 457.9, 514.5, 632.8, and 1064 nm. The size and shape distributions of the scattering particles in lntralipid-10% were determined by transmission electron microscopy. Mie theory calculations performed by using the particle size distribution yielded values for the scattering and anisotropy coefficients from 400 to 1100 nm. The agreement with experimental values is better than 6%.

Light scattering in Intralipid-10% in the wavelength range of 400-1100 nm.

Photodynamic therapy (PDT) is an innovative and attractive modality for the treatment of small and superficial tumours. PDT, as a multimodality treatment procedure, requires both a selective photosensitizer and a powerful light source which matches the absorption spectrum of the photosensitizer. Quadra Logic's Photofrin, a purified haematoporphyrin derivative, is so far the only sensitizer approved for phase III and IV clinical trials. The major drawbacks of this product are the lack of chemical homogeneity and stability, skin phototoxicity, unfavourable physicochemical properties and low selectivity with regard to uptake and retention by tumour vs. normal cells. Second-generation photosensitizers, including the phthalocyanines, show an increased photodynamic efficiency in the treatment of animal tumours and reduced phototoxic side effects. At the time of writing of this article, there were more than half a dozen new sensitizers in or about to start clinical trials. Most available data suggest a common mechanism of action. Following excitation of photosensitizers to long-lived excited singlet and/ or triplet states, the tumour is destroyed either by reactive singlet oxygen species (type II mechanism) and/or radical products (type I mechanism) generated in an energy transfer reaction. The major biological targets of the radicals produced and of singlet oxygen are well known today. Nucleic acids, enzymes and cellular membranes are rapidly attacked and cause the release of a wide variety of pathophysiologically highly reactive products, such as prostaglandins, thromboxanes and leukotrienes. Activation of the complement system and infiltration of immunologically active blood cells into the tumorous region enhance the damaging effect of these aggressive intermediates and ultimately initiate tumour necrosis. The purpose of this review article is to summarize the up-to-date knowledge on the mechanisms responsible for the induction of tumour necrotic reactions.

Photophysical and photobiological processes in the photodynamic therapy of tumours

Photodynamic therapy (PDT) uses light-activated drugs to treat diseases ranging from cancer to age-related macular degeneration and antibiotic-resistant infections. This paper reviews the current status of PDT with an emphasis on the contributions of physics, biophysics and technology, and the challenges remaining in the optimization and adoption of this treatment modality. A theme of the review is the complexity of PDT dosimetry due to the dynamic nature of the three essential components—light, photosensitizer and oxygen. Considerable progress has been made in understanding the problem and in developing instruments to measure all three, so that optimization of individual PDT treatments is becoming a feasible target. The final section of the review introduces some new frontiers of research including low dose rate (metronomic) PDT, two-photon PDT, activatable PDT molecular beacons and nanoparticle-based PDT.

https://iopscience.iop.org/article/10.1088/0031-9155/53/9/R01/pdf

The physics, biophysics and technology of photodynamic therapy

A simple multiple flux model, which is equivalent to the diffusion approximation, is derived from the equation of transfer in a plane as well as in a spherical geometry. The equations obtained are similar to those of the Kubelka-Munk and related heuristic models. This permits conclusions regarding the limitations of these models and the values of their constants. A simple calculation is also presented of the radiance as a function of direction in the diffusion domain. This, together with the effective attenuation coefficient, permits indirect experimental determination of both the albedo and the anisotropy factor (g) of the scattering function. Similarity relations are discussed, as they result from the so called delta-Eddington approximation, leading to the conclusion that far from boundaries and sources light propagation characteristics do not change very much when g and sigma s are varied, provided sigma s(1-g) is kept constant ( sigma s=scattering coefficient). Therefore, only two optical constants are required to approximately describe light propagation in homogeneous and isotropic media in the diffusion approximation.

https://iopscience.iop.org/article/10.1088/0031-9155/33/4/004/pdf

Light dosimetry in optical phantoms and in tissues: I. Multiple flux and transport theory

We have studied the influence of absorption, scattering, and refractive index of a phantom medium in conjunction with various beam diameters on the penetration depth of light at 633 nm. We used mixtures of Intralipid 10% (scattering medium) and Evans blue (absorbing medium). Measurements were performed in media with a scattering coefficient of 1 mm−1, an anisotropy factor of 0.71, absorption coefficients of 1.3 × 10−3, 0.01, and 0.05 mm−1, and a refractive index of 1.33. The experimental results were compared with an analytical solution of the fluence rate based on diffusion theory. We found good agreement (deviations of <10%) between theory and experiment for incident beam diameters between 10 and 60 mm.

Measurements and calculations of the energy fluence rate in a scattering and absorbing phantom at 633 nm

Knowledge of the radiant energy fluence rate in tissues during laser irradiation is important for the understanding and improvement of the results of preclinical as well as clinical treatments. Quantitative data are extremely rare, however. In this paper, quantitative measurements of energy fluence rates are reported, in vitro as well as in vivo, with emphasis on light dosimetry for photodynamic therapy. Examples are given of fluence rate distributions that may occur during surface irradiation, intracavity irradiation of hollow organs (bladder) and interstitial irradiation. For the same incident irradiance, the energy fluence rate in tissue may vary considerably, depending on type of tissue, wavelength and geometry. During experimental and clinical interstitial PDT-treatments a considerable decrease in light penetration into tumours was observed, apparently indicating changes in optical properties as a result of treatment. This demonstrates the importance of in vivo light dosimetry.

Quantitative light dosimetry in vitro and in vivo

Miniature light detectors with isotropic response (isotropic light dosimetry probes) permit quantitative measurement of light energy fluence rates in turbid media such as biological tissues. These isotropic probes are, for example, applied in photodynamic therapy to correlate light fluence in tissue with (tumour) tissue response, in vitro and in vivo. After description of its construction, two methods of calibration of an isotropic probe in air are discussed, in collimated and in diffuse light. The probe was first calibrated in air in collimated light, after which its response to diffuse light was checked in a flat and in a spherical geometry. Subsequently, the probe's response to collimated light in clear media, for example, water or glycerine which have refractive indices larger than that of air, has been established experimentally. The diffusion approximation to the transport equation in a simple spherical geometry has been used to calculate the probe's response as a function of the refractive index of clear media. The extent of agreement between theory and experiment indicates that the physical mechanisms are understood and indirectly validates the theoretical models.

https://iopscience.iop.org/article/10.1088/0031-9155/41/7/008/pdf

Calibration of isotropic light dosimetry probes based on scattering bulbs in clear media

Photodynamic therapy (PDT) using Photofrin IIR (PII) as a photosensitizer is currently being evaluated as a new treatment modality for superficial bladder cancer. An optimum therapeutic ratio requires uniform illumination of the whole bladder wall and accurate light dosimetry. The first clinical light dosimetry results (16 patients) are reported, obtained using a system which allows in situ measurement and control of the light fluence at the bladder wall. The true light fluence at the bladder wall (i.e. non-scattered incident light plus scattered light) appeared to be on the average a factor beta = 4.8 +/- 1.2 (mean +/- SD) larger than the non-scattered incident light fluence. The latter is often, but incorrectly, used in reporting light fluence. The factor beta varied between patients with extremes of 2.5 and 7.1. Because such large variations were unexpected, but may have significant clinical consequences, experiments in plastic bladder models were performed to study separately the various factors (e.g. bladder shape, air bubble) affecting the dosimetry in clinical treatments. The results imply that the clinical variations are most likely to be the result of variations in optical properties of the bladder wall mucosa, probably due to the disease and prior treatments. If light dosage is based on non-scattered light only (without in situ light dosimetry, according to a current clinical protocol) the present results indicate variations in the true (total) light fluence between patients by a factor of at least 2. At the least this may cause unnecessary discomfort to a number of patients.

Johannes P. A. Marijnissen

Papers

Light dosimetry in optical phantoms and in tissues: I. Multiple flux and transport theory

Measurements and calculations of the energy fluence rate in a scattering and absorbing phantom at 633 nm

Quantitative light dosimetry in vitro and in vivo

Calibration of isotropic light dosimetry probes based on scattering bulbs in clear media

In situ light dosimetry during whole bladder wall photodynamic therapy : clinical results and experimental verification