Gal Shafirstein

Optimal parameters for the treatment of leg veins using Nd:YAG lasers at 1064 nm

Background  The treatment of large vessels such as leg veins is successfully performed in clinical practice using pulsed Nd:YAG lasers. However, it is still unclear how laser parameters such as wavelength, fluence and pulse duration influence vessel destruction in leg veins.

Indocyanine green enhanced near-infrared laser treatment of murine mammary carcinoma.

It is well accepted that near‐infrared (NIR) lasers are appropriate to ablate benign lesions and induce irreversible thermal injury in deeply seated blood vessels. At this wavelength, the laser light penetrates deep (3–5 mm) into the skin. However, many researchers have reported noticeable pain, extending from mild to severe, during and immediately after NIR laser treatment. Intravenous administration of an exogenous chromophore [indocyanine green (ICG), dye] can effectively convert NIR laser light into heat. In this approach, the presence of ICG has shown to enhance thermal injury of blood vessels in the treatment of healthy tissues. However, the effectiveness of thermal injury on the regression of cutaneous carcinomas during ICG/NIR laser therapy has not been assessed. The purpose of our study was to evaluate the potential benefit of using ICG/NIR laser therapy to regress superficial carcinoma with thermal injury. Two groups of A/J mice with subcutaneous mammary adenocarcinoma tumors (7–9 mm) were irradiated with a 808‐nm NIR laser preceded by tail vein injection of ICG dye or sterile saline. Histological evaluation of the subcutaneous tissue revealed minor thermal damage and necrosis in the laser/saline group and substantial damage (up to 100% necrosis) in the laser/ICG group. The laser/ICG‐treated group showed a steady reduction in tumor volume compared to the laser/saline group: 48% by day 5 (p = 0.045) and 69–70% by days 8, 9 and 10 (p values 0.0005 or less). The vascular‐targeted ICG–NIR laser therapy appears to have potential for treating superficial tumors.

Photodynamic Therapy with 3-(1′-Hexyloxyethyl) Pyropheophorbide a for Cancer of the Oral Cavity

Purpose: The primary objective was to evaluate safety of 3-(1′-hexyloxyethyl)pyropheophorbide-a (HPPH) photodynamic therapy (HPPH-PDT) for dysplasia and early squamous cell carcinoma of the head and neck (HNSCC). Secondary objectives were the assessment of treatment response and reporters for an effective PDT reaction. Experimental Design: Patients with histologically proven oral dysplasia, carcinoma in situ, or early-stage HNSCC were enrolled in two sequentially conducted dose escalation studies with an expanded cohort at the highest dose level. These studies used an HPPH dose of 4 mg/m2 and light doses from 50 to 140 J/cm2. Pathologic tumor responses were assessed at 3 months. Clinical follow up range was 5 to 40 months. PDT induced cross-linking of STAT3 were assessed as potential indicators of PDT effective reaction. Results: Forty patients received HPPH-PDT. Common adverse events were pain and treatment site edema. Biopsy proven complete response rates were 46% for dysplasia and carcinoma in situ and 82% for squamous cell carcinomas (SCC) lesions at 140 J/cm2. The responses in the carcinoma in situ/dysplasia cohort are not durable. The PDT-induced STAT3 cross-links is significantly higher (P = 0.0033) in SCC than in carcinoma in situ/dysplasia for all light doses. Conclusion: HPPH-PDT is safe for the treatment of carcinoma in situ/dysplasia and early-stage cancer of the oral cavity. Early-stage oral HNSCC seems to respond better to HPPH-PDT in comparison with premalignant lesions. The degree of STAT3 cross-linking is a significant reporter to evaluate HPPH-PDT–mediated photoreaction. Clin Cancer Res; 19(23); 6605–13. ©2013 AACR.

Adjuvant Intraoperative Photodynamic Therapy in Head and Neck Cancer

IMPORTANCE There is an immediate need to develop local intraoperative adjuvant treatment strategies to improve outcomes in patients with cancer who undergo head and neck surgery. OBJECTIVES To determine the safety of photodynamic therapy with 2-(1-hexyloxyethyl)-2-devinyl pyropheophorbide-a (HPPH) in combination with surgery in patients with head and neck squamous cell carcinoma. DESIGN, SETTING, AND PARTICIPANTS Nonrandomized, single-arm, single-site, phase 1 study at a comprehensive cancer center among 16 adult patients (median age, 65 years) with biopsy-proved primary or recurrent resectable head and neck squamous cell carcinoma. INTERVENTIONS Intravenous injection of HPPH (4.0 mg/m2), followed by activation with 665-nm laser light in the surgical bed immediately after tumor resection. MAIN OUTCOMES AND MEASURES Adverse events and highest laser light dose. RESULTS Fifteen patients received the full course of treatment, and 1 patient received HPPH without intraoperative laser light because of an unrelated myocardial infarction. Disease sites included larynx (7 patients), oral cavity (6 patients), skin (1 patient), ear canal (1 patient), and oropharynx (1 patient, who received HPPH only). The most frequent adverse events related to photodynamic therapy were mild to moderate edema (9 patients) and pain (3 patients). One patient developed a grade 3 fistula after salvage laryngectomy, and another patient developed a grade 3 wound infection and mandibular fracture. Phototoxicity reactions included 1 moderate photophobia and 2 mild to moderate skin burns (2 due to operating room spotlights and 1 due to the pulse oximeter). The highest laser light dose was 75 J/cm2. CONCLUSIONS AND RELEVANCE The adjuvant use of HPPH-photodynamic therapy and surgery for head and neck squamous cell carcinoma seems safe and deserves further study. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT00470496.

Automatic delineation of malignancy in histopathological head and neck slides

BackgroundHistopathology, which is one of the most important routines of all laboratory procedures used in pathology, is decisive for the diagnosis of cancer. Experienced histopathologists review the histological slides acquired from biopsy specimen in order to outline malignant areas. Recently, improvements in imaging technologies in terms of histological image analysis led to the discovery of virtual histological slides. In this technique, a computerized microscope scans a glass slide and generates virtual slides at a resolution of 0.25 μm/pixel. As the recognition of intrinsic cancer areas is time consuming and error prone, in this study we develop a novel method to tackle automatic squamous cell carcinoma of the head and neck detection problem in high-resolution, wholly-scanned histopathological slides.ResultsA density-based clustering algorithm improved for this study plays a key role in the determination of the corrupted cell nuclei. Using the Support Vector Machines (SVMs) Classifier, experimental results on seven head and neck slides show that the proposed algorithm performs well, obtaining an average of 96% classification accuracy.ConclusionRecent advances in imaging technology enable us to investigate cancer tissue at cellular level. In this study we focus on wholly-scanned histopathological slides of head and neck tissues. In the context of computer-aided diagnosis, delineation of malignant regions is achieved using a powerful classification algorithm, which heavily depends on the features extracted by aid of a newly proposed cell nuclei clustering technique. The preliminary experimental results demonstrate a high accuracy of the proposed method.

Modelling millimetre wave propagation and absorption in a high resolution skin model: the effect of sweat glands

The aim of this work was to investigate the potential effect of sweat gland ducts (SGD) on specific absorption rate (SAR) and temperature distributions during mm-wave irradiation. High resolution electromagnetic and bio-heat transfer models of human skin with SGD were developed using a commercially available simulation software package (SEMCAD X™). The skin model consisted of a 30 µm stratum corneum, 350 µm epidermis and papillary dermis (EPD) and 1000 µm dermis. Five SGD of 60 µm radius and 300 µm height were embedded linearly with 370 µm separation. A WR-10 waveguide positioned 20 µm from the skin surface and delivering 94 GHz electromagnetic radiation was included in the model. Saline conductivity was assigned inside SGD. SAR and temperatures were computed with and without SGD. Despite their small scale, SAR was significantly higher within SGD than in the EPD without SGD. Without SGD, SAR and temperature maxima were in the dermis near EPD. With SGD, SAR maximum was inside SGD while temperature maximum moved to the EPD/stratum-corneum junction. Since the EPD participates actively in perception, the effect of SGD should be taken into account in nociceptive studies involving mm-waves. This research represents a significant step towards higher spatial resolution numerical modelling of the skin and shows that microstructures can play a significant role in mm-wave absorption and induced temperature distributions.

Using 5-Aminolevulinic Acid and Pulsed Dye Laser for Photodynamic Treatment of Oral Leukoplakia

OBJECTIVE To determine the safety and efficacy of photodynamic therapy in the treatment of oral leukoplakia with 5-aminolevulinic acid and pulsed dye laser. DESIGN Nonrandomized, single-arm, single-site phase 1/2 pilot study. SETTING Academic referral center. PATIENTS A total of 23 patients, aged 37 to 79 years, having a confirmed diagnosis of leukoplakia with or without dysplasia measuring at least 10 mm in diameter. INTERVENTIONS Application of 5-aminolevulinic acid to lesions followed by activation with high-power 585-nm pulsed dye laser. MAIN OUTCOME MEASURES Maximum tolerated dose of laser, postprocedure complications, objective response to treatment, and immunohistochemical changes in treated tissue. RESULTS No significant adverse events occurred; minor local adverse effects were observed during and following photodynamic therapy in the safety phase of the study. The maximum tolerated dose was 8 J/cm(2). Of 17 patients, 7 (41%) had more than 75% regression (significant response) and 9 (53%) had more than 25% regression (partial response), for an overall response rate of 94% at 90 days. This response rate was far higher than the null-hypothesis 20% rate (P < 10(-10)) and the alternative-hypothesis 50% rate (P = .0001) for which the study was powered. When compared with baseline levels immunohistochemically, p53 expression was increased in 8 of 11 available samples (73%) and Ki-67 expression was decreased in 7 of 12 available samples (58%). CONCLUSIONS Photodynamic therapy with 5-aminolevulinic acid and pulsed dye laser could be used to achieve regression of oral leukoplakia. The treatment is safe and well tolerated. An application time of 1.5 hours and laser radiant exposure of 8 J/cm(2) with 1.5-ms pulse time were found to be the optimal settings in this study. The high-power laser used in this study allows completion of laser therapy within 1 to 3 minutes. Further studies are necessary to determine the optimal laser radiant exposure and drug application to maximize the response rate.

Conductive interstitial thermal therapy device for surgical margin ablation: In vivo verification of a theoretical model

Purpose: To demonstrate the efficacy and predictability of a new conductive interstitial thermal therapy (CITT) device to ablate surgical margins. Method: The temperature distributions during thermal ablation of CITT were calculated with finite element modelling in a geometrical representation of perfused tissue. The depth of ablation was derived using the Arrhenius and the Sapareto and Dewey (S&D) models for the temperature range of 90 to 150°C. The female pig animal model was used to test the validity of the mathematical model. Breast tissues were ablated to temperatures in the range of 79–170°C, in vivo. Triphenyltetrazolium chloride viability stain was used to delineate viable tissue from ablated regions and the ablation depths were measured using digital imaging. Results: The calculations suggest that the CITT can be used to ablate perfused tissues to a 10–15 mm width within 20 minutes. The measured and calculated depths of ablation were statistically equivalent (99% confidence intervals) within ± 1mm at 170°C. At lower temperatures the equivalence between the model and the observations was within ± 2 mm. Conclusion: The CITT device can reliably and uniformly ablate a 10–15 mm wide region of soft tissue. Thus, it can be used to secure negative margins following the resection of a primary tumor, which could impede local recurrences in the treatment of local diseases such as early staged, non-metastatic, breast cancer.

Dead or alive? Autofluorescence distinguishes heat-fixed from viable cells

Purpose: A proof-of-concept study to evaluate a new autofluorescence method to differentiate necrotic thermally fixed cells from viable tissue following thermal ablation. Methods: A conductive interstitial thermal therapy (CITT) device was used to ablate swine mammary tissue and rabbit VX-2 carcinomas in vivo. The ablated regions and 10-mm margins were resected 24 h following treatment, embedded in HistOmer® and sectioned at 3 mm. The fresh sections were evaluated for gross viability with triphenyl tetrazolium chloride, 1 h post-resection. Representative non-viable and viable areas were then processed and embedded into paraffin, and sectioned at 5 µm. Standard H&E staining and proliferating cell nuclear antigen (PCNA) immunohistochemistry were compared against autofluorescence intensity, at 488-nm wavelength, for cellular viability. Results: Heat-fixed cells in non-viable regions exhibit increased autofluorescence intensity compared to viable tissue (area under receiver operating characteristics (ROC) curve = 0.96; Mann-Whitney P < 0.0001). An autofluorescence intensity-based classification rule achieved 92% sensitivity with 100% specificity for distinguishing non-viable from viable samples. In contrast, PCNA staining did not reliably distinguish heat-fixed, dead cells from viable cells. Conclusions: Examination of H&E-stained sections using autofluorescence intensity-based classification is a reliable and readily available method to accurately identify heat-fixed cells in ablated surgical margins.

Interstitial Photodynamic Therapy-A Focused Review.

Multiple clinical studies have shown that interstitial photodynamic therapy (I-PDT) is a promising modality in the treatment of locally-advanced cancerous tumors. However, the utilization of I-PDT has been limited to several centers. The objective of this focused review is to highlight the different approaches employed to administer I-PDT with photosensitizers that are either approved or in clinical studies for the treatment of prostate cancer, pancreatic cancer, head and neck cancer, and brain cancer. Our review suggests that I-PDT is a promising treatment in patients with large-volume or thick tumors. Image-based treatment planning and real-time dosimetry are required to optimize and further advance the utilization of I-PDT. In addition, pre- and post-imaging using computed tomography (CT) with contrast may be utilized to assess the response.