Herbert Stepp

Study of Protoporphyrin IX (PpIX) Pharmacokinetics After Topical Application of 5-Aminolevulinic Acid in Urethral Condylomata Acuminata†

The pharmacokinetics of 5‐aminolevulinic acid (ALA)‐induced protoporphyrin IX (PpIX) in lesions of urethral condylomata acuminata were investigated. Sixty patients (20 to 60 years old, 48 male and 12 female) were divided randomly into five groups and received topic application of different concentrations of ALA solution (0.5%, 1%, 3%, 5% or 10%). Biopsy was performed between 1 and 7u2003h and specimens were subjected to histological, PpIX fluorescence and human papillomavirus (HPV) DNA typing analyses. Fluorescence examination confirmed that ALA‐induced PpIX fluorescence was dominantly distributed in the HPV‐infected epidermis. In contrast, only a minimal amount of PpIX fluorescence was detected in the dermis. The maximal fluorescence intensity was detected at 5u2003h incubation. Higher ALA concentration (e.g. 5% and 10%) produced a stronger intensity. These results suggest that the topical application of 5–10% ALA solution for 3–5u2003h is the optimal condition for the photodynamic therapy of urethral condylomata acuminata. The selective damage of the condylomata acuminata lesions in the epidermis without damaging the dermis ensures a better control of recurrence and side effects such as ulceration or scarring. DNA typing showed that all patients were positive for low risk‐HPV DNA and among them 18.3% of patients harbored high risk‐HPV DNA.

In-vivo kinetics of inhaled 5-Aminolevulinic acid-Induced Protoporphyrin IX fluorescence in bronchial tissue

BackgroundIn the diagnosis of early-stage lung cancer photosensitizer-enhanced fluorescence bronchoscopy with inhaled 5-aminolevolinic acid (5-ALA) increases sensitivity when compared to white-light bronchoscopy. This investigation was to evaluate the in vivo tissue pharmacokinetics of inhaled 5-ALA within the bronchial mucosa in order to define the time optimum for its application prior to bronchoscopy.MethodsPatients with known or suspected bronchial carcinoma were randomized to receive 200 mg 5-ALA via inhalation 1, 2, 3, 4 or 6 hours before flexible fluorescence bronchoscopy was performed. Macroscopically suspicious areas as well as areas with visually detected porphyrin fluorescence and normal control sites were measured spectroscopically. Biopsies for histopathology were obtained from suspicious areas as well as from adjacent normal areas.ResultsFluorescence bronchoscopy performed in 19 patients reveals a sensitivity for malignant and premalignant changes (moderate dysplasia) which is almost twice as high as that of white-light bronchoscopy, whereas specificity is reduced. This is due to false-positive inflammatory lesions which also frequently show increased porphyrin fluorescence. Malignant and premalignant alterations produced fluorescence values that are up to 5 times higher than those of normal tissue. According to the pharmacokinetics of porphyrin fluorescence measured by spectroscopy, the optimum time range for 5-ALA application is 80–270 min prior to fluorescence bronchoscopy, with an optimum at 160 min.ConclusionAccording to our results we propose inhalation of 5-ALA 160 min prior to fluorescence bronchoscopy, suggesting that this time difference provides the best tumor/normal tissue fluorescence ratio.

Lymph node metastasis detection of ovarian cancer by porphyrin fluorescence photodetection: case report.

The concept of intraoperative in vivo diagnosis and selective resection of infiltrated lymph nodes in ovarian cancer has not been evaluated despite the increased morbidity associated with pelvic and paraaortic lymph node dissection and its questionable therapeutic value. Fluorescence photodetection is based on the application of a photosensitizer relatively selective for malignant tissue, which after light activation of appropriate wavelength, shows fluorescence. Six hours after oral application of 10xa0mg/kg body weight 5-aminolevulinic acid, the abdominal cavity of a patient with suspicion of recurrent ovarian cancer was inspected using a laparoscope and blue light at 380–440xa0nm. Spectral measurements at a wavelength of 635xa0nm, multiple peritoneal biopsies, and lymph node excisions were performed. White light inspection and porphyrin fluorescence photodetection revealed no intraperitoneal metastases and multiple biopsies were negative. Fluorescence-positive lymph nodes were visible only in the left common iliac region and a specific porphyrin fluorescence peak could be detected. In contrary, no increased porphyrin fluorescence of intraperitoneal tissues or skin was seen. Fluorescence microscopy showed the characteristic red fluorescence in the infiltrated parts of the lymph node tissue by the papillary ovarian cancer. Histology of the other sites was negative. No systemic or cutaneous side effects were recorded. This data is a proof of the concept that porphyrin fluorescence-guided lymph node metastasis detection is possible in ovarian cancer and should stimulate further research in this field.

[Fluorescence cystoscopy at bladder cancer: present trials].

ZusammenfassungDas Harnblasenkarzinom ist neben dem Prostatakarzinom die zweithäufigste urologische Tumorerkrankung. Obwohl viele Diagnose- und Behandlungspfade des nicht muskelinfiltrierenden Harnblasenkarzinoms mittlerweile etabliert sind, gibt es doch verschiedene Ansätze um das Management dieser Patienten zu optimieren. Kernstück ist eine frühzeitige multimodale Diagnose- und Therapieplanung, um in vielen Fällen einen Erhalt der Harnblase zu gewährleisten und die Lebensqualität und Morbidität der Patienten zu verbessern.Die Fluoreszenzzystoskopie oder photodynamische Diagnostik (PDD) mit der intravesikalen Applikation von photoaktiven Substanzen stellet einen Eckpfeiler in neune Diagnosekonzepten dar. Seit März 2007 ist als photoaktive Substanz der Hexyl-ALA-Ester (Hexvix®) in 27 Europäischen Ländern zugelassen. Hiermit konnte insbesondere die Rate an zusätzlich diagnostizierten flachen High-grade-Tumoren erhöht werden. Darüber hinaus hat sich gezeigt, dass durch den Einsatz der PDD die Residualtumorrate im Rahmen der TUR-B gesenkt werden kann. Eine daraus resultierende Reduktion der Rezidivraten muss in derzeit noch laufenden prospektiv randomisierten Studien noch bestätigt werden.AbstractBladder cancer is a frequent disease and represents the second most common genitourinary neoplasm. Although many aspects of the management of not-muscle-infiltrating bladder cancer are now well established, significant challenges remain, which influence patient outcome. Early detection and treatment of recurrent disease is required to optimize bladder preservation, reduce patient morbidity and increase quality of life and survival.Fluorescence cystoscopy, often referred to as “photodynamic diagnosis” (PDD) with intravesical application of photosensitizing agents has been developed in order to enhance the early detection of bladder cancer. Since March 2005 the hexyl-ALA ester (Hexvix®) has been approved for the diagnosis of bladder cancer in 27 EU/EEA countries through the European Mutual Recognition Procedure. There is growing evidence that PDD enhances the detection of bladder cancer, particularly of high-grade flat lesions. Furthermore, transurethral resection of bladder tumor under fluorescence guidance has been shown to reduce the risk of recurrent tumors. Nevertheless, a resulting relatively decreased number of recurrences have still to be verified in prospective randomized trials.

Detection of bone marrow-derived cells expressing a neural phenotype in the human brain.

Animal studies suggest that adult bone marrow cells have the potential to migrate into the brain and generate new neural cells. Because data on this physiologic repair mechanism in humans are lacking, we investigated bone marrow engraftment into the brain of bone marrow recipients after sex-mismatched transplantation. Brain sections of seven allogeneic female bone marrow recipients were examined. The Y-chromosome, which served as a natural marker of donor bone marrow-derived cells after male-to-female transplantation, was identified by in situ hybridization. The neural phenotype of Y-chromosome-positive cells was determined using neural nuclear protein (NeuN) immunohistochemistry. Y-chromosome-positive cells expressing NeuN were found within the first 3 months after transplantation in both the cerebrum and the cerebellum at a frequency of 0.003% to 0.013% of all neurons. These cells were observed only in patients with cerebral lymphocytic infiltration and graft-versus-host disease. Our data suggest that adult bone marrow cells are capable of generating cells that express the neural marker NeuN early after transplantation. Cells with this specific phenotype may contribute to tissue repair in brain regions remote from neurogenic zones.

Die Fluoreszenzzystoskopie beim Harnblasenkarzinom

ZusammenfassungDas Harnblasenkarzinom ist neben dem Prostatakarzinom die zweithäufigste urologische Tumorerkrankung. Obwohl viele Diagnose- und Behandlungspfade des nicht muskelinfiltrierenden Harnblasenkarzinoms mittlerweile etabliert sind, gibt es doch verschiedene Ansätze um das Management dieser Patienten zu optimieren. Kernstück ist eine frühzeitige multimodale Diagnose- und Therapieplanung, um in vielen Fällen einen Erhalt der Harnblase zu gewährleisten und die Lebensqualität und Morbidität der Patienten zu verbessern.Die Fluoreszenzzystoskopie oder photodynamische Diagnostik (PDD) mit der intravesikalen Applikation von photoaktiven Substanzen stellet einen Eckpfeiler in neune Diagnosekonzepten dar. Seit März 2007 ist als photoaktive Substanz der Hexyl-ALA-Ester (Hexvix®) in 27 Europäischen Ländern zugelassen. Hiermit konnte insbesondere die Rate an zusätzlich diagnostizierten flachen High-grade-Tumoren erhöht werden. Darüber hinaus hat sich gezeigt, dass durch den Einsatz der PDD die Residualtumorrate im Rahmen der TUR-B gesenkt werden kann. Eine daraus resultierende Reduktion der Rezidivraten muss in derzeit noch laufenden prospektiv randomisierten Studien noch bestätigt werden.AbstractBladder cancer is a frequent disease and represents the second most common genitourinary neoplasm. Although many aspects of the management of not-muscle-infiltrating bladder cancer are now well established, significant challenges remain, which influence patient outcome. Early detection and treatment of recurrent disease is required to optimize bladder preservation, reduce patient morbidity and increase quality of life and survival.Fluorescence cystoscopy, often referred to as “photodynamic diagnosis” (PDD) with intravesical application of photosensitizing agents has been developed in order to enhance the early detection of bladder cancer. Since March 2005 the hexyl-ALA ester (Hexvix®) has been approved for the diagnosis of bladder cancer in 27 EU/EEA countries through the European Mutual Recognition Procedure. There is growing evidence that PDD enhances the detection of bladder cancer, particularly of high-grade flat lesions. Furthermore, transurethral resection of bladder tumor under fluorescence guidance has been shown to reduce the risk of recurrent tumors. Nevertheless, a resulting relatively decreased number of recurrences have still to be verified in prospective randomized trials.

Fluorescence cytology. Improvement of urinary cytology

ZusammenfassungDas Urothelkarzinom der Harnblase ist eine häufige Erkrankung, und in der Routinediagnostik wird regelmäßig die Urinzytologie angewendet. Dieses Verfahren weist jedoch bei hochdifferenzierten Tumoren nur eine geringe Sensitivität auf, und es ist als subjektives Verfahren sehr stark von der Erfahrung des Untersuchers abhängig. Wir stellen hier die Fluoreszenzzytologie als Weiterentwicklung der Urinzytologie vor, die das Potential hat, als automatisiertes Verfahren auf der Basis der 5-ALA-induzierten photodynamischen Diagnostik (PDD) diese Nachteile der Standardzytologie auszugleichen.AbstractUrothelial cancer of the bladder is a frequent disease, and urinary cytology often is used as a routine diagnostic tool. But this technique has an impaired sensitivity in low-grade tumours, and as a subjective method it is highly dependent on the experience of the cytologist. Here we present the technique of fluorescence cytology as an improvement of conventional cytology. This method is potentially able to compensate for the disadvantages of urinary cytology as it is an automated process that uses the principles of 5-Ala-induced photodynamic diagnosis (PDD).

Die Fluoreszenzzystoskopie beim Harnblasenkarzinom@@@Fluorescence cystoscopy at bladder cancer: Aktueller Stellenwert@@@Present trials

ZusammenfassungDas Harnblasenkarzinom ist neben dem Prostatakarzinom die zweithäufigste urologische Tumorerkrankung. Obwohl viele Diagnose- und Behandlungspfade des nicht muskelinfiltrierenden Harnblasenkarzinoms mittlerweile etabliert sind, gibt es doch verschiedene Ansätze um das Management dieser Patienten zu optimieren. Kernstück ist eine frühzeitige multimodale Diagnose- und Therapieplanung, um in vielen Fällen einen Erhalt der Harnblase zu gewährleisten und die Lebensqualität und Morbidität der Patienten zu verbessern.Die Fluoreszenzzystoskopie oder photodynamische Diagnostik (PDD) mit der intravesikalen Applikation von photoaktiven Substanzen stellet einen Eckpfeiler in neune Diagnosekonzepten dar. Seit März 2007 ist als photoaktive Substanz der Hexyl-ALA-Ester (Hexvix®) in 27 Europäischen Ländern zugelassen. Hiermit konnte insbesondere die Rate an zusätzlich diagnostizierten flachen High-grade-Tumoren erhöht werden. Darüber hinaus hat sich gezeigt, dass durch den Einsatz der PDD die Residualtumorrate im Rahmen der TUR-B gesenkt werden kann. Eine daraus resultierende Reduktion der Rezidivraten muss in derzeit noch laufenden prospektiv randomisierten Studien noch bestätigt werden.AbstractBladder cancer is a frequent disease and represents the second most common genitourinary neoplasm. Although many aspects of the management of not-muscle-infiltrating bladder cancer are now well established, significant challenges remain, which influence patient outcome. Early detection and treatment of recurrent disease is required to optimize bladder preservation, reduce patient morbidity and increase quality of life and survival.Fluorescence cystoscopy, often referred to as “photodynamic diagnosis” (PDD) with intravesical application of photosensitizing agents has been developed in order to enhance the early detection of bladder cancer. Since March 2005 the hexyl-ALA ester (Hexvix®) has been approved for the diagnosis of bladder cancer in 27 EU/EEA countries through the European Mutual Recognition Procedure. There is growing evidence that PDD enhances the detection of bladder cancer, particularly of high-grade flat lesions. Furthermore, transurethral resection of bladder tumor under fluorescence guidance has been shown to reduce the risk of recurrent tumors. Nevertheless, a resulting relatively decreased number of recurrences have still to be verified in prospective randomized trials.

Clinical pharmacokinetics of protoporphyrin IX (PpIX) in condylomata acuminata patients: ex vivo fluorescence examination

Objectives: To investigate the pharmacokinetics of ALA induced protoporphyrin IX (PpIX) in lesions of urethral condylomata acuminata. Methods: Sixty patients (20 - 60 years old, 48 male and 12 female) with urethral condylomata acuminata were divided randomly into 5 groups to receive different concentrations of ALA solution (0.5, 1, 3, 5 or 10%). The ALA solution was applied topically to the lesion for a different length of time (1, 3, 5 or 7 h). Biopsy was performed at the end of incubation and specimens were subjected to histological and PpIX fluorescence analyses. Results: ALA-induced PpIX fluorescence was dominantly distributed in the epidermis. The maximal fluorescence intensity was detected at the 5 h of incubation. Higher ALA concentration (e.g. 5 and 10%) produced stronger intensity. In contrast, only the minimal amount of PpIX fluorescence was detected in the dermis. Conclusions: The results suggest that the topical application of 5 - 10% ALA solution for 3-5 h are the optimal conditions for ALA/PpIX-mediated photodynamic therapy for the treatment of urethral condylomata acuminata.