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The role of immune cells in photodynamic therapy Krosl, Gorazd 1996

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THE ROLE OF IMMUNE CELLS IN PHOTODYNAMIC THERAPY by Gorazd Krosl B.Sc. University of Ljublana, Slovenia, 1981 A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF DOCTOR OF PHILOSOPHY in THE FACULTY OF GRADUATE STUDIES Department of Pathology We accept this thesis as conforming to the required standard  THE UNIVERSITY OF BRITISH COLUMBIA September, 1996 ©Gorazd Krosl, 1996  In  presenting this  degree at the  thesis  in  partial  fulfilment of  University of British Columbia,  the  requirements for an advanced  I agree that the Library shall make it  freely available for reference and study. I further agree that permission for extensive copying of  this thesis for scholarly purposes may be granted by the head of my  department  or  by  his  or  her  representatives.  It  js .understood  that  copying  or  publication of this thesis for financial gain shall not be allowed without my written permission.  HQbQc^y  Department of  The University of British Columbia Vancouver, Canada Date  DE-6 (2788)  Oove-oq  Wi  ie  ,  )  t c  t t6 c  ABSTRACT The mechanisms of tumor destruction by photodynamic therapy (PDT) have proven to be very complex. The evidence from published work suggests that host factors may have an important role in both the uptake of photosensitizers and the effect of PDT.  Focusing on clinically established photosensitizer  Photofrin®, the role of tumor associated macrophages (TAMs) in accumulation of the drug using an experimental murine tumor mode! was examined in this thesis. To provide additional information about the inflammation processes that develop in the tumor after PDT treatment, the host cell infiltration into the treated tumor during and after the photodynamic light delivery was also investigated. The hypothesis that enhancing the host immune response can increase the curative potential of PDT was tested with two PDT-immunotherapy protocols. Photosensitizer accumulation in tumors is an important factor in the destruction of malignant lesions by PDT.  The role of tumor associated  macrophages in the accumulation of Photofrin in mouse SCCVII squamous cell carcinoma was studied by two different approaches. First,  in vitro  uptake and  retention of Photofrin in mouse peritoneal macrophages were compared to that in SCCVII cells. Second, the accumulation of Photofrin in SCCVII tumor cells and tumor associated macrophages analysis.  in vivo  was studied using flow cytometry  In all experiments, it was found that macrophages have a superior  capacity for Photofrin uptake in comparison to that observed in SCCVII tumor cells. The  in vivo  accumulation of Photofrin showed consistently higher levels  of the drug in TAMs compared to S C C V I I malignant cells throughout the observation period (up to 96 hours past Photofrin administration). At 24 hours after Photofrin administration, the drug content was 74±15 (SD) ng/ixg cell protein for TAMs compared to 15+2 ng/|ig cell protein for SCCVII tumor cells. In  Ill  addition, factors that modify macrophage phagocytic activity also influenced the ability of these cells to accumulate Photofrin. The infiltration of inflammatory cells is a central event in an acute inflammatory reaction. The major cellular populations contained in SGCVII tumors were analyzed at various time points after PDT. The cell populations were identified by staining with monoclonal antibodies against leukocyte membrane markers using indirect immunoperoxidase technique or by flow cytometry.  Photofrin-based PDT induced profound changes in the levels of  different cell populations comprising the treated tumor. The most immediate change was a dramatic increase in the content of neutrophils, which occurred within 5 min. after the onset of light treatment. This was followed by an increase in mast cell.numbers, while monocyte/macrophage infiltration followed between 0 and 2 h after PDT. The examination of  in vitro  cytotoxicity of macrophages  against S C C V I I tumor cells revealed a pronounced increase in cytolysis mediated by TAMs harvested from the tumor at 2 h after PDT compared to that seen with the TAMs recovered from an untreated tumor.  Such increased  cytotoxicity of TAMs suggests that PDT induces an acute inflammatory infiltration of myeloid cells into the treated tumor, that is associated with functional activation of immune cells. This inflammatory reaction may provide an appropriate environment for activation of immune cells, and therapy with immunostimulators may effectively enhance its contribution to tumor destruction by, PDT.  Two different PDT-immunotherapy protocols were tested for their  ability to improve the curative potential of PDT. In the first case, treatment of SCCVII tumor bearing mice with glucan SPG which raised the relative content of Mac-1 positive cells infiltrating the tumor was examined. The tumor cure rate following Photofrin-based PDT (25 mg/kg Photofrin; 60J/cm light) increased 2  approximately 3 times if PDT was preceded by the SPG therapy.  In vitro  colony  iv formation assay revealed a greater killing of tumor cells in groups pre-treated with SPG, and this enhancement was particularly pronounced when the tumor excision was delayed to 8 h after PDT. In another part of the study, the S C C V I I tumor cells were genetically engineered to produce the cytokine granulocyte-macrophage colonystimulating factor. (GM-CSF). 1x10 lethally irradiated GM-CSF producing cells 7  were injected under the parental SCCVII tumor, followed by PDT (25 mg/kg Photofrin; 60 J/cm  2  light) 48 h later.  This therapy resulted in a dramatic  increase in tumor cures (62% cure compared to 0% for PDT alone).  Similarly,  the POT with 10 mg/kg Photofrin and 150 J/cm light (that resulted in 6% tumor 2  cure) was enhanced to 75% cure by the GM-CSF immunotherapy administered 3 times in 2 day intervals starting at 2 days before the light treatment.  A  comparable effect of GM-CSF immunotherapy was observed in the combination with benzoporphyrin derivative mediated PDT. The immunotherapy alone did not have a visible effect on tumor growth, and did not significantly affect peripheral white blood cell counts.  However, a marked increase in TAM  cytotoxicity against syngeneic tumor cells was detected.  V  TABLE OF CONTENTS ABSTRACT....... TABLE  ...............  ..II  O F CONTENTS  V  LIST O F T A B L E S  .....VIII  LIST O F FIGURES  —IX  ABBREVIATIONS...............  ......X  LIST O F PUBLICATIONS...........  ...XIII  ACKNOWLEDGMENTS CHAPTER  1.  .....XIV  INTRODUCTION.............  1  1.1  Overview and thesis outline  .".  ...1  1.2  Historical perspective.....  3  1.3  PDT in clinical trials  4  1.4  Tumor localization of photosensitizers  ...8  1.5 Mechanism of action 1.5.1 Photosensitization 1.5.2 Cellular effects 1.5.3 The effect of PDT on tumor 1.5.4 PDT triggered inflammatory response 1.5.5. PDT and immunotherapy 1.6  Specific aims of the thesis  ;  10 10 12 ........14 17 20 ;  21  CHAPTER 2. THE ROLE OF TUMOR INFILTRATING M A C R O P H A G E S IN PHOTOFRIN ACCUMULATION IN THE TUMORS... 2.1  Summary  2.2  Introduction  23 .23  ,-.  24  2.3 Materials and methods -.25 2.3.1 Murine tumor model ....25 2.3.2 Measurement of Photofrin uptake 26 2.3.2.1 Harvesting macrophages and Photofrin exposure in vitro 26 2.3.2.2 Effect of plasma proteins on Photofrin . accumulation and retention 27  2.3.2.3 2.3.2.4 2.3.2.5  Fluorescence analysis of tumor cells... Photofrin measurement from cell extracts Determination of Photofrin content by radiolabeled drug...... : 2.3.2.6 Separation of macrophages by differential cell attachment 2.3.3 Statistical analysis...... 2.4  Results  27 28 29 29 30 30  2.4.1 The uptake of Photofrin by murine peritoneal macrophages and SCCVII tumor cells in vitro ...30 2.4.2 The effect of serum on Photofrin uptake by SCCVII cells and macrophages... 34 2.4.2.1 The effect of plasma proteins on uptake and retention of Photofrin, by SCCVII cells and macrophages ..36 2.4.3 Photofrin uptake by peritoneal macrophages is inhibited by cytochalasin-B ......37 2.4.4 The uptake of Photofrin by SCCVII tumor cells and tumor associated macrophages in vivo ..........41 2.4.4.1 The effect of separation method on Photofrin content in SCCVIItumorcells and TAMs 46 2.4.4.2 The effect of enzymatic digestion on Photofrin content in tumor cells and macrophages 46 2.5 Discussion 47  CHAPTER 3. INDUCTION OF IMMUNE CELL INFILTRATION INTO MURINE SCCVII TUMOR BY PHOTOFRIN BASED PHOTODYNAMIC THERAPY..... .......5 6 3.1  Summary.  3.2  Introduction.  3.3 Materials and methods 3.3.1 Tumor model.... 3.3.2 Photodynamic therapy 3.3.3 Indirect immunoperoxidase and Wright staining 3.3.4 Identification of blood derived tumor infiltrating cells 3.3.5 Macrophage cytotoxicity against tumor cells  ..56  ".  57 59 59 59 60 .61 .....63  3.4 Results.... 3.4.1 Changes in tumor cellular content 3.4.2 Hoechst 33342 staining of circulating leukocytes. 3.4.3 Cytotoxicity of TAMs after PDT  65 65 70 .75  3.5  77  Discussion  CHAPTER 4 . POTENTIATION OF PHOTODYNAMIC THERAPY BY IMMUNOTHERAPY THE EFFECT OF SCHYZOPHILLAN (SPG)  .80  4.1  Summary  4.2  Introduction:  80 ... .  .....80  r  4.3 Materials and methods 4.3.1 Tumor model, drugs......... 4.3.2 Analysis of immune cell infiltration 4.3.3 Determination of Photofrin levels in tumor tissue/cells 4.3.5 Clonogenic assay 4.4  Results and discussion  4.4.1 4.4.2 4.4.3 4.4.4  Photofrin tumour levels Leukocyte infiltration of SCCVII tumor The effect of SPG on tumor cell clonogenicity after PDT The effect on tumor recurrence  .82 -82 ......83 84 ........84 .......85  85 ......86 ......89 ...91  CHAPTER 5. POTENTIATION OF PHOTODYNAMIC THERAPY ELICITED ANTITUMOR R E S P O N S E BY LOCALIZED T R E A T M E N T WITH G R A N U L O C Y T E - M A C R O P H A G E C O L O N Y STIMULATING F A C T O R ......9 4 5.1  Summary  5.2  Introduction  •• •••94 •.;  95  5.3 Materials and Methods.. 5.3.1 Tumor model, cell lines  97 97  5.3.2 Generation of GM-CSF retroviral vector...:..... 98 5.3.3 Virus production and infection of SCCVII tumor cells ........99 5.3.4 Northern blot analysis 100 5.3.5 GM-CSF assay 100 5.3.6 Photodynamic treatment 101 5.3.7 GM-CSF immunotherapy ......102 5.3.8 Macrophage cytotoxicity 103 5.4 Results 104 5.4.1 GM-CSF production by SCCVII/JzGM-CSF cells. ............104 5.4.2 Blood leukocyte content in GM-CSF treated mice ..........107 5.4.3 The effect of GM-CSF treatment on growth of SCCVII tumor.. ....108 5.4.4 The effect of GM-CSF treatment on cytotoxic activity of TAM 111 5.4.5 The effect of GM-CSF treatment on the response of tumors ;  to PDT  5.5  Discussion....  CHAPTER 6.1  6.2  6.  ........112  .'.  CONCLUSIONS  Conclusions.....  Future directions  CHAPTER  7.  REFERENCES..  .116 AND FUTURE  DIRECTIONS...........120 ..........120  ..........123  .........125  LIST OF TABLES Table 1.1  Photophysical and photochemical reactions of photosensitization..  Table 2.1  11  Effect of presence of non-adherent cells from peritoneal exudate on the uptake of [ C]-polyhematoporphyrin by 14  murine peritoneal macrophages Table 2.2  Effects of cytochalasin B on in vivo uptake of Photofrin by peritoneal macrophagesa  Table 2.3  34  38  Photofrin content in tumor cells fraction and TAM fraction, derived from SCCVII tumor and separated by differential substrate attachment. „  Table 2.4  46  The effect of exposure to a mixture of trypsin, collagenase, and DNAase on Photofrin levels in tumor cells and macrophages  47  Table 4.1  The effect of SPG on Photofrin content in SCCVII tumor....  86  Table 4.2  The effect of SPG on Photofrin content in FcPr and FcR+ cell populations of SCCVII tumor  Table 4.3  89  The effect of SPG pretreatment on clonogenicity of SCCVII tumor cells isolated from PDT-treated subcutaneously growing tumors  Table 5.1  Blood leukocyte content in GM-CSF treated mice..  90 .107  ix  LIST OF FIGURES Figure 2.1  Photofrin uptake by peritoneal macrophages and S C C V I I tumor cells in vitro  Figure 2.2  .32  Uptake of [ C]-polyhematoporphyrin by peritoneal 14  macrophages and S C C V U tumor cells in vitro... Figure 2.3  .....33  Effect of serum on Photofrin uptake by peritoneal . macrophages in vitro...  Figure 2.4  35  Effects of plasma proteins on uptake and retention of Photofrin by peritoneal macrophages in vitro.....  Figure 2.5  37  Retention of Photofrin in macrophages and tumor cells under in vitro conditions.  Figure 2.7  40  Photofrin fluorescence intensity in tumor cells (FcR") and host cells (FcR+)  41  Figure 2.8  Photofrin content in two populations of S C C V I I tumor cells  43  Figure 2.9  The ratios of Photofrin content determined in FcR : FcR' +  cell populations derived from S C C V I I tumors. Figure 3.1  45  Levels of major cellular populations in S C C V I I tumor before and after PDT  Figure 3.2  S C C V I I tumor contents of neutrophils and mast cells  Figure 3.3  Distribution of Hoechst 33342 fluorescence in  ;  representative S C C V I I tumors determined by flow  cytometry.  66 69  72  Figure 3.4 . Infiltration induced by PDT of Hoechst 33342 labeled cells from the blood into the S C C V I I tumor....;. Figure 3.5  The content of various populations among tumor resident cells (Hoechst 33342 negative) and newly infiltrated cells  ....73  (Hoechst 33342 positive) in SCCVII tumors at 2 hours post PDT Figure 3.6  .........74  Cytotoxicity of tumor associated macrophages (TAMs), selected from PDT treated and non-treated SCCVII tumors, against in vitro cultivated SCCVII cells  Figure 4.1  76  The effect of SPG therapy on immune cell content of PDT non-treated (a) and PDT-treated (b) SCCVII tumor  88  Figure 4.2  The effect of SPG treatment on tumor eradication by PDT  92  Figure 5.1  Northern analysis of the total RNA isolated from SCCVII/JzGM-CSF and SCCVII/Jzneo cells....  ....,„.....105  Figure 5.2  GM-CSF bioassay....  Figure 5.3  The effect of GM-CSF treatment on growth of established SCCVII tumor  .106  109  Figure 5.4  Effect of GM-CSF treatment on inoculated SCCVIItumor  Figure 5.5  The effect of tumor localized GM-CSF treatment on cytotoxic activity of TAM  Figure 5.6  The effect of localized GM-CSF treatment on the control of  Figure 5.7  The effect of localized GM-CSF immunotherapy on the  ..110  112  SCCVII tumor by Photofrin mediated PDT.  ...114  control of SCCVII tumor by BPD mediated PDT...  ...115  ABBREVIATIONS ALA  5-aminolevulinic acid  AlCISPc  Chloraluminum sulfonated phthalocyanine  AlPcS  Aluminum phthalocyanine  BGG  Bacillus of Calmette and Guerin  BPD  Benzporphyrin derivative  BSA  Bovine serum albumin  cDNA  Complementary deoxyribonucleic acid  CFU  Colony forming unit  CP  Corynebacterium parvum  DNA  Deoxyribonucleic acid  E. coli  Escherichia coli  EDTA  Ethylenediaminetetraacetic acid  FACS  Fluorescence activated cell sorter  FBS  Fetal bovine serum  FcR  Fc receptor  FITC  Fluorescin isothyocyanate  GM-CSF  Granulocyte-macrophage colony stimulating factor  HBSS  Hank's balanced salt solution  HDL  High density proteins  IgG  imunoglobulin gamma  IL  Interleukin  LDL  Low density proteins  LTR  Long terminal repeat  m-THPC  m-tetrahydroxyphenylchlorin  MEM  Minimum.essential medium  mRNA  Messenger ribonucleic acid  NaCI  Sodium chloride  NaH2PC"4  Sodium phosphate, monobasic  NCS  Newborn calf serum  NPe6  Chlorin e6  PBS  Phosphate buffered saline  PDT  Photodynamic therapy  PE  Phycoerythrin  PMN  Polymorphonuclear leukocytes  RNA  Ribonucleic acid '  SD  Standard deviation  SDS  Sodium dodecyl sulphate  SF  Surviving fraction  xii Schizophillan Tumor associated macrophage T cell receptor Tumor necrosis factor-a Tetraphenylporphine  XIII  Publications containing material covered in this thesis 1.  Korbelik, M., Krosl, G., Olive, P.L, Chaplin, D.J, (1991) Distribution of Photofrin between tumour cells and tumour associated macrophages. Br. J. Cancer  2.  64, 508-512.  Korbelik, M., Krosl, G., Chaplin, D.J. (1991) Photofrin uptake by murine macrophages. Cancer  3.  Res. 51, 2251-2255.  Krosl, G., Korbelik, M. (1994) Potentiation of photodynamic therapy by immunotherapy: the effect of schizophyllan (SPG). Cancer  Lett. 84, 43-  49. 4.  Krosl, G., Korbelik, M., Dougherty, G.J. (1995) Induction of immune cell infiltration into murine S C C V I I tumour by photofrin-based photodynamic therapy. Br. J. CancerT\,  5.  549-555.  Krosl, G., Korbelik, M., Krosl, J., Dougherty, G.J. (1996) Potentiation of photodynamic therapy elicited antitumor response by localized treatment with granulocyte-macrophage colony stimulating factor. Cancer 3281-3286.  Res. 56:  xiv  ACKNOWLEDGMENTS I am very grateful to my supervisor Dr. Mladen Korbelik for his unlimited support, constant availability, and excellent guidance throughout this project. I would also like to thank Dr. Graeme Dougherty for his advice and constructive criticism that helped me at the critical points during my work. I owe special thanks to Dr. David Chaplin for encouragement and helpful advice. I am grateful to Dr. Branko Palcic for his support and the interest he always showed for my work. I would like to thank the members of my supervisory committee for advice and helpful discussions during our meetings that helped to formulate sharp and focused questions to be answered by this project. In addition I would like to thank the staff of Cancer Imaging, Terry Fox Laboratory and Medical Biophysics for their companionship and assistance throughout the years I spent at the Cancer Agency. I would like to acknowledge expert advice I received from Dr. Ralph Durand. My thanks also to Dr. Andrew Minchinton for unlimited use of the laboratory and equipment. I would also like to thank Sandra Lynde for the technical and friendly support that she had given me in the laboratory. Nancy LePard and Denise McDougal were very helpful in the experiments involving flow cytometry analysis. Last, but not least it was Jana's love, patience and understanding that supported and helped me to carry this work through. The work on this thesis was supported by the Research Golincil of Slovenia, British Columbia Health Research Foundation, and Medical Research Council of Canada.  Introduction  1  CHAPTER 1 Introduction 1.1  Overview and thesis outline Photodynamic therapy (PDT)  requires three simultaneously present  components for its cytotoxicity: 1)- a light-sensitive drug (photosensitizer); 2) light of an appropriate wavelength, consistent with absorption characteristics of photosensitizer; and 3) molecular oxygen. The therapy involves a sequential administration of photosensitizer and light for the treatment of diseased tissue: The mechanism of cytotoxicity involves the conversion of molecular oxygen to an excited form called singlet oxygen by energy transfer from the excited photosensitizer to the oxygen.  This form of extremely reactive oxygen is  believed to be responsible for most of the PDT-mediated cytotoxicity. The ideal drug for PDT of solid cancers would have to satisfy five conditions : 1) no dark toxicity; 2) selective uptake and/or retention by tumor; 3) high production of cytotoxic oxygen species; 4) excitation by light of sufficient tissue penetration; and 5) photostability (Pass 1993). However, such a photosensitizer does not exist at this time and intense research is underway for a drug that would satisfy most of the listed conditions. Accumulation of photosensitizers in tumor tissue is an important determinant for selective destruction of malignant lesions by PDT. Photofrin®, an improved and purified version of hematoporphyrin derivative (HPD) is the most widely used and studied photosensitizer. Much research has been done on its pharmacokinetics and factors that influence its uptake and retention in malignant tumors, but a number of these factors still remain to be elucidated. As reviewed, Photofrin accumulates at high levels in tumors, at the sites that have  Introduction  2  high content of elements of the reticuloendothelial system, at sites of inflammation, and in traumatized tissue. The destruction of tumor cells by PDT. is believed to originate from singlet oxygen mediated oxidative damage to vital cellular components. However, as will be reviewed in this Chapter, only a fraction of tumor cells are killed by such "direct" phototoxic damage. It is known that PDT induces a cascade of events responsible for so called "secondary damage" characterized by vascular stasis, blood vessel leakage and hemorrhagic necrosis and can ultimately lead to tumor cure. In this process a variety of biological mediators are released from malignant and host cells in treated tumor which appear to have an important role in the development of tumor necrosis. Reports in the literature indicate that it is possible, by modulating the immune status of a tumor bearing animal, to influence the response of tumor to PDT. Based on these reports, we have hypothesized that the immune cells of a tumor bearing host play a significant role in the accumulation of Photofrin in tumor tissue and in the outcome of PDT. To test this hypothesis we first compared the  in vitro  uptake of Photofrin by  the cells of an experimental murine tumor to that of murine macrophages. We also tested the influence of different serum proteins on Photofrin uptake and retention in malignant cells and macrophages cultured proceeded to analyze the  in vivo  in  vitro.  We then  levels of the photosensitizer in malignant  tumor cells and tumor associated macrophages (TAMs) at different time points after Photofrin administration. Next we tested the hypothesis that host immune cells are involved in tumor response to PDT.  Since the reaction to PDT closely resembles the acute  inflammatory reaction, we examined the possibility that PDT induces infiltration of circulating immune celis at the treated site. To study this, we employed flow  Introduction  3  cytometry analysis and immunoperoxidase staining of cells that were recovered from the tumor site at different time points after PDT. To differentiate between the newly arrived and resident immune cells we selectively stained the cells in circulation using a supravital nuclear stain Hoechst 33342. The results have shown, that PDT indeed induces a massive and regulated infiltration of myeloid cells into the treated site. In the last part of the study we attempted to enhance the efficacy of PDT by modulating the immune system of the host.  The results indicate that  immunotherapy given in a proper sequence with PDT can significantly improve the rate of tumor cure. Taken together these results support our initial hypothesis that host cells have a significant role in the accumulation of Photofrin in tumors and that they also participate in the eradication of tumors treated by PDT. 1.2  Historical  perspective  PDT has developed into one of the clinically accepted therapies of malignant disease in the last 20 years.  The idea of treating tumors with  photosensitizers and light, however, is much older. It was already known at the beginning of this century, that a combination of light and a topically applied aqueous solution of eosin results in regression of some cutaneous tumors (Tappenier and Jesionek 1903). The first observation of porphyrin fluorescence in human and animal tumors was reported by Policard (Policard 1924) who attributed the reddish fluorescence to endogenous porphyrins that accumulated after infection of neoplastic tissue by hemolytic bacteria. Selective retention of hematoporphyrin (HP) in primary and metastatic tumors was first observed in 1942 by Auler and Banzer (Auler and Banzer 1942), who observed HP fluorescence in the lymph nodes. Later it was noted that hematoporphyrins and  Introduction  4  metallohemafoporhyrins are selectively retained in neoplastic, embryonic and regenerating tissues in rodents (Figge et al. 1948). coworkers  In 1960, Lipson and  (Lipson and Baldes 1960) improved upon the tumor-localizing  properties of HP by treating it with acetic and sulfuric acid. They named the improved drug hematoporphyrin derivative (HPD) and demonstrated that it is selectively retained by malignant and proliferating tissues. A year later they performed the first endoscopic determination of malignant lesions by detecting HPD fluorescence in the respiratory and upper digestive tract (Lipson et al. 1961). Lipson was also the first to actually treat a patient for metastatic chest wall breast cancer with PDT (Lipson et al. 1966). Although the tumor was not cured, there was objective evidence of a cytotoxic effect of PDT (Lipson et al. 1966). Kelly et al. reported the destruction of recurrent bladder cancer by HPD and light delivered through fiber optics (Kelly et al. 1975). The first phase l/ll clinical trials were reported in 1977 and 1979 by Dougherty et al. (Dougherty et al. 1977; Dougherty et al. 1979), who also identified the tumor localizing fraction of HPD (Dougherty et al. 1984) which was characterized as dihematoporphyrin ether/ester (DHE) (Kessel 1986). Dougherty et al. also explored the mechanism and applications of HPD-mediated PDT (Dougherty 1984; Dougherty 1987) for treatment of diverse animal and human malignancies. 1.3  PDT in clinical trials. Since these first trials, PDT has developed into a promising modality forthe  treatment of malignant lesions. It has the potential to be used both as a primary and palliative treatment for a variety of malignant and non-malignant conditions. PDT has now received regulatory approval for use in cancer treatment in Canada, Japan, and some European countries. Clinically, the most utilized drug is Photofrin® (porfimer sodium), an improved and purified preparation of.  Introduction  5  the original HPD, however, a new generation of photosensitizers is being intensely tested. In addition to Photofrin, several other photosensitizers have entered clinical studies. Protoporphyrin IX, derived from its precursor 8-aminolaevulonic acid (ALA), is being studied for the treatment of superficial basal cell carcinomas (Kennedy et al. 1990; Cairnduff et al. 1994). Benzoporphyrin derivative mono acid (BPD) (Richter et al. 1991) is being studied for the treatment of cutaneous tumors and several non-malignant conditions. (Lui et al. 1993; Lui 1994) . The aspartic acid derivative of chlorin e6 (NPe6) (Volz and Allen 1992) and mtetrahydroxyphenylchlorin (m-THPC), which has been noted for the low light and drug doses needed to achieve the tumor necrosis, is also being investigated in the treatment of cutaneous malignancies (Ris et al. 1992). Controlled phase III clinical trials using Photofrin mediated PDT for bladder, lung, and esophageal carcinomas were initiated in late 1980s. Photofrin based PDT for bladder carcinoma is now approved for use in Canada, while Photofrin PDT for esophageal, endobronchial, stomach, and cervical carcinoma is approved for use in Japan.  In addition to the recent FDA approval for PDT  treatment of esophageal cancer in USA, this modality has been regulatory approved in a number of European countries. Evidence from clinical studies indicate that PDT can have a beneficial role in the management of many other malignant conditions, including tumors of the bladder, bronchus, esophagus, skin, head and neck, cervix and colorectal cancers, metastatic breast carcinoma and ocular tumors (Dougherty 1989; Pass 1993). This review will outline only a few of these studies. A large number of lung cancer patients have received PDT in many different centres. The most promising use of PDT appears to be for early stage lung cancer (reviewed by Lam (Lam 1994)). In a Phase ll-lil clinical trial in Japan,  6  Introduction  89% of patients with early stage lung cancer showed complete response (Furuse et al. 1993). Studies at Mayo Clinic (Cortese et al. 1992; Eddel and Cprtese 1992) showed that PDT may be an alternative to surgery in patients with early stage lung cancer. In a study at the British Columbia Cancer Agency, a group of patients with mostly larger tumors was treated with PDT (Lam 1994). The results suggested that larger tumors, especially bronchial stump tumors are difficult to treat with PDT because of difficulties in light delivery.  PDT in  combination with external radiotherapy may also produce very good results in palliative therapy in patients with obstructive bronchial cancers (Lam 1994). PDT for cancer of the esophagus was shown to be potentially curative in patients with early tumors of either squamous or glandular histology (Tian et al. 1985; Marcon 1994). In a study by Hier et al. (Hier et al. 1993), it was shown that palliative PDT for obstructive esophageal cancers compares favorably with traditional Nd-YAG thermal ablation.  PDT appears to have an added  advantage of less frequent treatment and higher efficacy (Marcon 1994). PDT utilizing protoporphyrin IX which is synthesized  in situ  from either  topically or systemically administered ALA, has been developed by Kennedy et  al. (Kennedy et al. 1990). They obtained encouraging results with ALA cream applied to superficial basal and squamous cell carcinomas subsequently illuminated with 600-800 nm light (Kennedy and Pottier 1992). Similarly good results were obtained by Cairnduff et al. (Cairnduff et al. 1994) for Bowen's disease. BPD, a second generation photosensitizer has an absorption peak at 690 nm, which results in better light penetration. It has faster tissue clearance compared to Photofrin (Richter et al. 1991). In the studies of Lui et al. (Lui et al. 1993; Lui 1994) better results were obtained in treatment of cutaneous lesions with BPD-mediated PDT compared to Photofrin-mediated PDT.  In addition to  Introduction  7  malignant lesions, BPD-mediated PDT has shown to induce a positive response in the treatment of psoriasis (Hruza et al. 1993; Lui 1994) human papilloma virus infections (Abramson et al. 1992; Abramson et al. 1994), and vascular malformations (Orenstein et al. 1990). The aspartic acid derivative of chlorin e6 (NPe6) (Nelson et al. 1987) is also being studied in clinical trials with cutaneous lesions.  Preliminary results  indicate very good responses with minimal adverse reactions (Volz and Allen 1992). Bonnett and Berenboum first described m-tetrahydroxyphenylehlorin (mTHPC) (Bonnett and Berenbaum 1989). In a study by Ris et al. (Ris et al. 1992), the authors noted a good sparing of normal tissues and favorable tumor responses. Of special interest is the application of PDT in combination with surgery for peritoneal seeding of ovarian tumors (DeLaney et al. 1993) and diffuse intrathoracic cancers including malignant mesothelioma, or AIDS-related Kaposi's sarcoma (Dougherty et al. 1992). High dose chemotherapy with autologous bone marrow transplantation can be an effective strategy for the treatment of some malignant disorders. Unfortunately, autologous grafts may be contaminated with malignant cells. While there are several techniques available for purging of bone marrow, PDT is an interesting possibility. Both, Photofrin and BPD have been extensively studied and show promise in this regard (Mulroney et al. 1994). The great advantage of this new modality is that it can be repeated many times since there was no dose-tolerance build-up noted so far. Patients with recurrence after chemotherapy, radiation, or immunotherapy can still be effectively treated by PDT. The only side.effect for Photofrin-mediated PDT is cutaneous photosensitivity, which may last for 4 weeks.  New generation  Introduction  8  photosensitizers, like BPD, which have a faster skin clearance compared to Photofrin, may not cause prolonged skin photosensitivity. 1.4  Tumor localization of photosensitizers Hematoporphyrin derivative, the first established photosensitizer, was  initially known as a tumor; localizing agent. Its  in situ  fluorescence is currently  being employed for detection and delineation of various malignancies with newly developed fluorescence imaging and non-imaging devices  (Lam et al.  1990; Andersson-Engels et al. 1992; Lam et al. 1993). This tumor localizing property of photosensitizers is also important for selective destruction of tumors by PDT.  However, even in early studies, it was noted that porphyrins  accumulate at high levels in the lymph nodes (Auler and Banzer 1942) and healing wounds (Figge et al. 1948).  Several studies with Photofrin and  aluminum phthalocyanine sulfonate (AlPcS) have shown that considerable levels of both types of photosensitizers are retained in the organs that are rich in reticuloendothelial cell components (Gomer and Dougherty 1979; Kessel 1986; Chan et al. 1988; Henderson and Bellnier 1989). It is now known that many photosensitizers are retained at high levels in the liver, kidney, lymphatic organs, inflammatory sites, and atherosclerotic plaques (Spears et al. 1983; Nseyo et al. 1985; Bellnier and Henderson 1992). In addition, the tumor vs normal tissue (muscle, skin) ratio of most photosensitizers, including Photofrin, BPD or phthalocyanines is rarely above 2:1 (Bellnier and Dougherty 1989; Tarlau et al. 1990; Bellnier and Henderson 1992; Ma et al. 1992). Several hypothesis have been put forward to explain the retention of photosensitizers within tumors. Changes in cellular and tissue pH have been proposed to have an effect on Photofrin biodistribution (Pottier and Kennedy 1990). Repeated glucose administration, which induced a transient decrease of  Introduction  9  tumor pH in experimental animals, resulted in increased retention of Photofrin and enhanced effect of PDT (Thomas et al. 1987; Peng et al. 1991) and seem to support this hypothesis. The role of plasma lipoproteins and albumin in the delivery of photosensitizers to the malignant lesion and their uptake by the cells comprising the tumor has also been proposed (Kessel 1986). Cancer cells may have augmented expression of the low-density lipoprotein (LDL) receptor expression, and since lipoproteins are major carriers of lipophilic porphyrins in the bloodstream (Jori et al. 1984), photosensitizer/LDL complex uptake by LDL receptors was proposed for porphyrin localization in tumors. However, not all photosensitizers which bind to serum LDL are good tumor localizers; an example is protoporphyrin (Kongshaug et al. 1989).  The increased  permeability of tumor vasculature has also been proposed to play a role in sensitizer accumulation (Bugelski et al. 1981).  However, the increased  interstitial pressure may also affect the extravasation of photosensitizers (Jain 1989).  In this respect, work in our laboratory (Korbelik and Krosl 1994) has  shown how proximity to the blood supply affects the levels of different photosensitizers in the cells of a murine fibrosarcoma. It was demonstrated that there are marked differences among photosensitizers in their capacities to reach tumor cells distant from the vasculature.  The lack of difference with  regard to diffusion potential between di- and tetrasulphonated forms of tetraphenylporphine  ( T P P S 2  and  T P P S 4 ,  respectively), and disulphonated and  tetrasulphonated derivatives of aluminum phthalocyanine  ( A I P C S 2  and  A I P C S 4 ,  respectively) implied that the lipophilicity of the sensitizers was not a decisive factor, nor were their affinities for binding to plasma proteins. It is possible that the factor that determines the distribution of photosensitizers within the tumor is their affinity for cellular or other structures within the tumor. Peng et al. (Peng et al. 1991) have studied the distribution of several photosensitizers with different  Introduction  10  hydrophobicity within a human tumor growing in nude mice. They found that. A I P C S 4  and T  P P S 4  accumulate mainly in acellular tumor stroma. Mono- and  disulfonated forms of these photosensitizers were found retained more selectively in cells than in acellular tissue components. Since the study of Bugelski et al. (Bugelski et al. 1981), it has been known that elevated Photofrin levels accumulate in tumor associated, macrophages (TAMs). Jori (Jori 1989) suggested that porphyrins, phthalocyanines, and other photosensitizers that can remain in highly aggregated form  in  vivo  are  phagocytized to a large degree by TAMs. Following the initial studies described in Chapter 2, the distribution of various photosensitizers between malignant and host cell populations of experimental tumors has been extensively studied by our group (Korbelik and Krosl 1995; Korbelik and Krosl 1995; Korbelik and Krosl 1995; Korbelik and Krosl 1996).  It was shown that there is a marked  heterogeneity in photosensitizer levels between the different cell populations that comprise a tumor.  The consistent observation in all tumor models  examined was that by far the highest cellular levels of photosensitizers are accumulated in a subpopulation of TAMs which is characterized by a high granularity and highly elevated expression of interleukin (IL)-2 receptor, indicating that activated TAMs may be responsible for accumulation of significant portion of retained photosensitizer (Korbelik and Krosl 1995). 1.5  Mechanism of action  1.5.1  Photosensitization  Photosensitization refers to a light-activated process in which the presence of a chromophore leads to changes in a substrate that otherwise would not take place (Grossweiner 1989). Porphyrins and photosensitizers in general have a common mechanism of action.  The major pathways by which an excited  Introduction photosensitizer can transfer energy are depicted in Table 1.1.  11 After absorbing  light of appropriate wavelength the photosensitizer is converted from stable ground state (P) to a short lived excited state (1P*) also known as the singlet state.  The excited molecule may then undergo conversion to a longer-lived  excited state known as the triplet state (3P*). This triplet state may become involved in forming cytotoxic species or may release energy by other processes including fluorescence decay (Grossweiner 1994). Table 1.1  P  +  1P* 1P* 3P* 3P* 10 * 3P* P2  Photophysical and photochemical reactions of photosensitization  hv  +  0  + + +  S S  o  2  2  -> 1P*  -> -> -> '.-> -> -> ->  3P* + P hv' w + P P S(O) p+ S(O) p + O 2 -  light absorption  intersystem crossing fluorescence energy transfer non-radioactive decay reaction mediated by singlet oxygen Type I reaction  Where:  P = Photosensitizer in ground state hv = . Light quantum 1P* = Excited singlet state of photosensitizer 3P* = Excited triplet state of photosensitizer 0 = Oxygen in the ground (triplet) state 1o * = Excited singlet state of oxygen S = Tissue target (substrate) S(O) = Oxidized tissue target . Modified from: Dougherty, T.J. (1989) Photodynamic therapy: Status and potential. Oncology 3, 67-78. 2  2  The pathways of photosensitization in biological systems are divided into two broad categories (Foote 1984). Type I process refers to a mechanism where excited photosensitizer reacts directly with a substrate involving hydrogen or electron transfer to yield transient radicals. This process can take place under anoxic conditions.  In the alternative Type II mechanism, the  Introduction  .  '  12  energy transfer from the excited photosensitizer in triplet state to molecular oxygen takes place, leading to  singlet  oxygen  ( C*2*) which further reacts with  substrates susceptible to oxidation (S(O)).  1  Photodynamic processes are;  believed to take place via a Type II pathway, since when oxygen is not present, or is present at levels less than 2%, cells are resistant to PDT (Lee See et al. 1984; Mitchell et al. 1985). This is supported by the fact that singlet oxygeawas observed  in vivo  during the PDT of an experimental mouse tumor (Parker 1986)  although these results seem to be in dispute. requirements for PDT was provided by Tromberg  Further evidence for oxygen etal.  (Tromberg et al. 1990)  who observed that (presumably due to its consumption) oxygen tension in a tumor becomes irreversibly low with high. PDT fluences. Foster and coworkers (Foster et al. 1991) suggested that fractionating light delivery may partially overcome the oxygen depletion at high fluences. It should be noted that the possibility of Type I reaction occuring in PDT under certain conditions cannot be ruled out, For example, this type of reaction may be favoured in systems where the sensitizer is bound to an easily oxidized biomolecule, (Foote 1984). It was also suggested that a competition between photo-oxidation and photo-reduction of porphyrin photosensitizers can take place, as evidenced by formation of a chlorin-type molecule following photoirradiation (Rotomskis et al. 1996). 1.5.2  Cellular  effects  Singlet oxygen lifetime and diffusion distance in a cellular environment are extremely limited by its avid reactivity with cell constituents. It was estimated that the diffusion distance of C>2* in cells is about 0.1 u.m (Moan and Berg 1  1991).  The cell damage will therefore occur very close to the site of 0*2* 1  generation; hence the intracellular localization of photosensitizer will dictate the  Introduction  13  type of cellular damage that will occur during PDT. For anionic and lipophilic photosensitizers (like Photofrin), major target are cellular membranous structures. PDT induced damage to plasma membrane is indicated by changes in cellular shape (swelling, formation of blebs) (Moan et al. 1982), changes to microvilli as seen by electron microscopy (Moan et al. 1982; Yanhua et al. 1990), and depolarization of the plasma membrane (Specht and Rodgers 1990).  Candide et al. observed PDT induced alteration of endoplasmic  reticulum associated enzymes (Candide et al. 1989).  Hilf and coworkers  reported that cytosolic enzymes were much less affected by PDT compared to enzymes associated with the mitochondrial membrane (Hilf et al. 1984). Mitochondrial enzymes that are impaired the most are those involved in electron transport, oxidative phosphorylation, and ATP/ADP and phosphate/H+ translocation (Hilf et al. 1984; Hilf et al. 1984; Atlante et.al. 1989; Atlante et al. 1990; Yamamoto and Kawanishi 1991).  These latter changes result in a  decreased rate of oxidative phosphorylation and decreased cellular ATP levels (Hilf et al. 1986). In addition to the damage to cellular membranous structures described above, Berg and coworkers observed that cells exposed to PDT using porphyrin and phthalocyanine photosensitizers accumulate in mitosis (Berg et al. 1990; Berg and Moan 1992).  In the case of  T P P S 4  the non-  polymerized form of microtubules was identified as a. target, which prevented the organization of spindle apparatus. induced by PDT  in vitro  Depolymerization of microtubules  in human endothelial cells was also observed (Sporn  and Foster 1992). This damage results in disruption of plasma membrane and cytoskeleton which causes the endothelial cells to contract, exposing the underlying basement membrane (Fingar et al. 1993). This effect on endothelial cells is probably one of the important factors in the development of the vascular response to PDT discussed later in this chapter.  Introduction  14  Hydrophilic photosensitizers seem to accumulate  preferentially  in  lysosomes (Moan et al. 1989; Specht and Rodgers 1990). Damage to these . structures with ensuing release of proteolytic enzymes is probably a major cause of PDT induced cell death with NPes and  T P P S 4  (Moan et al. 1989;  Roberts and Berns 1989; Roberts et al. 1989). Mitochondria are most likely the major target for cationic photosensitizers and protoporphyrin IX, which seem to preferentially localize in these organelles (Salet and Moreno 1990). Preferential intracellular localization of lipophylic photosensitizers leads to photoperoxidation  of  membrane  cholesterol  and  phospholipids (Henderson and Dougherty 1992).  other  unsaturated  Cell leakage, which  ultimately leads to loss of cell integrity, was observed to start almost immediately after the onset of light treatment (Henderson and Donovan 1989). The damage to plasma membrane is accompanied by the release of a variety of substances including metabolites of arachidonic acid, and lipid fragments. Metabolites of arachidonic acid, produced via cyclooxygenase or lipoxygenase pathway (Samuelsson 1982), were detected after PDT Donovan 1989; Henderson et al. 1992) or  in vivo  in vitro  (Henderson and  (Fingar et al. 1990; Fingar et  al. 1991). 1.5.3  The effect  of PDT on tumor  The development of macroscopic and microscopic tissue damage following PDT has been studied with several photosensitizers, including Photofrin (Reed et al. 1989; Reed et al. 1989; Reed et al. 1989), phthalocyanines and NPe6 (Nelson e t a l . 1988), and purpurins (Morgan et al. 1990).  The general  phenomenon accompanying PDT seems to be vessel occlusion. The time interval between the treatment and this vascular response varies with different photosensitizers and from tumor to tumor (Henderson and Dougherty 1992).  Introduction  15  Clumps of red blood cells can be seen in the tumor vasculature almost immediately after the onset of light treatment, which is followed by transient vascular dilatation, constriction and eventual blood stasis leading into hemorrhage (Fingar et al. 1993). The gross edema that accompanies these vascular effects is usually seen immediately after the completion of light treatment and increases for some time post PDT (Lim et al. 1986; Kerdel et al. 1987). Once the vessel occlusion is complete it is irreversible and is followed by  ischemic tissue  necrosis  (Henderson  and  Fingar  1987). Tumor  disappearance usually occurs within 1-2 days after PDT (Pass 1993).  The  importance of vascular occlusion events has been demonstrated in studies by Henderson et al. (Henderson et al. 1985) and Star and coworkers (Star et al. 1986). Two major determinants contribute to PDT induced destruction of tumors. The first is the degree of tumor cell destruction by the cytotoxic action of excited photosensitizer, and the second is vascular photosensitization that leads to vascular collapse and general nutrient deprivation and tumor hypoxia (Henderson and Dougherty 1992), The relative contribution of each these two factors depends on the type of photosensitizer used.  For Photofrin, where  vascular shutdown commences immediately after the onset of light treatment, the direct cell kill is typically responsible for approximately 20% of tumor cell death (Henderson et al. 1985; Krosl and Korbelik 1994). However, further cell death proceeds immediately, and its kinetics is similar to that caused by anoxia (Henderson et al. 1985). Monosulfonated aluminum phthalocyanine (AlPcSi) was reported to kill 10 times more tumor cells than Photofrin by direct phototoxic action while secondary damage proceeds immediately due to the shutdown of the tumor vasculature. With bacteriochlorophyll-a, the direct cell kill is limited by its rapid photobleaching (Henderson et al. 1991), and reduces the clonogenic  Introduction  16  fraction of tumor cells for approximately 50%. However, additional cell death does not commence until 2-3 h later, when the shutdown of tumor vasculature occurs. The vascular effects described above are probably triggered by several mechanisms. One is the direct photodynamic damage to endothelial cells. This results in damage to their cytoskeleton (Sporn and Foster 1992) and contraction and rounding which exposes the underlying basement membrane. The contact between the exposed basement membrane and platelets triggers the clotting cascade and results in the formation of thrombus and is accompanied by the action of vasoactive molecules that were identified to be released during and after PDT (Fingar et al. 1993). Another mechanism most likely involves PDT triggered release of vasoactive substances from the cells comprising the tumor. Administration of indomethacin, which is an inhibitor of cyclooxygenase, was shown to block many of the observed vascular effects (Fingar et al. 1990; Fingar et al, 1992; Hampton and Selman 1992).  Fingar et al. also tested several  specific thromboxane inhibitors and observed that the tumor response inversely correlated with the inhibition of vessel stasis (Fingar et al. 1993).  The  interesting observation made by Fingar and coworkers in this study was that some initial tumor response was seen even when the synthesis of thromboxane was completely blocked.  This is not the case when indomethacin is used,  which blocks the production of both prostaglandins and thromboxanes. These results have suggested that thromboxane plays an important role in the vascular effects of PDT, but is not the only mediator responsible for overall tumor response to PDT (Fingar et al. 1992).  Another factor that leads to  vascular damage is the inflammatory reaction induced by PDT in treated tumors.  17  Introduction 1.5.4  PDT  triggered  inflammatory  response  The relationship between PDT and the host response was first proposed by Elmets at al. (Elmets and Bowen 1986) who described immunological suppression observed in mice that underwent PDT. Lynch and coworkers then established that PDT.induced suppression of contact hypersensitivity is induced by macrophages, and that it can be adoptively transferred to naive mice (Lynch et al. 1989; Lynch et al. 1989). The ability of spleen cells from PDT treated mice to act as stimulators in mixed lymphocyte response was significantly impaired (Lynch et al. 1989).  It was suggested that this immunosuppression may be  mediated by cyclooxygenase pathway metabolites of arachidonic acid, since it was ameliorated by a continuous low dose indomethacin treatment. and Gomer  Ferrario  (Ferrario and Gomer 1990) reported that PDT induces acute  lethality in some mouse strains. The histological profiles of different organs from dead mice indicated that this effect was consistent with a traumatic shock syndrome.  The protective action of anti-inflammatory drugs such as  indomethacin, aspirin, and antihistamine suggested,that prostaglandins, thromboxanes and histamine are associated with the lethality observed, in PDT treated mice.  As mentioned above, these inflammatory mediators were all  observed to be released after PDT  in vitro  and  in vivo.  In addition to the pro-inflammatory metabolites of arachidonic acid, PDT induces the release of other biologically active molecules.  PDT treatment  causes degranulation of mast cells (Kerdel et al. 1987), and induces macrophages to release tumor necrosis factor (TNF-a) in a dose dependent fashion (Evans et al. 1990). TNF-a, IL-1p\ and IL-2 have been detected in the urine of patients with urinary bladder carcinoma treated with PDT (Nseyo et al. 1990). Kick and coworkers recently described findings that  in vitro  PDT of HeLa  cells induces increased messenger RNA expression and protein synthesis of  18  Introduction pro-inflammatory cytokine IL-6 (Kick et al. 1995).  The accumulation of T  lymphocytes and plasma cells that has been observed subsequent to PDT of bladder carcinoma (Shumaker and Hetzel 1987) and increased adherence of polymorphonuclear leukocytes (PMN) to venules during PDT (Fingar et al. 1992) suggest that the host immune system responds immediately and strongly to the PDT. -With the observed edema and erythema that develop during and after the light irradiation, the host response to PDT resembles an acute inflammatory reaction.  - ,  The importance of the host response to PDT in the control of the tumor can be recognized in the fact that the treatment with anti-inflammatory drugs reduces the effect of PDT (Fingar et al. 1993). While treatment with Flunarizine (inhibitor of thromboxane release from platelets) did inhibit the release of thromboxane from platelets, it did not prevent PDT induced vessel leakage. Fingar et al. (Fingar et al. 1993) hypothesized that accumulated PMN could release enough eicosanoids to induce such, vessel leakage.  If the entire  pathway for production of prostaglandins and thromboxanes is blocked by inhibitors then the tumor response to PDT is diminished more strongly than with thromboxane inhibitors alone.  This suggests not only that the vascular  response to the release of eicosanoids is important for the effect of PDT, but also that the role of the members of prostaglandin series in modulation of inflammatory response and immune modulation must not be ignored. The inflammatory reaction that develops subsequent to PDT may be stronger in tumor tissue than.in surrounding normal tissue. Star et al. (Star et al. 1986) observed that no hemorrhage developed in the blood vessels adjacent.to PDT treated tumors. In addition, the PDT treatment of normal tissue (rat ears) resulted in only slightly larger damage than that induced in tumors in observation chambers, despite the fact that Photofrin content in the normal  Introduction  19  tissue was six times higher than in the observation chambers. occlusion or hemorrhage was observed after  No vascular  and ALA-mediated PDT  A I P C S 2 -  of.normal rat femoral arteries (Grant et al. 1994). The blood vessels in PDT field did loose the endothelial cell layer but remained patent.  Even more striking  was the complete absence of an inflammatory reaction (Grant etal. 1994). These observations imply that the PDT induced inflammatory response is much stronger in the tumor compared to normal tissue. One of the reasons for this effect could be the composition of malignant cell membranes, which contain alkylether derivatives of phospholipids, that are present in very low levels in the membranes of normal cells (Snyder and Wood 1969; Howard et al. 1972). The PDT induced activation of membrane-bound phospholipases (Agarwal et al. 1993) triggers the release of alkyl-lipid derivatives that were shown to be more potent macrophage stimulating agents than inflammation derived lipid metabolites from non-malignant cells (Yamamoto and Ngwenya 1987). The initial PDT damage to cellular membranes, which is not necessarily lethal, may trigger a cascade of events that lead.to tumor destruction (Yamamoto et al. 1992; Korbelik and Krosl 1994). We have shown that  in vitro,  PDT treatment of  the human tumor cells A549 markedly enhanced their killing by macrophages. X-ray treatment of A549 cells did not similarly affect macrophage mediated killing of these cells. On the other hand, very limited macrophage toxicity was noted against PDT treated normal kidney cells.  This suggests, that  macrophages recognize PDT induced damage on PDT treated malignant cells (Korbelik and Krosl 1994). The activation of macrophages induced by PDT may be an additional factor in the "secondary effects."  In addition to their enhanced cytotoxicity to PDT  damaged tumor cells mentioned above, macrophages can act as antigen presenting cells. They can present putative tumor antigens to T lymphocytes  Introduction  20  and induce the development of specific antitumor immunity. This possibility is supported by the observation by Canti et al. (Canti et al. 1994), that aluminum phthalocyanine mediated PDT induced in cured mice a specific immunity against subsequent challenge by the parental tumor. 1.5.5.  PDT  and  immunotherapy  The inflammatory reaction triggered by PDT offers perspectives for adjuvant treatment with immunomodulating agents. Myers and coworkers (Myers et al. 1989)  have  Corynebacterium  successfully parvum  combined  PDT  and  immunotherapy  with  (CP) vaccine of the murine carcinoma MRT-2. They  observed that the timing and the dose of immunotherapy administration is very important for the efficacy of combined therapy.. Their results suggest that the vaccination with high dose CP which resulted in acute inflammatory infiltration should be given after PDT. In contrast, low dose CP vaccination that elicits a slower inflammatory response with predominant T cell infiltration, enhanced the effect of PDT if it was given before the light treatment (Myers et al. 1989). These results suggest that PDT can produce an environment where tumor specific immunity may develop.  Similarly positive results were obtained in PDT of  experimental murine bladder carcinoma combined with Bacillus Calmette and Guerin (BCG) vaccination (Cho et al. 1992). Dima et al. successfully combined PDT with endotoxin (Dima et al. 1994), and Bellnier (Bellnier 1991) showed that combination of PDT with TNF-a administration significantly enhances the tumor response to PDT. Positive initial results have also been obtained with PDT in combined treatment with IL-7 secreting tumor cells (Dougherty et al. 1992) and serum vitamin D 3 binding protein (Korbelik et al. 1995), It seems that due to its inflammatory character, PDT is a particularly good candidate for optimized adjuvant immunotherapy.  Introduction 1.6  21  Specific aims of the thesis In summary, evidence available at the time when work on this thesis was  initiated, implicated cells of the macrophage lineage in the localization of photosensitizers (including Photofrin) in solid tumors. In addition, the nature and development of the tumor response to P D T indicated the existence of an acute inflammatory  response  with  involvement  of p o l y m o r p h o n u c l e a r a n d  monocyte/macrophage cellular components. Several questions emerged at the beginning of my project: 1.  What is the role of tumor associated macrophages in the localization of Photofrin in tumors?  2.  Is the reaction that develops in tumor after P D T characterized by an inflammatory cell infiltration?  If so, is this associated with functional  ., •• activation (tumoricidal activity) of inflammatory cells? 3.  If host cells are involved in tumor reaction to PDT, will immunotherapy designed to activate inflammatory cells enhance the P D T effect?  The following specific aims were formulated to answer these questions: 1.  To examine the uptake of Photofrin in malignant and macrophage populations contained in an experimental murine tumor, in order to determine if tumor-associated macrophages have increased Photofrin accumulation compared to malignant cell population.  2.  To determine if Photofrin-mediated P D T of an experimental murine tumor is associated with inflammatory cell infiltration and to investigate the antitumor cytotoxic activity of macrophages recovered from the tumor site following PDT.  Introduction 3.  22  To determine if immunotherapy, designed to activate the tumor infiltrating and/or  resident  immune  cells,  particularly  those  of  monocyte/macrophage lineage, improves the curative potential of PDT.  The work carried out to answer these questions is presented in the following chapters.  Photofrin in murine macrophages  23  CHAPTER 2 The role of tumor infiltrating macrophages in Photofrin accumulation in tumors 2.1  1  Summary The uptake of Photofrin by mouse peritoneal macrophages was studied in  vitro  and compared to the levels of the drug in SCCVII tumor cells accumulated  under the same conditions. We also studied the Photofrin levels in the cells isolated from murine SCCVII tumor from mice that had previously received the drug.  The cellular content of Photofrin in peritoneal macrophages was  measured either by a fluorometric assay or by using C-labeled drug. The 14  level of Photofrin in the cells comprising the SCCVII tumor growing in C3H/HeN mice was determined using fluorescence activated cell sorter (FACS). In addition, the cells obtained from excised tumors were stained for the presence of Fc receptors using fluorescein isothiocyanate (FITC) labeled anti-mouse antibody which enabled us to discriminate between Fc receptor negative (i.e. malignant S C C V I I cells) and Fc receptor positive (predominantly tumor associated macrophages [TAM]). The Photofrin content in malignant SCCVII cells and TAMs sorted by FACS was also determined by chemical extraction. The data from all experiments demonstrate that macrophages have a much greater capacity for Photofrin uptake than SCCVII cells. The Photofrin content at 24 hours after drug administration (25 mg/kg) measured 420 ± 90 ng/u.g (SD), 74 + 15 ng/u,g , and 15 + 2 ng/u,g of cell protein for peritoneal macrophages,  'The data presented in this chapter have been published in following papers: 1. 2.  Korbelik, M., Krosl, G., Olive, P.L., Chaplin, D.J. (1991) Distribution of Photofrin between tumour cells and tumour associated macrophages. Br. J. Cancer64, 508-512. Korbelik, M., Krosl, G., Chaplin, D.J. (1991) Photofrin uptake by murine macrophages. Cancer Res. 51, 2251-2255.  Photofrin in murine macrophages TAMs, and SCCVII cells, respectively.  24  Factors that influence macrophage  activity also influenced the accumulation of the drug in these cells. Analysis of in vivo  accumulation of Photofrin in SCCVII tumor cells and TAMs comprising  the growing tumor showed consistently higher Photofrin levels in TAMs throughout the 96 hour observation period.  In vivo  accumulated material in  TAMs, SCCVII cells and peritoneal macrophages showed very similar  in  vitro  clearance rate. 2.2  Introduction One of the most important properties of Photofrin that makes it a clinically  successful photosensitizer is its localization in tumors (Henderson 1989; Lin 1989). The effectiveness of tumor destruction by PDT is related not only to the tissue distribution of the administered photosensitizer, but also to its distribution within the tumor (Henderson and Bellnier 1989). In recent years there has been increasing evidence that Photofrin and other photosensitizers specifically accumulate in the macrophages which infiltrate tumors;  One of the earliest observations was published by Bugelski and  coworkers (Bugelski et al. 1981). They found high levels of HPD located in macrophages scattered throughout a mouse tumor. In addition, they observed that the normal tissues showing the most prominent accumulation of photosensitizers (liver, kidney, spleen, lymph nodes, and skin) are all characterized by the presence of cells of mononuclear phagocyte system, also called the reticuloendothelial system (Bugelski et al. 1981). Chan et al. (Chan et al. 1988) have used flow cytometric analysis and cell sorting to study the levels of chloraluminum sulfonated phthalocyanine (AlCISPc) in cellular fractions of a mouse colorectal carcinoma.  Based on photosensitizer  fluorescence, they separated populations of high and low photosensitizer  Photofrin in murine macrophages content from suspensions of tumor cells after  in vivo  25  drug administration. They  identified macrophages among the cells with high drug content.  Henderson  and Bellnier (Henderson and Bellnier 1989) suggested that macrophages exhibit very high affinity for Photofrin and may contribute significantly to the overall effect of PDT. Consequently, Henderson and Donovan (Henderson and Donovan 1989) demonstrated PDT induced release of prostaglandin E 2 from mouse peritoneal macrophages treated with Photofrin based PDT  in  vitro.  Evans et al. (Evans et al. 1990) showed increased TNF-a secretion by macrophages treated with PDT  in  vitro.  In this work we have examined the uptake of Photofrin by murine peritoneal macrophages  in  vitro  and  in  vivo.  We have also compared the uptake and  retention of Photofrin in macrophages and tumor cells. By using fluorescence activated cell sorting we studied photosensitizer levels in cells from excised, disaggregated tumors. Using a dual staining technique we identified a subset of cells that showed an increased uptake and retention of the photosensitizer. . 2.3  Materials and methods  2.3.1  Murine  tumor  model  Female C3H/HeN mice, 9-11 weeks of age, were used in all experiments. The mice were kept in Joint Animal Facility and fed standard rodent chow. The maintenance and tumor implantation of SCCVII murine squamous cell carcinoma was performed as described in detail earlier (Chaplin et al. 1987). Intramuscularly growing SCCVII tumor was excised and thoroughly minced with two scalpels. For maintenance, the resulting tissue was repeatedly passed through 18 and 20 gauge needles, respectively, and resuspended in phosphate buffered saline (PBS)  (Sigma Chemical Co., St. Louis, MO, USA) at a 1:4  (tissue : PBS, v/v) ratio. 100 uL of tissue suspension was then injected into the  Rhotofrin in murine macrophages thigh muscles of an anaesthetized mouse.  26  For tumor implantation, minced  tumor was enzymatically dissociated into single cell suspension using the following enzyme cocktail: 0.02 % Collagenase I, 0.015% DNAse.l, (Sigma) and 0.125 % Trypsin (Difco Laboratories, Detroit, Ml, USA) in PBS, and incubated for 30 minutes at 37°C with gentle rotation. Approximately 200 mg of tumor tissue was digested in 5 mL of this cocktail. The resulting cell suspension was then filtered through a nylon mesh filter with pores of 80 |im and washed 2x with Eagle's minimum essential medium (MEM) (Gibco, Grand Island, NY, USA), supplemented with 10% fetal bovine serum (FBS)  (Gibco).  Cells were then  counted and cell concentration adjusted to 1x10 cells/mL. Thirty \iL of this cell 7  suspension was injected subcutaneously over the shaved sacral region of anaesthetized mouse. Tumors were used for experiments when they attained a size of 500-800 mg (wet weight). 2.3.2 Measurement  of Photofrin  uptake  2.3.2.1 Harvesting macrophages and Photofrin exposure in vitro Peritoneal macrophages were collected from 9-11 week old C3H/HeN mice. The mice received one intraperitoneal injection 0.5 mL of thyoglycollate broth (Difco Laboratories, Detroit, Ml, USA) at 3 days before macrophage collection. After the sacrifice, the peritoneum was washed with 5 mL of ice-cold (0°C) PBS. The lavages from three to five mice were pooled, cells were pelleted by centrifugation and resuspended in Eagle's MEM supplemented with 10% FBS (all by GIBCO) at a concentration of 1-2x10 cells/mL. 6  The cells were  transferred into 60 mL tissue culture dishes (Falcon, Becton Dickinson and Company, Lincoln Park; NJ, USA) and incubated for 2h in a complete growth medium at 37°C.  Nonadherent cells were then washed away and Photofrin  was added to the samples at given concentrations. The growth medium with  Photofrin in murine macrophages  27  1% FBS was used during the exposure to Photofrin, unless stated otherwise. The exact number of cells per sample was determined by substracting the number of nonattached cells from the total number of nucleated cells originally plated. The macrophage preparations used in this study consisted of 90-95% macrophages as judged by the expression of nonspecific esterase activity. 2.3.2.2  Effect of plasma proteins on Photofrin accumulation and retention  In the experiments testing the effects of individual plasma proteins, macrophages were exposed to Photofrin (40 u.g/ml_) in the presence of low density lipoproteins (LDL), high density lipoproteins (HDL) (both at 0.2 mg/mL), albumin (5 mg/mL), or in protein free medium.  Before cell exposure, the  Photofrin-protein mixture was first incubated for 30 min. at 37°C to allow for the optimal interaction between Photofrin and the proteins. For Photofrin clearance incubations, the macrophages were washed free of the drug and plasma proteins and further incubated in a complete medium for 24 hours. In all cell culture experiments, the pH was maintained at 7.2-7.4.  To prevent  photodestruction of Photofrin, all procedures were performed in subdued light and culture dishes were wrapped in aluminum foil. 2.3.2.3 In  Fluorescence analysis of tumor cells all  experiments  Phototherapeutics, photosensitizer.  Inc.,  Photofrin® Vancouver  (kindly BC,  provided Canada)  by was  Quadralogic used  as  a  Mice received 25 mg/kg of Photofrin by injecting the  appropriate volume of the original Photofrin solution (2.5 mg/mL) via the tail vein.  At the indicated times after the Photofrin administration,, mice were  sacrificed and tumors excised, weighed, and single cell suspensions prepared as described in section 2.3.1. The cell concentration was then adjusted to 12 x 1 0 cells/mL in MEM 7  supplemented with 10% FBS.  Fluorescein  Photofrin in murine macrophages  28  isothiocyanate (FITC) goat anti-mouse IgG (whole molecule) (Sigma) was then added to the cell suspension at 1:200 (v/v) final dilution, as described previously (Olive 1989). The cells were then incubated at 37°C for 3-5 minutes and then washed 2x with ice cold MEM.  This procedure was shown to  effectively stain Fc receptor bearing (FcR+) cells in tumor cell suspensions. Antimouse IgG binds to either Fc receptor or to mouse antibody which is occupying the Fc receptor on the FcR+cell (Lindsay et al. 1982; Olive 1989). The cells were analyzed by a dual laser fluorescence activated cell sorter (FACS 440, Becton-Dickinson, Mountainview, CA, USA).  Fc receptor positive  (FcR ) and Fc receptor negative (FcR ) cells were simultaneously analyzed for +  -  the intensity of the Photofrin fluorescence. FITC was excited by a 488 nm laser and the emission was measured through a 530 ± 15 nm bandpass filter. Photofrin® was excited by UV lines (350-360 nm) and emission recorded through a 635 nm longpass filter. 1-2x10 cells were analyzed per sample in 4  these measurements. In addition, 0.5-1.0x10 FcR+ and FcR- cells per sample 6  were sorted for independent determination of Photofrin content using the chemical extraction of porphyrin material from the cells. 2.3.2.4  Photofrin measurement from cell extracts.  Following centrifugation of the cells which were collected from the FACS as described in the previous section, 3 mL of ScintiGest tissue solubiliser (Fisher Scientific, Fair Lawn, NJ, USA) at 1:10 (v/v) aqueous dilution was added to the cell pellet. The hydrolysis of porphyrin material was facilitated by incubating the samples overnight at 60°C. As a result, all Photofrin components are converted into a more uniform material with optimal fluorescence yield (Brown and Vernon 1990; Korbelik and Hung 1991).  Fluorescence of the cell extracts was  measured by a System 3 Scanning Spectrofluorometer (Farrand Optical Co:,  Photofrin in murine macrophages  29  Valhalla, NY, USA). The fluorescence intensity recorded was at the maxima for excitation and emission, at 405 and 625 nm, respectively. The actual Photofrin concentration was calculated using standard calibration curves obtained with known Photofrin concentrations. 2.3.2.5  Determination of Photofrin content by radiolabeled drug  [ C]-polyhematoporphyrin (which is identical to Photofrin), 4 (iCi/mL (1 14  Ci/mol), was purchased from Leeds Radioporphyrins (University of Leeds, Industrial services Ltd., Leeds, England); the labeled atoms are located within the porphyrin ring. Cells were exposed to [ C]-polyhematoporphyrin under the 14  same  in vitro  conditions as for the other Photofrin uptake experiments. The cell  extracts in ScintiGest were also prepared the same way as for the fluorimetric assay. Before radioactivity measurement, the cell extracts were neutralized with glacial acetic acid.  H 2 O 2  (30%) was the added (0.5 mL/1.5 mL cell extract),  followed by a scintilation fluid (ScintiVerse Bio-HP; Fisher Scientific Co.). Radioactivity was measured in an .LKB 1214 liquid scintilation spectrometer. The concentration of photosensitizer in the samples was determined using a calibration curve prepared from radioactivity counts obtained with the ScintiGest-treated solutions of known concentrations of radiolabelled drug. 2.3.2.6 .  Separation of macrophages by differential cell attachment  Macrophages have the capacity of fast and firm attachment to a plastic substrate, while SCCVII tumor cells need a much longer time for firm substrate attachment. This difference can be exploited as a means of obtaining separate populations of tumor cells and TAM (Russell et al. 1980).  Single cell  suspensions in MEM + 10% FBS were prepared from S C C V I I tumor as described above. The cells were plated in 10 cm tissue culture dishes (Falcon, Becton Dickinson and Comp., Lincoln Park, NJ, USA) at a concentration of 5-  30  Photofrin in murine macrophages 6x10  6  cells per dish and left 5 min. in the CO2 incubator at 37°C.  The  supernatant was then removed and non-attached cells rinsed with two washes using 5 mL of the medium. The attached cells consisted almost exclusively of macrophages. Over 8 5 % of these cells were positively stained for non-specific esterase, and the morphology, of some non-positively stained cells suggested that they were macrophages. The non-attached cells in the original supernatant and the two washings were pooled together and transferred into second 10 cm dish.  The macrophages remaining in the cell suspension were allowed to  attach to the bottom surface of this second dish by 10 min. incubation at 37°C. The non-attached cells remaining suspended in the medium were finally plated in the third 10 cm tissue culture dish, or they were taken immediately for determination of Photofrin content. The tumor cell population obtained by this procedure contained no positively stained cells for non-specific esterase. 2.3.3  Statistical  analysis  The significance of the difference between two mean Values was in most c a s e s carried out using an unpaired t-test assuming a normal sample distribution. A pooled variance was used with assumption that samples were drawn from populations with equal Variance. considered statistically significant.  P-values smaller that 0.05 were  Standard deviation was employed as a  mesaure of dispersion. 2.4  Results  2.4.1 macrophages  The uptake  of Photofrin  and SCCVII  by murine  peritoneal  tumor cells in vitro.  The results of Photofrin uptake by peritoneal macrophages and S C C V I I tumor cells are shown in Figure 2.1. Measurement of drug fluorescence in  Photofrin in murine macrophages  31  live cells (Figure 2.1 A) showed much better accumulation of Photofrin in tumor cells than in macrophages.  The uptake curves of both cell types show that  saturation is reached after the initial 2-3 hours of exposure to the drug. However, quite different results were obtained when Photofrin fluorescence in the same cells was measured in the cell extracts (Figure 2.1 B).  The uptake  capacity of macrophages was in this case clearly much superior to that seen in tumor cells. The shape of the curves remained basically unchanged.  Photofrin in murine macrophages  3  32  -•—  Macrophages  -•—  SCCVII  "ai o CO  o CD Ql <D O C CD O CO CD  o 3  n 6  1 — T 1 1 T 1 1 r —r— 8 1 0 1 2 1 4 1 6 1 8 20 22 24 -  Uptake time [h] 3 JO  75  o  CD  o CD  o_ CD  o c  CD O , CO CD O D  1 5  r 20  1 25  Uptake time [h]  Figure 2.1  Photofrin uptake by peritoneal macrophages and SCCVII tumor  cells in vitro.  Cells were exposed to Photofrin (40 u-g/mL) in Eagle's MEM with 1% FBS for the time intervals indicated. A, Photofrin fluorescence measured in suspension of live cells; B, Photofrin' fluorescence in cell extracts. Bars indicate SD.  Photofrin in murine macrophages  33  Photofrin uptake by macrophages and S C C V I I tumor cells following exposure to different photosensitizer concentrations was also measured, t h e macrophages and tumor cells were exposed to [ C]-polyhematoporphyrin for 14  24 hours and the results are expressed per cell protein to compensate for differences in cell size. Determination of cellular protein content based on the Lowry method showed that S C C V I I tumor cells have on average 3 times more cellular protein than macrophages (278 versus 92 pg/cell, respectively). The data presented in Figure 2.2 clearly  demonstrate that  macrophages,  compared to tumor cells have significantly greater capacity for photosensitizer uptake.  5  10  15  Photofrin e x p o s u r e Tjig/ml]  Figure 2.2 , Uptake of [ C]-polyhematoporphyrin by peritoneal macrophages and SCCVII tumor cells in vitro. Cells were exposed for 24 hours to different concentrations of the radiolabeled drug in Eagle's MEM with 1% FBS. Radioactivity in the samples was measured using a scintillation counter. Bars indicate SD. 14  Photofrin in murine macrophages  34  The effect of the presence of nonadherent cells from the peritoneal exudate on photosensitizer uptake by macrophages is shown in Table 2.1. Two hours after the initiation of  in vitro  culture, the non-adherent cells were washed away  in one group of samples, while in the other samples these cells were not removed.  All the samples were then incubated for 24 hours in seruni-free  growth medium and exposed to [ C]-labeled photosensitizer. The presence of 14  non-adherent cells, was obviously stimulating the photosensitizer uptake by macrophages, which was 40-50% greater than in the samples where nonadherent cells were washed away shortly after the initiation of in Table 2.1  vitro  culture.  Effect of presence of non-adherent cells from peritoneal exudate on the uptake of [ C]-polyhematoporphyrin by murine peritoneal macrophages. . . 14  Photosensitizer content  3  (ng/u.g cell protein) 42 + 3  Non-adherent cells not present  60 ±3  Non-adherent cells present  Determined after 4 hours of exposure to 10 u.g/mL (0.016 |xGi/mL) of [ C ] polyhematoporphyrin in serum-free medium, using a scintillation counter. The values for photosensitizer content for the two groups are statistically different (P<0.01), as determined by Student's t test. Values are mean + SD.  a  1 4  2.4.2 cells  The effect and  of serum  on Photofrin  uptake  by  SCCVII  macrophages.  In experiments testing the effect of serum on photosensitizer uptake, macrophages were always cultured in the presence of. non-adhering cells. A s shown in Figure 2.3 the presence of 1 % F B S strongly inhibited sensitizer uptake by both S C C V I I cells and macrophages.  Little additional effect on  uptake was seen at higher serum concentrations. The inhibitory effect of serum was more pronounced with macrophages than with tumor cells (a reduction of  Photofrin in murine macrophages  35  approximately V-io, compared to a reduction of V4 - V 5 of the sensitizer level seen in serum-free medium with tumor cells).  -  w 0 "53  Macrophages  •  SCCVII cells  6 r  °1 2 •*—> — 1 |1 0 c0 c ~ 8 CO  0 0  % 6  jSU  •  §"2  CD N  T  o CO cE, CD  ^  5  CD O  O  co 4 O  0 0%  1 % 5%  10%  Percent serum  4  Hill!  Br  CD _N  V-< '(Ii  c  CD CO  5  T 1  0%  1%  Percent of FBS  Figure 2.3  .  10%  5%  in culture media  Effect of serum on Photofrin uptake by peritoneal macrophages in vitro.  Cells were exposed to [ C]-polyhematoporphyrin (10 ug/mL; 0.016 uCi/mL) for 4 h in Eagle's MEM with 0, 1, 5 or 1 0 % FBS in the presence of non-adhering cells from peritoneal exudate. S C C V I I tumor cells exposed to the drug under the same conditions were examined for comparison. The cellular sensitizer content was determined as for Figure 2.2. . Inset: Ratios (macrophages : tumor cells) of the sensitizer content per cellular protein calculated from the drug uptake levels obtained in the presence of different serum concentrations. Bars indicate SD. 14  This is best illustrated by following the ratio macrophages/tumor cells of the sensitizer levels on per cellular protein basis (Figure 2.3, inset).  The ratio value,  Photofrin in murine macrophages  36  which in the absence of serum was 11.0 +1.4 (SD), was reduced by almost 5 0 % with 1% serum present. With higher serum concentrations, the ratio declined even further, although much less prominently. 2.4.2.1  .  The effect of plasma proteins on uptake and retention of Photofrin  by S C C V I I cells and macrophages. The effects of different plasma proteins on the uptake and subsequent retention of Photofrin are shown in Figure 2.4.  The inhibition of Photofrin  uptake (compared to protein free samples) was obtained with all the proteins, with the greatest effect shown by albumin. The ensuing retention of the drug in macrophages was not affected to any greater degree by the interaction with plasma proteins during the Photofrin uptake period, although the samples with LDL and albumin showed somewhat inferior Photofrin retention. A s the net result of these differences in Photofrin uptake and retention in peritoneal macrophages, the levels of the drug that remained in the cells were the lowest in albumin and LDL samples.  Photofrin in murine macrophages  ^  100 -  . c. cD C o 80 o  •  Uptake  H  Uptake and clearance  I  £O 60 •—»  o  JO _C0  CD  o  40  CD >  37  CO  ^5 in  CM CM  20  CM  CD CO  00  DC  d MEM.  d LDL  HDL  ALBUMIN  Figure 2.4  Effects of plasma proteins on uptake and retention of Photofrin by peritoneal macrophages in vitro. Cells were exposed to Photofrin (40 ug/mL) for 1 hour in Eagle's MEM with LDL (0.2 mg/mL), HDL (0.2 mg/mL), or albumin (5 mg/mL). or in the absence of protein. For the ensuing retention of the drug, the cells were incubated for 24 hours in drug-free medium with 1 0 % FBS. Photofrin content was determined from the cell extracts using the fiuordmetric assay. Photofrin uptake values relative to the uptake values obtained with protein-free samples and percentage of the retained drug following the clearance incubation are indicated in the uptake and clearance columns, respectively. Bars indicate SD  2.4.3 by  Photofrin  uptake  by peritoneal  macrophages  is  inhibited  cytochalasin-B. In vivo  uptake of Photofrin by peritoneal macrophages was also examined.  In this case, Photofrin was administered i.v. and the mice were sacrificed at different times after the drug injection. Peritoneal macrophages were harvested and the photosensitizer content was determined in the cell extracts by the fluorometric assay.  The data (Table 2.2) show that Photofrin accumulates  faster during the initial hours following drug administration. Subsequently, it took 20 hours to double the cellular level reached at 4 hours after administration  Photofrin in murine macrophages  38  of the drug. The results of Photofrin measurement in macrophages obtained from mice which received cytochalasin B immediately before Photofrin are also shown in the same table. It is evident that the uptake of the photosensitizer by, peritoneal macrophages  in vivo  was strongly inhibited by cytochalasin B (p <  0.01). Table 2.2  Effects of cytochalasin B on in vivo peritoneal macrophages . 8  uptake of Photofrin by •  Photofrin content (ng/pig cell protein) Time after drug administration (h)  No cytochalasin B  With . cytochalasin B  4  210 + 40°  60 ± 30°  24  420 ± 90  70 ± 40°  Photofrin, 25 mg/kg, i.v.; cytochalasin B, 15 mg/kg, i.p. Photofrin content was determined from cell extracts by the fluorometric assay. Mean ±SD. a  b  c  p < 0.01  Retention of Photofrin (accumulated  in vivo)  in peritoneal macrophages,  tumor associated macrophages, and S C C V I I tumor cells under  in  vitro  conditions is depicted in Figure 2.5. The clearance curves for all three cell types are remarkably similar. They show some loss of Photofrin material from cells between the 1st and 4th hour of clearance incubation, and a very limited further clearance between 4 and 24 hours of incubation. All three cell types retained 70-80% of Photofrin after 24 hours of clearance period.  The initial  values of Photofrin per |ig of cell protein in peritoneal macrophages and T A M were 420 ± 90 and 74 + 13 ng, respectively, and 15 + 2 ng in tumor cells. Calculated per cell protein, the levels of Photofrin in T A M were approximately  Photofrin in murine macrophages 15 times higher than in tumor cells. Retention of Photofrin accumulated  39 in  vitro  in SCCVII tumor cells is also shown (Figure 2.5.b). In contrast to the other three clearance curves shown in Figure 2.5, the rate of Photofrin loss from the cells was in this case evidently greater during the initial hours of incubation.  Photofrin in murine macrophages  40  1  Peritoneal macrophages Tumor assoc. macrophages 0 L_i_l 0 2  i  • i  4  6  •  i  8  •  •' •i  .1 , I 1 0 1 2 1 4 1 6 1 8 20 22 2 4 2 6 i  •  i  • i  C l e a r a n c e time [h]  •  0  2  4  6  8  •  Uptake in vitro  •  Uptake in vivo  •  •• i  •  '  •  '  •  '  1 0 1 2 1 4 1 6 1 8 20 22 24 26  C l e a r a n c e time [h] Figure 2.5  Retention of Photofrin in macrophages and tumor cells under in vitro  conditions.  A, retention of the drug accumulated in vivo in peritoneal and tumor associated macrophages; B; retention of the drug accumulated either in vivo or in vitro in SCCVII tumor cells.. The clearance incubation was in drug free medium with 1 0 % FBS. Photofrin retention was calculated from the drug contents determined from the cell extracts using the fluorometric assay. Bars, SD.  Photofrin in murine macrophages  2.4.4  The uptake of Photofrin  tumor  associated  macrophages  by SCCVII  4.1  tumor  cells  and  in vivo.  In next series of experiments Photofrin fluorescence in FcR+ and FcPr cell populations from  SCCVII  tumors excised at different times after  the  administration of photosensitizer to mice was determined by flow cytometry analysis (Figure  2  CO  2.7).  r  1.5 -  1 -  o o 3  0.5  -  O  JO  12 Time  Figure 2.7  24 after  36 Photofrin  48  60  72  administration  84  ,9 6  (hours)  Photofrin fluorescence intensity in tumor cells (FcR") and host cells (FcR ). Cells were sorted from SCCVII tumor cell suspension and fluorescence intensity measured by FACS 440. The measurement was performed for a series of tumors (three or more per point) excised at different times post administration of Photofrin (25 mg/kg). " = Photofrin level significantly lower compared to that at12.hours. (p<0.01). Bars represent standard deviations. +  Photofrin in murine macrophages  42  The Photofrin levels in both cell populations reached a maximum 12 h after the drug administration. This was followed by a steady decrease in Photofrin levels in both cell populations at 2, 3, and 4 days after the administration of the photosensitizer.  The decrease was statistically significant for F c R  population (p < O.Oi). The Photofrin level in F c R  +  +  cell  populations was constantly  higher than in FcR- populations at all time intervals examined. The results of an independent method of Photofrin content measurement employing chemical extraction of porphyrin material from F c R sorted by F A C S are presented in Figure 2.8.  +  and F c R ' cells  Similar to the results obtained  by flow cytometry (Figure 2.7), constantly higher levels of the photosensitizer were detected in the FcR+ tumor cell population. The Photofrin content reached its highest level at 24 h post administration of the drug. During the next 2 days the Photofrin levels decreased in both cell populations. Compared to the value at 24 h, the decrease was statistically significant at 96 h with FcR+ cells.  Photofrin in murine macrophages 5  43  r  FcR  +  FcR"  0  12  24  Time  after  36  Photofrin  48  60  72  administration  84  96  (hours)  Figure 2.8  Photofrin content in two populations of S C C V I I tumor cells; FcR and FcR". The cells were separated and sorted by FACS and the Photofrin content was determined by fiuorometric assay from the cell extracts. The FACS measurement of Photofrin fluorescence in the same samples is shown in Figure 2.7. **= Photofrin level significantly lower than at 24 h (p<0.05). Bars are SD. +  The results for Photofrin measurements shown in Figures 2.7 and 2.8 are expressed on per cell basis and thus do not take into account a marked difference in size and protein content that exists between cells found in F c R  +  and FcR- populations. For FcR+ cells, the measurements in Figure 2.8 with protein content calculated per u,g cell protein gives 0.38 and 0.18 ng of Photofrin per jig of cell protein at 24 and 96 h, respectively. The values at 24 and 96 h for FcR- cells are 0.05 and 0.04 ng of Photofrin per |ig of cell protein, respectively. The analysis of Photofrin content per weight of cell protein clearly emphasizes the higher levels of the photosensitizer accumulation in F c R populations.  +  Photofrin in murine macrophages  44  The ratios of the Photofrin levels determined in FcR+ and F c R ' populations expressed on per cell basis, are shown in Figure 2,9.  The ratio values  derived from flow cytometry analysis are always greater than 1.7, and reach 2.7 at 12 h post Photofrin administration. Compared to the value at 12 h, the ratios at 1 and 24 h are significantly lower, while at the other time points the difference is not statistically significant. The comparative ratio values derived from the porphyrin extraction method shown on the same graph are very similar, except that the maximal value (3.0) is already reached at the 4 h time point. Compared to this maximal value, the ratios at 48, 72, and 96 h are significantly lower (p<0.005), while at the other time points the difference is not statistically significant.  Photofrin in murine macrophages • 4.0  rr o  o o  3.5  45 Flow  cytometry  • .Extraction  r  method  -  3.0 2.5 I  +  2.0  I  i  rr o  1.5  •£  1 -0 0.5 0.0  1  4  12  24  48  Time after Photofrin administration  Figure 2.9  72  96  (h)  The ratios of Photofrin content determined in FcR : FcR" cell populations derived from SCCVII tumors The ratio values were derived from the data shown in Figure 2.7 (flow cytometry analysis) and Figure 2.8 (chemical extraction of porphyrin from the cells). Values significantly lower than the values at 4 h (cell extracts), or 12 h (flow cytometry analysis): **p<0.005; *.= p<0.01. +  The calculation, based on weight of cell protein of the FcR+ / FcR- ratios of Photofrin content obtained with the extraction method, give essentially the values shown in Figure 2.9 multiplied by a factor 3.02, average ratio of protein content in FcR- cells compared to FcR+ cells. Such analysis shows that FcR+ cells can accumulate 9.2 times more Photofrin on a per cell protein basis at the peak time, i.e. at 4 h post Photofrin administration.  Photofrin in murine macrophages 2.4.4.1  46  The effect of separation method on Photofrin content in SCCVII  tumor cells and TAMs. The results of Photofrin content measurement in populations of S C C V I I tumor derived cells separated by the differential attachment  separation  technique are shown in Table 2.3. The T A M population obtained with this separation technique again showed much higher levels of Photofrin than the tumor cell fraction. The measurement, with cells harvested at 24 h post drug administration, showed a Photofrin level in the tumor cell fraction very similar to that  obtained  with  FACS  sorted  F c R " cells (Figure 2.8, 24 h).  The  photosensitizer level in the T A M fraction, however, was over two times higher than in F A C S sorted F c R cells, i.e. 7.37 u,g compared to 3.6 fig of Photofrin per +  108 cells. Table 2.3  Photofrin content in tumor cells fraction and TAM fraction, derived from S C C V I I tumor and separated by differential substrate attachment.  Photofrin content ( m g / 1 0 cells) 8  Tumor cell fraction T A M fraction  i.50±  Ratio (TAM : tumor cells)  0.17a  7.37 ±1.30  4.9 ±0.9  Tumors excised 24 h after Photofrin administration (25 mg/kg)". Photofrin content determined by porphyrin extraction method followed by fluorometric measurement (see Materials and Methods). a  S t a n d a r d deviations given.  2.4.4.2  The effect of enzymatic digestion on Photofrin content in tumor  cells and macrophages. The issue of a possible disproportionate photosensitizer loss from different cells during the exposure to the enzymatic digestion procedure used for dissociation of cells from tumor tissue was analyzed in a separate in vitro experiment. Three different types of cells, S C C V I I tumor cells, S C C V I I tumor  Photofrin in murine macrophages  47  T A M , and peritoneal macrophages from .C3H/HeN mice, were exposed to Photofrin  in vitro,  and then harvested either by using a rubber policeman, or by  employing the enzymatic procedure identical to that used for dissociating cells from tumor tissue. The macrophages (both T A M and peritoneal) accumulated more Photofrin than the tumor cells (Table 2.4) under these  in vitro  conditions.  The loss of cellular Photofrin following enzymatic digestion was approximately 6 0 % with tumor cells, and around-75% with both types of macrophages. Table 2.4  The effect of exposure to a mixture of trypsin, collagenase, and DNAase on Photofrin levels in tumor cells and macrophages.  Photofrin content (mg / 1 0 cells) 8  Mechanical  Enzymatic treatment  detachment S C C V I I tumor c e l l s  3  10+1.8°  3.8 ±0.3  TAM  62 ± 18  - 15±3  Peritoneal macrophages  80+15  21 ± 1  Cells were exposed to 10 ug Photofrin/mL in growth medium (MEM with 1% FBS) for 24 h at 37°C. Subsequently, they were rinsed with PBS, and then harvested using either a rubber policeman, or by the enzymatic digestion procedure identical to that used in dissociation of cells from tumor tissue. Photofrin content was determined by Photofrin extraction from washed cell pellets, followed by fluorometric measurement. Tumor cells and TAM were selected from SCCVII tumors by the differential attachment procedure (see Materials and Methods); the tumor cells were cultivated in vitro for 2 weeks before the experiment. Cultures with peritoneal macrophages were isolated from C3H mice as described in Materials and Methods. a  b  Standard deviations given.  2.5  Discussion It was suggested by Jori (Jori 1989) that porphyrins, phthalocyanines, and  other photosensitizers that can remain in a highly aggregated form  in vivo,  are  phagocytized to a large degree by TAMs. The evidence presented in this study demonstrates that macrophages have a capacity for Photofrin accumulation vastly superior to that of S C C V I I tumor cells. In addition, it is shown that factors  Photofrin in murine macrophages  48  that modify macrophage activity also influence Photofrin uptake by these cells. Cytochalasin B, a known inhibitor of phagocytosis (Axline and Reaven 1974), reduced  in vivo  uptake of Photofrin by peritoneal macrophages (Table 2.2). In  contrast, the presence of non-adherent cells from peritoneal lavage (mainly lymphocytes) induces macrophage activation (Yamamoto et al. 1988) and stimulates Photofrin uptake by peritoneal macrophages  in vitro  (Table 2.1). All  of these results support the assumption that Photofrin uptake by macrophages is dominated by phagocytic internalization of a, highly aggregated drug component.  The interaction of Photofrin with human plasma proteins and  complete serum inhibits the uptake of this drug by macrophages, as it does with tumor and other cells (Korbelik et al. 1990; Korbelik and Hung 1991). However, the presence of serum inhibits the photosensitizer uptake to a greater extent in macrophages than it does in tumor cells (Figure 2.3). The above can be interpreted as a consequence of disaggregation of Photofrin material induced by serum and its components (Korbelik and Hung 1991).. This disaggregation of the drug affects its uptake by macrophages more (fewer aggregates to be phagocytized) than its uptake by tumor cells. Photofrin-plasma protein interaction affects the ensuing retention of the Photofrin material in macrophages less than in tumor cells (Korbelik and Hung 1991).  In the experiments with individual plasma proteins (Figure 2.4), the  macrophages have presumably still phagocytized the same type of drug material, i.e., the remaining Photofrin aggregates.  Tumor cells in such  circumstances, however, take up altered drug material with more poorly retaining Photofrin species, released upon interaction with plasma proteins (Korbelik and Hung 1991). Both peritoneal macrophages and T A M s have shown a very good retention of Photofrin accumulated  in vivo,  and similar retention qualities were exhibited  Photofrin in murine macrophages by tumor cells (Figure 2.5).  49  In these experiments it was not possible to  determine cellular Photofrin contents immediately after collecting cells from the mice, because of the time needed for separation (15-20 min. for peritoneal macrophages, and more than 1 h for T A M s and tumor cells). However since the clearance of Photofrin from these cells is very limited, there is no indication that there could be a significant loss of the drug from the cells during the isolation procedure. The clearance of Photofrin from peritoneal macrophages (Figure 2.4), tumor cells (Figure 2.5 B), and other cells (Korbelik and Hung 1991) following the uptake of the drug vivo.  in vitro  is much greater than for the Photofrin accumulated  in  In the former case, the clearance curves are characterized by an early  phase of rapid Photofrin loss during the initial 1-3 hours of the clearance incubation, followed by a phase of further limited loss of the drug from the cells (Henderson et al. 1983; Korbelik and Hung 1991).  It c a n be a s s u m e d ,  therefore, that in the cells collected after 24 hour accumulation of Photofrin in vivo  the initial phase of fast Photofrin clearance has mostly been completed. One of reliable methods for discrimination between tumor cells and host  cells in solid tumors is based on the presence of surface receptors for the Fc portion of immunoglobulin on the membranes of the host cells and the absence of these receptors on the membranes of tumor cells (Wood and Gollahon 1977; Lindsay et al. 1982). This principle was successfully employed by Olive (Olive 1989) to separate tumor and host cells derived from murine S C C V I I tumor by flow cytometry using the FITC-conjugated anti-mouse IgG. Over 9 5 % of FcR+ (i.e. IgG positive) cells in S C C V I I tumor were identified as T A M (Olive 1989). The FcR- fraction contains tumor cells contaminated with 5-10% diploid cells, presumably host cells devoid of Fc receptor. In this study we have combined the above method for separation of host and tumor cells with simultaneous  Photofrin in murine macrophages  50  excitation and fluorescence measurement of photosensitizer Photofrin using a dual laser F A C S apparatus.  This enabled the examination of Photofrin  distribution between malignant tumor cells (FcR negative) and host cells (FcR positive) contained in the murine S C C V I I tumor following  in vivo  administration  of the photosensitizer. The flow cytometry analysis of cellular Photofrin content in FcR+ and F c R ' populations Comprising the S C C V I I tumor demonstrated that, at least up to 4 days after Photofrin administration, there is more drug accumulated in F c R  +  than in F c R ' cells (Figure 2.7). Taking into account the content of host cells in S C C V I I tumor (-40%), the data indicate that most of the photosensitizer material is. in fact contained in T A M s , not in the tumor cells. This is particularly pronounced between 4 and 24 h after Photofrin administration when there is up to 3 times more photosensitizer in FcR+ than in F c R  -  cells on per cell basis.  Based on a per cell protein calculation the ratio is greater than 9 times for F c R  +  over F c R ' cells. The measurement of Cellular Photofrin content by flow cytometry was verified by an independent measurement of the drug content in sorted cells using chemical extraction of porphyrin followed by the fluorometric assay.  This  method includes hydrolysis and disaggregation of porphyrin material, which results in conversion of all photosensitizer components into a more uniform material with optimal fluorescence yield (Brown and Vernon 1990; Korbelik and Hung 1991). This is not the case with Photofrin fluorescence measurements in live cells during flow cytometry analysis, which registers the fluorescence intensity strongly dominated by highly fluorescing monomeric species, and reflects to a much lower degree the presence of highly aggregated and lessfluorescing species of this drug (Moan and Sommer 1983; Brown and Vernon  Photofrin in murine macrophages 1990).  51  The total Photofrin content in the cells not determined by the flow  cytometry analysis was thus assessed by the extraction method. The comparison of the results obtained by these two methods of Photofrin measurement (Figure 2.9) does not reveal any major discrepancies; both methods show higher levels of the sensitizer in F c R then in F c R cells. The +  -  only possible difference may be observed in the time when the maximal value for FcR /FcR- ratio in Photofrin levels is reached. This peak time is observed +  earlier for the extraction method (4 h post administration) than with flow cytometry analysis (24 h post administration); however, this difference cannot be fully supported by statistical calculation (see Figure 2.9). This possible difference is not unexpected, since at its highest levels (attained 4 h post administration) much of the Photofrin material in the cells could be in the highly aggregated form and thus underestimated by the flow cytometry. A few hours later, following intracellular dissociation of its aggregates, Photofrin can reach its strongest fluorescence.  Nevertheless, Figure 2.9 suggests that in general  there is no substantial difference in Photofrin content as revealed by the two methods (fluorescence in the live cells and fluorescence following the extraction procedure). This implies that the form in which the photosensitizer is presented to cells under  in vivo  conditions is.not the same as  in vitro  (Figure 2.1). In fact,  an alternate possibility to the existence of aggregated species c o m p l e x e s of non-aggregated  in vivo  photosensitizer associated with  would be various  macromolecules. There seem to exist two potential impediments to the F A C S method used in this study. The procedure for dispersion of the tumor into single cell suspension takes time (more than 1 hour) and exposes cells to digestion enzymes; all of which could result in some loss of photosensitizer from the cells. The other potential problem is photodestruction (photobleaching) of Photofrin by exposure  Photofrin in murine macrophages to the strong excitation light ( F A C S laser).  52  In a control experiment, in which  T A M s were separated,from tumor cells by taking advantage of their much more rapid attachment to the plastic substrate; a 4.9 times higher level of Photofrin was detected in T A M s enriched population compared to the tumor cell population (Table 2.3).  In this case F A C S was not used, and thus there could  be no Photofrin.photobleaching. Compared to the T A M population sorted by F A C S , the macrophages selected by differential attachment procedure may be enriched in activated TAMs. The most likely reason for this difference is that not all macrophages contained in FcR+ fraction would attach equally well to the substrate.  The non-attaching T A M s , which are probably less active and  accumulate less Photofrin, are lost in the differential attachment procedure. This factor seems most likely to be responsible for the difference iii the Photofrin levels found in T A M populations selected by these two procedures. The enzymatic procedure used for obtaining single cell suspension, from tumors could induce a differential loss of Photofrin from T A M s and. tumor cells. The Photofrin loss seen in the experiment designed to address this issue (Table 2.4) was greater in macrophages than in tumor cells. This suggests that higher -Photofrin levels in F c R cells compared to FcR cells (Figures 2.7-2.9) could not +  -  be an artifact induced by the enzymatic digestion procedure. It should also be noted that the enzymatic treatment is much harsher to isolated cells attached to the tissue culture dish than to the cells contained in pieces of tumor tissue. It can be assumed that the photosensitizer loss from the cells induced by.the enzymatic procedure before the flow cytometry analysis was substantially lower than that seen  in Table 2.4.  This is also inferred by the  retention  measurements, which suggest that Photofrin material accumulated in wVo.in cellular populations of the S C C V I I tumor (at 24 h after the drug administration) is bound more firmly to the cells than following brief in vitro exposure to the  Photofrin in murine macrophages drug.  53  In the latter case, the drug may be bound loosely to the outer cellular  membrane, where it is more readily removed by the enzymatic treatment. The data presented in this study clearly show that in S C C V I I murine tumor much higher levels of Photofrin are accumulated in T A M s than in tumor cells. This result strongly supports previously published but less direct evidence and suggestions by others (Bugelski et al. 1981; Chan et al. 1988; Henderson and Donovan 1989; Jori 1989)!  In tumors with a high macrophage content the  preferential accumulation of Photofrin in T A M s could significantly contribute to the localization of Photofrin in tumor tissue.  The fact that most of the  photosensitizer material could be accumulated in the T A M population has obviously important implications for PDT. Light energy dependent production of tumor necrosis factor alpha (TNF-a) by murine macrophages has been demonstrated after  in vitro  P D T using Photofrin (Evans et al. 1990). Release of  prostaglandin E from peritoneal macrophages after Photofrin-based P D T has also been reported (Henderson and Donovan 1989).  There are strong  indications that PDT-induced immunosuppression (Lynch et al. 1989) and lethality due to TNF-a induced cahexia following P D T are mediated by macrophages (Darling et al. 1990; Ferrario and Gomer 1990).  PDT-induced  release of a variety of bioactive substances from T A M s , either by their destruction or activation can have profound effects on tumor cells, tumor vasculature, and other host cells. Recently,  an alternative  accumulation in T A M s and Newman  1994).  in vivo  mechanism  for selective  photosensitizer  was proposed by Hamblin and Newman (Hamblin  The authors hypothesize that T A M s  accumulate  photosensitizers which are bound to low density lipoproteins (LDL) and other plasma proteins via the LDL receptors and scavenger receptors.  Photofrin in murine macrophages  54.  Photofrin accumulation in malignant and host cell populations of various tumors was more recently studied in depth in our laboratory. In an extension to the initial work described above, we have performed more detailed analysis of different host cell populations infiltrating murine tumors. The study of Photofrin distribution in the murine fibrosarcoma F s a R growing in syngeneic C3H/HeN mouse or severe combined immunodeficient (SCID) mouse (Korbelik and Krosl 1995) has shown that there is marked heterogeneity in the cellular content of Photofrin within the tumor. Photofrin content in some T A M s was not higher.than in malignant cells. However, a subpopulation of macrophages characterized by high expression of C D 2 5 (IL-2 receptor) and high granularity accumulated on average almost 13 times more Photofrin than malignant cells. A study with various tumor models of different histological types  and d e g r e e s  of  differentiation, including chemically induced squamous cell carcinoma in Syrian hamster and a spontaneous adenocarcinoma that arose in C 3 H mouse, has shown very similar results (Korbelik and Krosl 1996). While the overall levels of Photofrin varied in different tumors, a subpopulation of T A M s that accumulated by far the highest cellular levels of photosensitizer was found in all of the examined tumors. Based on the results presented in this Chapter and the findings described above, it can be concluded that Photofrin accumulation in solid tumors does not depend on host species, the histological type or degree of differentiation of the tumor, or immunogenicity.  Moreover, no difference was noted in Photofrin  distribution between hamster and murine tumors despite the difference in the blood LDL content between hamster (similar to human) and mouse (low LDL content) (Chapman 1986). In bur view, it is the activation state of T A M s and their relative content in the tumor that is the determining factor for the degree of accumulation of Photofrin in solid tumors.  This is also consistent with the  Photofrin in murine macrophages  55  observation of photosensitizer accumulation in areas of inflammation (Nseyo et al. 1985). The evidence that in human malignancies T A M s mostly localize in a lesion's periphery (Svennevig and Svaar 1979; Bucana et al. 1992) gives support to our hypothesis that the T A M population that accumulates the highest cellular levels of Photofrin is responsible for the tumor fluorescence of this photosensitizer which delineates the tumor from normal tissues.  PDT induced host cell infiltration  56  CHAPTER 3 Induction of immune cell infiltration into murine SCCVII tumor by Photofrin based photodynamic therapy  1  3.1  Summary Cellular populations in the squamous cell carcinoma S C C V I I , growing in  C3H/HeN mice given Photofrin, were examined at various time intervals during the photodynamic light treatment and up to 8 hours later.  Cell populations  present within excised tumors were identified by monoclonal antibodies directed against cell type specific membrane markers using a combination of indirect immunoperoxidase and Wright staining or by flow cytometry.  Photofrin  based photodynamic therapy (PDT) induced dramatic changes in the level of different cellular populations contained in the treated tumor.  The most  pronounced was a rapid increase in the content of neutrophils, which increased 200 fold within 5 min. after the initiation of light treatment.  This was followed  immediately by an increase in the level of mast cells, while another myeloid cell type, most likely monocytes, invaded the tumor between 0 and 2 hours after PDT.  Macrophages harvested from S C C V I I tumor 2 h post P D T exhibited  pronounced increase in tumoricidal activity against autochtonous S C C V I I tumor cells. It seems, therefore, that P D T induced both the recruitment and functional activation of host-derived myeloid cells.  'The data presented in this chapter have been published in the following paper: -.1.  Krosl, G., korbelik, M., Dougherty, G.J. (1995) Induction of immune cell infiltration into murine SCCVII tumour by photofrin-based photodynamic therapy. Br. J. CancerTK, 549555.  PDT induced host cell infiltration 3.2  57  Introduction A combined effect of several cancer tissue destroying mechanisms is  responsible for tumor regression following photodynamic therapy (PDT).  (n  addition to direct killing of tumor.cells by phototoxic action and ischemic necrosis secondary to the collapse of the vascular system, there are indications of the involvement of P D T induced immune reaction (Bellnier and Henderson 1992; P a s s 1993). A n understanding of this rather complex interaction is made more difficult by the fact that the events leading to the vascular damage are different with different photosensitizers (Henderson and Fingar 1994). The most abundant lesion induced in P D T treated tumor is the phototoxic damage to the surface membranes of tumor cells. We have hypothesized that this subtle initial and not necessarily lethal damage may trigger a chain of events leading to tumor eradication (Korbelik and Krosl 1994).  The invoked  damage is probably the peroxidation of membranous lipids (Thomas et al. 1987), which  prompts a rapid (< 1 min.) activation  p h o s p h o l i p a s e s (Agarwal et a l . 1993) for accelerated phospholipids.  of  membranous  degradation of  It should be noted that very similar events occur in cell  membranes with the initiation of inflammation by microbial infection or by some other types of tissue injury (Chien et al. 1978; Yamamoto and Ngwenya 1987). The membrane damage discussed above can be thus described a s P D T induced inflammatory cellular damage. Inflammatory immune responses induced in cancerous tissues may be of different nature and more intense than those induced in normal tissues (Yamamoto and Ngwenya 1987); this may very well be the c a s e with the reaction triggered by P D T in solid tumors. The lipid composition of tumor cell membranes is different than that of normal cell membranes (Snyder and Wood 1969; Howard et al. 1972).  Fragments released from tumor cell membranes  PDT induced host cell infiltration  58  damaged by P D T include a variety of lysophospholipids and alkylglycerols (Yamamoto et al. 1988), as well as arachidonic acid and its metabolites (Henderson and Donovan 1989;. Bellnier and Henderson 1992; Fingar e t a l . 1992), all of which can serve as highly potent, stimulatory signals for the amplification of the inflammatory reaction. They are powerful chemotactic and stimulatory agents for immune cells, or highly active vasomodulatory mediators (Zurier 1982; Yamamoto and Ngwenya i 9 8 7 ; Yamamoto et al, 1988). A strong inflammatory reaction may be the most important contributor to the destruction of vasculature in PDT treated tumor. Very high doses of inflammatory products of cancerous tissues can cause immunosuppression, which was observed following P D T (Lynch et al. 1989). On the other hand, at different dose levels these same agents cause immune stimulation (Ngwenya and Yamamoto 1986; Yamamoto and Ngwenya 1987). It is therefore of a critical importance to better understand the P D T induced inflammatory/immune reaction in order to develop improved strategies for therapeutic benefit. The accumulation of inflammatory cells is a central event in the inflammatory process.  Yet, there, is very little information available on the  infiltration of these cells into the treated tumor during and after photodynamic light delivery. Obtaining this information was the main objective of this study. Focusing on the clinically established photosensitizer Photofrin, we, have chosen as tumor model the squamous cell Carcinoma S C C V I I subcutaneously in C3H/HeN mouse.  growing  The photodynamic light treatment was  performed 24 hours after the administration of Photofrin.  The  results  demonstrate a rapid, massive and regulated infiltration of various immune cells into the tumor site during and immediately following PDT.  PDT induced host cell infiltration 3.3  Materials and  3.3.1  Tumor  59  methods model  Female C3H/HeN mice, age 10-12 weeks, were used for experiments. The S C C V I I squamous cell carcinoma was maintained by intramuscular passage as described previously (Korbelik 1993). This is a weakly immunogenic tumor which originated spontaneously in the abdominal wall of a C 3 H mouse (Suit et al. 1985)  For experiments, tumors were induced by injecting 3 x 1 0 cells,  obtained  by  5  enzymatic  digestion  of  intramuscularly  growing  tumor,  subcutaneously over the sacral region of the back of anesthetized mice. Prior.to tumor inoculation all the hair was removed from the injection site by shaving. Tumors were used for experiments two weeks after the inoculation at which point their largest diameter was 7-8 mm and thickness 3-4 mm. 3.3.2  Photodynamic  therapy  Photofrin® (Quadralogic Technologies Phototherapeutics Inc., Vancouver, B.C., Canada) was administered at 25 mg/kg intravenously 24 hours before light treatment.  A tunable light source (Photon Technology International Inc.,  Model A5000) equipped with a 1 kW Xenon arc bulb and infrared filter was used to deliver 6 3 0 + 10 nm light to the tumor by a liquid light guide (Oriel Corp., Stratford, CT, USA) with a 5 mm core diameter. The output light power was 35 mW.  Mice were restrained unanesthetized in specially designed  holders. A dose of 60 J c n r (average fluence rate 45 mW/cm) was used in all 2  experiments and the average treatment time was 24 min; the exception was the analysis of tumors for the effects occurring before the full light dose was delivered.  Tumor temperature measured using a hypodermic thermocouple  (YSI, Yellow Springs, O H , USA) increased to 38-39°C at the end of the light treatment.  PDT induced host cell infiltration 3.3.3  Indirect  immunoperoxidase  and  Wright  60 staining  At various times after light treatment, mice were sacrificed by cervical dislocation, tumors were then excised and minced using two scalpels. Tumor tissue was then enzymatically dissociated by a 30 min. treatment in a mixture of dispase, collagenase and DNAse as described in detail previously (McBride et al. 1992; Korbelik 1993).  Briefly, minced tumor tissue was resuspended in  5 mL of H B S S and 300 |iL of each 4 mg/mL Collagenase I, 3 mg/mL D N A s e (both from Sigma), and 25 mg/mL Dispase (Boehringer, Meincheim, Germany) was added. After 30 min. of gentle mixing the resulting cell suspension was filtered through a 100p:m nylon mesh to remove any remaining tissue clumps and washed with Eagle's Minimum Essential Medium (EMEM) containing 1 0 % fetal bovine serum (FBS, HyClone Laboratories Inc., Logan, UT, USA). C D 4 5 (panleukocyte marker), and ap-TCR (T cell receptor) were detected using supernatants from hybridomas YE1.21 and HB218 that were generously provided by Dr. Fumio Takei (Terry Fox Laboratory). F4/80 antigen (marker for macrophages) was stained with hybridoma supernatant HB198 from A T C C . Cells were stained with an indirect immunoperoxidase technique as previously described (Dougherty et al. 1986). Briefly, acetone fixed cytospin preparations of cell suspensions were overlaid with 100[iL of hybridoma supernatant and incubated for 30 min. at room temperature. Cytospins were then washed 3x in H B S S , and left in last wash for 5 minutes. Rabbit anti-rat IgG F(ab')2 fragment conjugated with horseradish peroxidase (Sigma Chemical C o . , St. Louis, M O , USA) was used as a secondary antibody. Staining dilutions as to manufacturer recommendations were made in H B S S + 2 % F B S immediately prior to use. Cells were then overlaid with 100 |iL of secondary antibody and incubated for an additional 30 min. at room temperature.  After 3 washes in H B S S the  cytospins were immersed in peroxidase substrate dilution (Sigma) prepared  PDT induced host cell infiltration  61  according to manufacturers recommendation and incubated until sufficient staining had developed.  Slides were then counterstained with  Harris  hematoxylin, air dried and covered. At least 200 positive cells were scored on each slide. The levels of neutrophils and mast cells were determined using Wright stain (Accustain, Sigma) to manufacturers recommendations.  For this purpose,  10 [it of a suspension which contained 5 x 1 0 cells was layered onto glass 4  slides (3 slides per sample), which were left to dry in air before Wright staining. 3.3.4  Identification  of blood  derived  tumor  infiltrating  cells  The bisbenzimide dye Hoechst 33342 purchased from Sigma was used to identify newly infiltrated leukocytes in tumors exposed to PDT.  Since this  fluorescent nuclear stain is cleared rapidly from the plasma of mice following intravenous administration (Olive et al. 1985), it is possible to prevent the blood flow through the tumor for the time needed for the dye to disappear from the circulation. Tumor bearing mice injected with Hoechst 33342 (16 mg/kg, i.v.) were divided into two groups.  In the first group, the tumors were clamped  before the injection in order to prevent Hoechst 33342 from reaching the tumors.  In the second group, the tumors were not clamped. The clamp was  removed after 10 min. to allow re-perfusion of the tumor. Half of the mice from each group were exposed to photodynamic light treatment at 30 min after the Hoechst 33342 injection.  The mice were sacrificed at 2 hours after the  termination of light treatment, the tumors were excised and disaggregated into single cell suspensions as described above. The cells were then stained with monoclonal antibody to mouse C D 4 5 , or a combination of anti-mouse Gr1 (myeloid marker) and F4/80.  62  PDT induced host cell infiltration The antibodies to C D 4 5 and Gr1, labeled with phycoerythrin (PE)  were  purchased from PharMingen (San Diego, CA), while fluorescein isothiocyanate (FITC) conjugated anti F4/80 was obtained from Serotec Canada Ltd. (Toronto, Ontario, Canada).  The staining was performed using a modification of the  procedure described earlier (Dougherty et al. 1989). Each sample (total volume 1 0 0 u.L)  contained  0.5-1 x 1 0  6  cells  suspended  in  HBSS  (Sigma)  supplemented with 2 % F B S , to.which the antibodies were added at a dilution recommended by the supplier.  The samples, kept in subdued light, were  incubated on ice (0°C) for 30 min. The cells were then washed twice in H B S S + 2 % F B S using centrifugation. For each sample, 1 0 cells were analyzed by 4  flow cytometry on a Coulter Epics Elite E S P apparatus (Coulter Electronics Ltd.). The 488 nm laser was used to excite FITC and PE. The emission of FITC and P E was recorded through 530 ± 15 and 5 8 0 + 10 nm bandpass filters, respectively. Hoechst 33342 was excited by the UV laser and its fluorescence measured through a 449 + 5 nm bandpass filter.  Light scatter signals,  (forward and side scatter) were also recorded and used for gating out dead cells, erythrocytes and debris. The P D T treated cells of S C C V I I  tumor have shown  decreased  autofluorescence in the 530-580 nm region compared to non-treated cells. A s the cells die, their forward light scatter signal will drop substantially. We have not seen any significant difference in the staining signal (Hoechst 33342, FITC or P E fluorescence intensity) between the cells from a non-treated tumor and those cells from P D T treated tumors that still show the forward scatter signal within the values for live cells (although some of them will eventually die). The objective of the above described flow cytometry analysis, indirect immunoperoxidase and Wright staining, was to identify and determine the levels of major cellular populations contained in S C C V I I tumor. The total yield  P D J induced host cell infiltration  63  of viable cells per gram of tumor tissue was determined immediately after the single cell suspension was obtained from previously weighed tumor tissue. The cells were counted using a hemacytometer, with Trypan blue staining used to eliminate dead cells. Yields of individual cell populations were calculated from their relative shares in the tumor cell suspension. The determination of the levels of mast cells (and in some cases neutrophils), whose incidence was very low, was based on the fact that a known number of cells were deposited on the glass slide. It was therefore not necessary to count the cells that were not mast cells (or neutrophils), which enabled scoring in average 1.5 x 1 0  5  cells per  sample. 3.3.5  Macrophage  cytotoxicity  against  tumor  cells  The target cells were obtained from an enzymatically digested S C C V I I tumor and cultivated in vitro for 2-3 weeks, which resulted in the elimination of non-malignant cells from the culture.  The growth medium was RPMI-1640  (HyClone) supplemented with 1 0 % F B S . The cells were labeled by exposure to [ H-methyl]thymidine (2.0 Ci/mmol, N E N , Du Pont Canada Inc.) at 2 uCi/mL for 3  24 hours in cell growth medium. Next, they were washed twice with cell growth medium and left to incubate further at 37°C to facilitate elimination of the radioactive label from the cytoplasm.  Actinomycin D (Sigma) was added 2  hours later in a final concentration of 1.5 mg/mL.  Four hours later, the cells  were washed, trypsinized and transferred into a 24-well plate (Falcon 3047, Becton Dickinson and Comp., Lincoln Park, NJ, USA) where they were admixed with the effector cells. Macrophages from P D T treated and non-treated S C C V I I tumors were harvested  using a modification of the differential attachment  procedure  described earlier (Korbelik et al. 1991). A known number of cells obtained by  PDT induced host cell infiltration  64  the above described enzymatic dissociation of tumor tissue (suspended in RPMI-1640 + 1 0 % FBS) was transferred into the wells of a 24-well plate a n d : incubated for 30 min. at 37°C. The medium was then collected, the attached cells overlaid with 0.5 mL of Trypsin-EDTA solution (Sigma) and incubated for 30 seconds at room temperature.  After that, the Trypsin-EDTA solution was  collected and the wells were washed vigorously three times with 1 mL of HBSS.  The washout containing removed cells was collected each time.  The  number of tumor associated macrophages (TAMs) isolated by this procedure (ceils remaining in the wells) was determined by subtracting the number of cells removed by washings from the number of plated cells.  Before admixing the  target cells, the effector cells were incubated with lipopolysaccharide  (LPS)  from E. colt 011 :B4 (Sigma) at 0.1 ng/mL in RPMI-1640 + 1 0 % F B S for 24 hours. The F B S used in these experiments was inactivated by heating at 56°C for 30 min. The effector and target cells were admixed at a 20:1 ratio, each well containing 2 x 1 0  5  T A M s and 1 x 1 0 tumor cells. 4  All testing was done in  quadruplicates (4 wells for each T A M population). The plates with effector and target cells were incubated 72 hours at 37°G, before the supernatants were collected from the wells and radioactivity counted using an L K B 1214 liquid scintillation spectrometer.  The total radioactivity  incorporated into the target cells was determined from the cells transferred directly into the scintillation vials. Spontaneous release of [ H]-thymidine from 3  the target cells (in the absence of effector cells) was determined for each group of samples; its levels ranged between 10 and .15%. This value was subtracted from the experimental release in the calculation of the percent of [ H]rthymidine 3  release from the target cells caused by the effector cells. described in more detail elsewhere (Korbelik and Krosl 1994).  This assay was  POT induced host cell infiltration  65  The data presented are based on the analysis of at least 6 identically treated tumors.  3.4  Results  3.4.1  Changes  in tumor  cellular  content  Mice bearing S C C V I I tumors were given Photofrin (25 mg/kg, i.v.) and the tumors were irradiated with red light (60 J/cm ) 24 h later. This PDT treatment 2  results in the average tumor cure rate of 1 8 % (Krosl and Korbelik 1994).  The  effect of such treatment on the cell content of the S C C V I I tumor is shown in Figure 3.1.  Indirect immunoperoxidase staining with monoclonal antibodies  was used to identify the malignant cell population (CD45"), T A M s (F4/80+) and T cells (TCR+). The remaining immune cells infiltrating the S C C V I I tumor were described as "other myeloid cells"; most, but not all of these, stained positively for the M a d myeloid marker, and appeared by morphological criteria to be members of the monocytic lineage.  It should be noted that the neutrophils  occasionally present in these slides were not included in the analysis. We.have observed that nearly all of the neutrophils present in single cell suspensions obtained from S C C V I I tumors are destroyed during the preparation of cytospins for the indirect immunoperoxidase staining. These cells, which are known, to be especially fragile, are too sensitive for the centrifugal forces used in the cytospin preparations.  PDT induced host cell infiltration  0 hours post PDT  Control  66  4 hours post PDT  .sVv.%.^.i..\.s.h.s..•h>h*H>>>>>>>>>" L . \ . % . - . . \ . \ . \ . -  •  CD45" F4/80+ a(3TCR  l x i o  CO  lxlO  8  lxlO  7  •  r  9  i  o  a o  e  +  Neutrophils Other myeloid cells  - \*  t-l  «  lxlO  6  i—i  U  I  s  lxlO  5  Control  0 hours  2 hours  4 hours  8 hours  Time after light treatment Figure 3.1  Levels of major cellular populations in SCCVII tumor before and after PDT.  The mice were sacrificed at various time intervals relative to the PDT treatment (Photofrin 25 mg/kg, 60 J/cm light), and the cells dissociated from the tumors analyzed by the indirect immunoperoxidase staining, except for neutrophils which were determined, in Wright, stained preparations/The inserted pie graphs depict relative contributions of the examined cell populations in control tumors and tumors excised either immediately or 4 hours after the termination of photodynamic light treatment. The data are average values from a group of 6 or more identically treated mice. The bars show SD. 2  PDT induced host cell infiltration  67  Because of this problem, separate aliquots of single cell suspensions were always taken for Wright staining. Instead of cytospin centrifugation, 10u,L of concentrated cell suspensions were gently layered onto glass slides and left to dry before Wright staining was performed.  In this way, neutrophils were  preserved, and they were easily identified by the characteristic shape of their nuclei.  The number of neutrophils in relation to the other immune and non-  immune cells was also determined in these preparations. In addition, mast cells were also identified by the Wright staining. The above described combination of the indirect immunoperoxidase staining (with neutrophils  selectively  eliminated) and Wright staining of slides specially prepared to  preserve  neutrophils enabled reliable determination of major cellular populations found in the S C C V I I tumor. The columns in Figure 3.1 represent cell yields for the main populations recovered from tumors at indicated times after the completion of light treatment. Their proportions in the total cell mass are given in the pie graphs . The data in 2  the histogram section demonstrates that the yield of individual cell populations decreased markedly at 4 hours post PDT, and even more so at 8 hours post PDT. However, important changes were also seen at 0 hours (immediately after the termination of light treatment) and at 2 hours post PDT. The most dramatic occurrence noted at 0 hours is a 100-fold increase in the neutrophil content compared to the control tumor.  In addition, the level of "other myeloid cells"  significantly decreased relative to the level in the controls at this time point. In contrast, the neutrophil content dropped markedly at 2 hours post PDT, while the yield of "other myeloid cells" increased. All these changes are statistically significant (p < 0.01). They also affected the proportions among the major cell  The values for total number of cells per gram of tumor tissue for specific cell populations were calculated using tumor cell yields and determined proportions of these cell populations. 2  PDT induced host cell infiltration populations.  68  A s shown in the pie graphs, the percentage of malignant cells  decreased at 0,hours compared to the controls (due to markedly increased percentage of neutrophils), but it decreased even further at 4 hours post PDT. More than half of the cells at this latter time point were F4/80+, and there was also a high proportion (-25%) of "other myeloid cells". No substantial changes in the percentage of T lymphocytes were seen during the observation period. The striking changes in neutrophil numbers detected at 0 hours post PDT, prompted us to examine the neutrophil content in tumors during the photodynamic light treatment,  t h i s analysis (based on Wright stained  preparations), which included also mast cells, is shown in Figure 3.2. A s early as 2 min. after the onset of light delivery, the number of neutrophils increased from 1.6 x 1 0 cells/g tumor tissue (control tumors) to 2.4 x 1 0 cells/g tumor 6  8  tissue. Three min. later the neutrophil levels were even higher, but at 12 min. into the light delivery decline.  of the total light dose) they already showed a marked  The neutrophil content then continued to decrease more slowly.  It  should be emphasized that the weight of tumors used in this study was 7-10 times lower than 1 g, the weight used conventionally (and also in the presentation of this data) in the calculations of cell yields. This is important to mention, because the total'number of neutrophils in a mouse is lower than 3.2 x 1 0 , the peak level of these cells that would be contained in a 1 g tumor. 8  An increase in the number of mast cells was observed at 5 min. into the light treatment and continued during the light delivery and beyond, reaching the highest value at 30 min. post PDT (Figure 3.2). A similarly high level of mast cells was detected at 2 and 4 hours after PDT (data not shown). Even at these levels the mast cell content in the tumors was much lower than the content of the other cell populations shown in Figure 4.1, and thus they could not affect the percent distributions given in the pie graphs. It should be noted that the scale  PDT induced host cell infiltration  69  for mast cells (right ordinate in Figure 3.2) has much lower values than the scale for neutrophils (left ordinate), as the levels of these cells were several logs lower than the neutrophil levels.  Duration of light Neutrophils  treatment Mast  cells  Time after onset of light treatment [minutes]  Figure 3.2 SCCVII tumor contents of neutrophils and mast cells. The neutrophil, and mast cell numbers were determined in Wright stained preparations, at various times during and after photodynamic light delivery . t h e PDT treatment was as in Fig. .3.1. The bars show SD.  PDT induced host cell infiltration  70  Photofrin administered to S C C V I I tumor bearing mice (24 hours earlier) not combined with photodynamic light treatment, or light treatment of tumors in the absence of Photofrin administration, produced no effect on the content of tumor cell populations (data not shown). 3.4.2  Hoechst  33342 staining  of circulating  leukocytes  The changes in the cellular populations present within S C C V I I tumors presented in Figures 4.1 and 4.2 cannot be explained without a contribution, at least in part, from newly arrived cells from the circulation. With neutrophils and mast cells, whose incidence in non-treated tumors is below 1 % (neutrophils) or even below 0 . 0 1 % (mast cells), their dramatic increase in the tumor can be explained only by the infiltration of cells from the circulation. However, the situation is less clear with cells whose levels in non-treated tumors are much higher, and a possible P D T induced infiltration would not result in a multi-fold increase in their total tumor content. In such case, the relative increase in one type of cells may result also from selective killing of the other cell types. In the next series of experiments we used the fluorescent dye Hoechst 33342 to selectively label immune cells in the blood stream and to determine their presence in the tumor after PDT, as described in Materials and Methods. The limitation of this type of experiment is that the time interval between the Hoechst 33342 injection and tumor excision cannot be extended longer than 2-3 hours, because at later times the dye levels in the labeled cells markedly decreased.  B a s e d on this consideration, and on the result indicating a  significant increase in "other myeloid cells" between 0 and 2 hours post P D T (Figure 3.1), we have chosen 2 hours post P D T as the time point in these experiments. The combination of GR1 and F4/80 antibodies in the two color flow cytometry seemed to us the best solution for the identification of myeloid  PDT induced host cell infiltration  71  cells that are not mature macrophages. The majority of cells stained as Gr1 + F4/80" can be assumed to be monocytes, since we know that tumor levels of other G r 1 cells (neutrophils and other granulocytes) at that time interval are +  low (1-2%).  In our experience, the Gr1 antibody served better for the  identification of myeloid cells than the M a d ; not all G r 1 cells stained positively +  for M a d . The representative examples of Hoechst 33342 fluorescence in cells obtained from differently treated tumors are shown in Figure 3.3, while the average values from groups of identically treated tumors are depicted in Figure 3.4. With control samples, it can be seen that around 3 5 % of cells from the undamped tumors were Hoechst 33342 positive, while only a small cell fraction from the clamped tumors were within the gate for Hoechst 33342 positive staining.  It seems that the clamping itself induced a minor influx of Hoechst  33342 positive cells, due probably to a reaction stemming from temporary vessel occlusion. The results with the tumors growing in mice not injected with Photofrin exposed to the photodynamic light treatment were very similar to those with the control tumors.  In the undamped P D T treated tumors, the  percentage of Hoechst 33342 positive cells was similar to that seen with the undamped control tumors. In contrast, the level of Hoechst 33342 positive cells in the clamped P D T treated tumor (more than 2 0 % of the cells were newly infiltrated) was much higher than that observed with the non-treated clamped tumors.  This finding demonstrates that PDT treatment induced infiltration of  Hoechst 33342 positive cells from the circulation. Shuch was not the case with the light treatment in the absence of the photosensitizer.  P D T induced host cell infiltration  72  log Hoechst fluorescence Figure 3.3  Distribution of Hoechst 33342 fluorescence in representative SCCVII tumors determined by flow cytometry. The tumors treated with PDT (as in Fig. 1) were excised at 2 hours after the termination of light treatment. The graphs show Hoechst 33342 fluorescence per cell in arbitrary units on the logarithmic scale (abscissa) and cell number on a linear scale (ordinate), a) Cells from an undamped tumor excised from a control mouse not injected with Hoechst 33342 (gate B defining Hoechst 33342 positive cells and gate E delimiting Hoechst 33342 negative cells were set in this graph for all the other cell samples); b) cells from an undamped control tumor excised from a mouse given Hoechst 33342; c) cells from a control tumor that was clamped before the mouse was given Hoechst 33342; d) cells from a photodynamic light treated tumor that was clamped before the mouse was administered Hoechst 33342, but which had not received Photofrin; e) cells from an undamped tumor treated with Photofrin based PDT that was growing in a mouse given Hoechst 33342; f) cells from a tumor treated with Photofrin based PDT that was clamped before the mouse was injected with Hoechst 33342.  PDT induced host cell infiltration  40  r  1  I  _co  "c5  73  •  Clamped  •  Undamped  •  I  o  a> 3 0 > 'co o a. CO  o  20  CD O  X  g  1  0  o  CD  Q_  0  Control  Light only P D T treated  Figure 3.4  Infiltration induced by PDT of Hoechst 33342 labeled cells from the blood into the S C C V I I tumor. Average values are shown for the clamped and undamped tumors (shaded and unshaded columns, respectively) exemplified in Fig. 3.3. The bars are SD. . .  The reconstruction of cellular composition of P D T treated tumor at 2 hours post treatment, showing the contribution of resident and newly infiltrating cells, is shown in the histogram section of Figure 3.5. From the data it is evident that Gr1 + F4/80" cel|s are the major component of the P D T induced infiltrate at this time interval. Approximately % are those that invaded after PDT.  of the Gr1+ F4/80" cells present in the tumor  PDT induced host cell infiltration  Hoechst positive cells (2 hours post PDT)  CD45" Figure 3.5  74  Hoechst negative cells (2 hours post PDT)  F4/80+  GR1+F4/80"  Other CD45+  The content of various populations among tumor resident cells (Hoechst 33342 negative) and newly infiltrated cells (Hoechst 33342 positive) in SCGVII tumors at 2 hours post PDT. Relative contributions of these cell populations are shown in the pie graphs. The experimental details were as in Figs. 3.3 and 3.4. The bars show SD.  PDT induced host cell infiltration  75  The pie graphs in Fig. 3.5 show the percent distribution of major cellular populations separately for newly infiltrated and resident cells.  Over 8 0 % of  newly infiltrated cells were Gr1+ F4/80', while - 1 0 % were F4/80+. The values for the percentage of the remaining Hoechst 33342 positive cells (other CD45+, C D 4 5 " ) were at the levels which fall within the experimental error, and the presence of these cells cannot be supported by statistical evaluation.  The  percent distribution of tumor resident cells (Hoechst 33342 negative) shows that the share of malignant cells (CD45") is very similar to that in the non-treated tumors (pie graph in Figure 4.1).  In spite of different methods (indirect  immunoperoxidase staining vs flow cytometry) and somewhat different combinations of antibodies used, the results suggest that the  percent  composition of resident immune cells has also not drastically changed at 2 hours post PDT compared to the non-treated tumor. Given the fact that the total cell yield was reduced by approximately half at 2 hours after PDT, these results indicate that the level of killing of different types of resident leukocytes and malignant cells was similar. 3.4.3  Cytotoxicity  of TAMs  after  PDT  The occurrence of a pronounced invasion of leukocytes into P D T treated tumor may, together with the other inflammatory changes, affect the activity of immune cells directed against the tumor.  To test this, we harvested T A M s  contained in S C C V I I tumor using a differential attachment technique employed in our earlier studies (Korbelik et al., 1991).  Staining with monoclonal  antibodies showed that over 9 0 % of the cells selected in this way were Mac1 and - 7 0 % were F4/80+. The cytotoxicity of these cells against  in vitro  +  cultured  S C C V I I malignant cells was examined. The results (Figure 4.6) show that T A M s harvested from a PDT treated S C C V I I tumor at 2 hours after the treatment  PDT induced host cell infiltration  76  were almost five times more effective in the cytolysis of target cells than the T A M s from non-treated tumor.  30  r  25  S  2  0  CO <D CD C  15 -  Iv 1  0  X CO  5 -  0 T A M s from control  Figure 3.6  tumour  T A M s from P D T treated  tumour  Cytotoxicity of tumor associated macrophages (TAMs), selected from PDT treated and non-treated S C C V I I tumors, against in vitro cultivated S C C V I I cells.  The cultured (malignant) S C C V I I cells, were labeled with [ H]thymidine and admixed with macrophages harvested from SCCVII tumors as described in Materials and Methods section. The treatment by Photofrin based PDT of SCCVII tumors used for TAMs isolation was as in Figure 3.1, with the tumor excision performed at 2 hours post PDT. The bars show SD. 3  PDT induced host cell infiltration  3.5  77  Discussion Dramatic changes occur in the cellular composition of S C C V I I tumors  treated with Photofrin based PDT.  The most striking change is the massive  invasion of neutrophils into the tumor that starts rapidly (within 2 min.) after the onset of photodynamic light treatment. Within 5 min., the neutrophil content in the treated tumor increased 200 fold, before decreasing once again to the levels seen in non-treated tumors between 2 and 4 hours after PDT. Mast cells were the other type of immune cells that started to invade the tumor very early after the onset of photodynamic light treatment (within 5 min.). The number of these cells in non-treated S C C V I I tumor is very low (about 1,000 cells in a 100 mg tumor) but their levels were more than 5 times higher between 1/2 and 4 hours after PDT.  Mast cells are powerful mediators of inflammatory response,  and their recruitment, in spite of the low tumor content, could have a pronounced effect in the PDT treated tumor. Selective labeling, of circulating leukocytes enabled the detection of the PDT induced infiltration by another myeloid cell type into treated S C C V I I tumors between 0 and 2 hours post PDT.  These cells expressed the Gr1 antigen (a  common myeloid cell marker) and most of them stained negatively io the F4/80 antigen (a marker for mature macrophages).  Based on this fact, and oh the  morphological examination, we concluded that the majority of these cells were most likely monocytes. The percentage of malignant cells in S C C V I I tumor decreased markedly during the photodynamic light treatment due to the massive neutrophil invasion. The proportion of these cells in the tumor decreased even further during the next several hours following light delivery because of newly infiltrating monocytic cells.  However, the total number of malignant cells in the tumor  PDT induced host cell infiltration  78  started to decrease substantially only after 2 hours post PDT, presumably due to rapidly developing tumor tissue ischemia (Henderson et al. 1985). The results based on the identification of resident malignant and immune cells in S C C V I I tumor in the experiments with Hoechst 33342 suggest that within the first two hours after PDT all these cells exhibit a similar sensitivity to the lethal effects of PDT.  The only exception may be the inactivation of  monocytes, suggested by the reduction in tumor content of "other myeloid cells" observed at 0 hours post PDT.  A fast disappearance of newly infiltrated  neutrophils from the treated tumor indicates that these cells were killed relatively quickly. These cells, as well as "other myeloid cells" might have been localized in the area of tumor vasculature already extensively damaged during the light treatment. In contrast, the percent distribution of cellular populations at 4 hours post P D T (pie graph in Figure 4.1) infers that newly infiltrated monocytes may outlive most of the tumor resident cells. Taken together, the above results portray a typical scenario of acute inflammatory infiltration of myeloid cells at the affected site.  The rapid and  massive neutrophil invasion is promptly accompanied by the arrival of mast cells. Massive release of chemotactic substances from degranulating mast cells (Kerdel et al. 1987), dying neutrophils, as well as from damaged membranes of tumor cells (alluded to in Introduction), is the probable impelling force behind another wave of infiltration, this time involving monocytes, that follows 1-2 hours later. There was no evidence for the participation of lymphocytes in these P D T induced tumor infiltration events during the observation period of this study (up to 8 hours post PDT). The inflammatory reaction in PDT treated tumor appears to have similarities with the cutaneous inflammation, identified as the main factor in PDT induced  PDT induced host cell infiltration  79  skin phototoxicity, where neutrophils and mast cells also have a critical role (Lim 1989). The data demonstrating a pronounced increase in the tumoricidal activity of T A M s (Fig. 3.6) offers evidence that this inflammatory response is actually associated with the functional activation of immune cells. In a related study with cultured macrophages and tumor cells, we have demonstrated that in vitro P D T treatment of tumor cells (but not normal cells) potentiates their killing by macrophages (Korbelik and Krosl 1994).  The implication is that potentially  repairable damage induced by P D T in tUmor cells triggers macrophage mediated tumoricidal activity.  Such activity of non-specific immune cells may  lead in a later phase to the development of a T cell specific immune activity. The ingestion of PDT damaged or killed tumor cells by macrophages, which are antigen presenting cells, can result in tumor antigen presentation with the consequent induction of tumor specific immunity (Yamamoto et al. 1992). Such a development of PDT induced immunopotentiation is suggested by the work of Ganti and co-workers (Canti et al. 1994). A number of reports documented enhancement  of tumor control by combining P D T  with a variety  of  immunotherapy regimens (Myers et al. 1989; Bellnier 1991; Dougherty et al. 1992; Dima et al. 1994; Krosl and Korbelik 1994). This supports the idea that P D T induced immune reaction may be amplified and directed towards more effective tumor destruction. Much work remains to be done in exploring the effects of P D T on cellular composition of tumors treated with different Photofrin / light dose combinations, examining the effects in different tumor models and with other photosensitizers. Each of these aspects requires a substantial experimental effort.  S P G potentiation of P D T  80  CHAPTER 4 Potentiation of photodynamic therapy by immunotherapy: the effect of schizophillan (SPG) 4.1  1  Summary Treatment of squamous cell carcinoma ( S C C V I I ) bearing mice with the  immunostimulant Schizophillan (SPG) raised the relative content of M a d positive host cells infiltrating the tumor and increased Photofrin retention in these tumors.  In  vitro  colony formation assay following Photofrin based  photodynamic therapy (PDT)  in vivo  revealed a greater killing of tumor cells in  the S P G pre-treated group, particularly pronounced when tumor excision was delayed until 8 hours after PDT.  The tumor cure rate increased approximately  three fold when P D T was preceded by the S P G therapy.  In contrast, the  administration of S P G after P D T had no benificial effect on tumor control. 4.2  Introduction Tumor destruction and cure after Photofrin based photodynamic therapy  (PDT) is a result of several contributing factors, including the direct cytotoxicity to tumor cells, vascular stasis with the ensuing ischemia, and immune reaction (Bellnier and Henderson 1992). tumor microvasculature  Primary events, which initiate changes in  leading to irreversible vascular  occlusion a n d  eventually to tissue necrosis in P D T treated tumor (Fingar et al. 1990) have not been clearly identified. Early, not necessary lethal effects of P D T on multiple targets including endothelial cells (Ben-Hur et al. 1988; Sporn and Foster  1  The data presented in this chapter have been published in following paper:  1.  Krosl, G. & Korbelik, M. (1994). Potentiation of photodynamic therapy by immunotherapy: the effect of schizophyllan (SPG). Cancer Letters, 84, 43-49.  S P G potentiation of PDT  81  1992), mast cells and macrophages (Henderson and Bellnier 1989), and platelets (Fingar et al. 1990) may be involved. powerful  p h y s i o l o g i c a l mediators,  They trigger the release of  including t h r o m b o x a n e  and  other  eicosanoids, histamine, and various cytokines. In addition to their procoagulant and vasoconstricting activity, these mediators are the initiators of a strong local inflammatory response which is itself capable of destroying the affected tissue. The inflammatory reaction induced in a PDT treated tumor is characterized by a rapid and massive invasion of neutrophils occurring within minutes after the initiation of the light, treatment, and followed later by mast c e l l s  and  monocytes/macrophages arriving from, the circulation (Krosl et al. 1995). The development of a strong inflammatory reaction in response to P D T suggests that the tumor infiltrating leukocytes may play a role in tumor eradication by PDT. The observation that tumoricidal activity of macrophages is markedly elevated when the target tumor cells are pretreated with  PDT  (Korbelik et al. 1993) suggests that the damaged membrane structures on P D T treated tumor cells can be recognized by the macrophages. The inflammatory reaction induced by PDT can also be a source of immune cell activation. In this respect, we have reported that tumor associated macrophages (TAM) isolated from the P D T treated tumors show increased tumoricidal activity compared to the T A M isolated from non-treated tumors (Korbelik et al. 1993). We have suggested that the effect of PDT can be potentiated by adjuvant immunotherapy (Korbelik et al. 1991). This is supported by the studies with several PDT-immunotherapy combinations reported by different authors (Myers et al. 1989; Bellnier 1991; Dougherty et al. 1992).  In this work, we have  examined the effect of a non-specific immunostimulant Schizophyllan administered either before or after P D T .  (SPG)  This glucan isolated from  Schizophyllum comunae (Norisuye et al. 1980) is used in clinical cancer  S P G potentiation of P D T  82  therapy (Okamura et al. 1986; Nakano et al. 1993). Leukocytes isolated from mice treated with S P G showed increased response to cytokines and to the mitogen concavalin A (Tsuchiya et al. 1989). It was found that S P G directly stimulates macrophage-mediated antitumor activity (Sugawara et al. 1984). The improved tumor control seen with mice treated with radiotherapy in combination with S P G correlated with the increased infiltration into the tumor of immune cells, especially macrophages (Inomata et al. 1987). 4.3  Materials and  4.3.1  Tumor  methods  model,  drugs  C3H/HeN female mice were used for experiments when they were 10-12 weeks old. Murine squamous cell carcinoma ( S C C V I I ) was maintained by biweekly intramuscular passages as described, elsewhere (Korbelik 1993). For experiments the tumors were implanted subcutaneously by injecting 3 x 10^ cells in a 0.03 mL volume over the sacral region of the back of the mouse. P D T was performed when the tumors reached 6-8 mm in size, measuring the largest diameter. Schizophillan ( S P G ) , produced by Kaken Pharmaceutical Ltd. (Tokyo, Japan) was kindly provided by Dr. T. Inomata.  Mice treated with S P G were  given 9 consecutive daily doses of 15mg/kg of the drug intramuscularly injected into the hind leg. For each type of experiment, a control group with mice receiving the treatment with SPG-free saline was also examined. In all the c a s e s , treatment with the control saline showed no effect on measured parameters. Photofrin was obtained from QuadraLogic Technologies Phototherapeutics Inc. (Vancouver, BC., Canada). Mice were administered a dose of 25 mg/kg of Photofrin intravenously 24 hours before the dose of 60 J / c m  2  (630 ± 10 nm)  S P G potentiation of POT  : 83  light was delivered from a tunable light source equipped with the 1kW Xenon bulb (model A 5000, Photon Technology International Inc.). The power output was 30 mW. The light treatment was delivered either 48 hours after the last S P G injection or 24 hours before the first daily dose of S P G . In the former case, the S P G therapy was initiated 4 days after the tumor inoculation. Following P D T , the tumors were observed every second day and the 3 orthogonal diameters were measured using a caliper. calculated by a formula V =  4  X  Tumor volume was  7t  x(axbxc)  where a, b, and c represent the 3  6  orthogonal diameters. The mice were sacrificed if one of the diameters reached 12 mm. Each treatment group consisted of at least 6 mice. The experiment was done three times. 4.3.2  Analysis  of immune  cell  infiltration  Tumors from mice treated with S P G and from the non-treated animals were excised, minced, and then enzymatically digested for 30 min. at 37°C with 0 . 0 2 % Collagenase (type IV, Sigma Chemical C o . , St. Louis, Mo,, U S A ) , 6 . 0 1 5 % D N A s e (type I, Sigma), and 0 . 1 % dispase (Boerhinger, Mannheim, Germany) (McBride et al. 1992). The cell suspensions obtained in this way were washed twice in Hank's balanced salt solution (Sigma) supplemented with 2 % Fetal Bovine Serum (FBS, HyGlone Laboratories Inc., Logan, UT, USA).  The cytospin preparations prepared from the cell suspensions were  fixed with acetone and stained for M a d or C D 4 5 (T200) antigen using, an indirect immunoperoxidase technique (Korbelik et al. 1992).. Hybridoma TIB 128 producing anti-Mad antibody was purchased from A T C C (Maryland, USA).  Monoclonal antibody YE1.21 directed against the T-200 antigen (CD45)  was generously provided by Dr. Fumio Takei (Terry Fox Laboratory, B.C. Cancer Research Centre). The secondary antibody used was a rabbit anti-rat  S P G potentiation of PDT IgG  conjugated  with horseradish  peroxidase  84 (Sigma), diluted as  per  manufacturer specifications. At least 200 positive cells were scored on each Slide. 4.3.3  Determination  of Photofrin  levels  in tumor  tissue/cells  T h e excised tumors were weighed; minced and left at 60°C overnight in ScintiGest (Fisher Scientific Co., Fair View, NJ, USA).  Two mL of ScintiGest  plus 0.2 mL of double distilled water was used per 0.T mg of tumor tissue. Alternatively, the tumors were first dissociated into single cell suspensions by the enzymatic digestion procedure as for the analysis of immune cell infiltration. The cells were counted, pelleted by centrifugation and left at 60°C overnight in 1:10 (vol/vol) ScintiGest dilution in distilled water.  Photofrin concentration in  lysates of tumor tissue or cells lysates was determined by a flubrometric assay as described.earlier (Korbelik et al. 1991). Lysates obtained from the tumors of mice that had not received Photofrin served as the background contrbls. 4.3.5  Clonogenic  assay  Clonogenicity of S C C V I I cells isolated from the tumors was assessed using a soft agar clonogenic assay (Chaplin et al. 1986; Chaplin et al. 1987; Korbelik et al. 1992). The tumors were excised either immediately following PDT or at 8 hours post PDT and cell suspensions were prepared by the enzymatic digestion, procedure.  Cell viability and cell yield per gram of tumor tissue were  determined.  A known number of cells resuspended in Eagle's Minimal  Essential Medium (GIBCO Laboratories, Grand Island, NY, USA) supplemented with 1 6 % of F B S was plated on the soft agar layered into the petri dish.  S P G potentiation of PDT  85  Tumor cell colonies were counted two weeks later and the clonogenicify of the plated cells was. determined based on the plating efficiency and cell yield (Henderson et al. 1985). The results are presented as colony forming units per gram of tumor (CFU), which is derived as follows: CN Cell yield (CY) for the tumour is calculated by the formula:  CY =  where CN is total number of cells, and TW is tumour weight in grams. Plating efficiency (PE) is derived:  PE =  N  c  a  l  Ncell . where N oi is number of colonies, and N i i represents number of cells plated. C  ce  PEt  Surviving fraction S F is then calculated:  SF =  —PEc  where PEt represents plating efficiency of treated sample, and P E  C  is plating  efficiency of a control. Colony forming units per gram of tumor tissue are then calculated: CFU =  SFx^^L CY C  where CYt is cell yield of treated sample and C Y 4.4  Results and  4.4.1  Photofrin  C  is cell yield of a control.  discussion tumour  levels  The effect of S P G therapy on Photofrin level in S C C V I I tumor determined 24 hours after the administration of the photosensitizer (25 mg/kg, i.v.) is shown in Table 4.1.  It can be seen that the S P G treatment results in a small, but  statistically significant increase in Photofrin content per gram of tumor tissue. An even greater effect of S P G was seen with another mouse model, Lewis lung carcinoma growing subcutaneously in C57/BI mice (Korbelik et al. 1991). This study has concentrated on S C C V I I tumor, since Lewis lung carcinoma is not  S P G potentiation of PDT  86 {  •  •  •  suitable for the experiments with tumor cure as an endpoint due to the lung metastases that develop in the early stages of the growth of this tumor. Table 4.1  The effect of SPG  on Photofrin content in SCCVII tumor  |ig Photofrin per gram of tumor  |ig Photofrin per 10^ cells.  Control tumors  7.58 + 0.28  0.251 ±0.031  S P G treated tumors  9.71 ±0.13*  0.288 ±0.036  Tumor bearing mice received 9 daily injections of SPG (15 mg/kg i.m.) or the control solvent. Photofrin (25 mg/kg) was administered one day after the last SPG treatment. The mice were sacrificed 24 hours after receiving Photofrin. The tumors were excised, minced and dissolved either immediately in ScintiGest, or they, were first enzymatically dissociated into single cell suspensions. Photofrin levels in the tumor tissue or in cell lysates were .determined using the fluorometric assay. The results of a representative experiment (mean ± SD, six mice per group) are shown. * = significantly different (p < 0.001) then the control group.  The results of measurements of Photofrin content per cell are also shown in Table 4.1. In this case, S C C V I I tumors were minced and cell suspensions obtained by the enzymatic digestion procedure.  In contrast to the Photofrin  tumor tissue levels, the average cellular level of the photosensitizer was  not  significantly increased in the S P G treatment group. The cell yield per gram of tumor tissue does not seem to be affected by the S P G therapy, as shown in Table 4.2. However, the composition of cell populations in the S C C V I I tumor may have changed as a consequence of the immunomodulating effect of S P G . This could affect the average Photofrin tumor level, because the level of this photosensitizer is several times higher in tumor associated macrophages (TAM) than in parenchymal malignant cells of S C C V I I tumor (Korbelik et al. 1991). 4.4.2  Leukocyte  infiltration  of SCCVII  tumor  Cellular composition of S C C V I I tumors was analyzed using monoclonal antibodies that can identify major populations of host immune cells infiltrating the tumor. The results (Figure 4.1a) show that the tumors treated with S P G  S P G potentiation of PDT  87  have an increased content of cells that are positively stained with the antibody to M a d , the antigen that is specific for macrophages and granulocytes.  This  may reflect either increased expression of the integrin identified by M a d by cellular populations already present in the tumor,"or S P G induced infiltration of M a d positive cells into the tumor.  The latter was reported to be the c a s e  following the S P G treatment of the MM46 tumor in C 3 H mouse (Inomata et al. 1987). The analysis using a pan-leukocyte marker C D 4 5 , also shown in Figure 4.1a, suggests that the total immune cell content in the S C C V I I tumor was not significantly affected by the S P G therapy. In our related studies (Korbelik et al. 1992), we have observed that P D T treatment of S C C V I I tumor has a marked effect on tumor infiltrating leukocyte populations. An example of this can also be seen in Figure 4.1b. In this case, the tumors were excised at 4 hours after the photodynamic light treatment; at later time intervals rapidly developing necrosis may affect the quality of staining for membrane antigens. It is shown that the content of both C D 4 5 positive and Mad  positive cell populations at 4 hours post P D T is increased when  compared to the levels in the PDT non-treated tumor depicted in Figure 4.1a (p<0.01).  With the S P G treatment before Photofrin based PDT, the M a d  positive cell population reached 6 0 % of the total tumor cell content. Thus, the incipient M a d  +  level in un-treated tumors was more than doubled by the  apparently additive effect of S P G and PDT. The levels of C D 4 5 positive cells were again, on average, slightly higher but not statistically different, than in the corresponding S P G non-treated group (Figure 4.1b).  The administration of  Photofrin without the light treatment or light treatment without Photofrin showed no effect on the tumor leukocyte content (not shown).  S P G potentiation of P D T  80  88  r  60 _C0  "53 o © 40 CO  o  Q_  o  20  0  75 -  CD45+  Mac-1 +  CD45+  Mac-1 +  B  o  "E  _co 5 0 o >  CO  o Q.  25 -  0 Figure 4.1  The effect of SPG therapy on immune cell content of PDT nontreated (a) and PDT-treated (b) SCCVII tumor. Tumor bearing mice received 9 daily injections of SPG (15 mg/kg, i.m). Mice treated with PDT were given Photofrin (25 mg/kg, i.v.) 24 hours after the last SPG injection which was followed by 60 J/cm light treatment 24 hours later. The tumors were excised either 24 hours after the last SPG injection (A), or 4 hours after the.photodynamic light treatment (B). The percentage of cells positive to CD45 and M a d antigens was determined using the indirect immunoperoxidase staining. * = significantly different than the No S P G group (p < 0.05). 2  S P G potentiation of PDT  89  Using a flow cytometry technique described earlier (Korbelik et al. 1991) we have also analyzed Photofrin levels in Fc receptor (FcR) positive cell population (predominantly T A M ) and in F c R negative cell population (predominantly malignant cells) of S C C V I I tumor. The results revealed no significant difference (p > 0.05) for both of these populations between the S P G treated and S P G non-treated groups (Table 4.2). Table 4.2  The effect of SPG on Photofrin content in FcR" and FcR populations of SCCVII tumor  cell  +  Photofrin content [u.g/10 cells] 6  FcR+  FcR" Untreated  0.251 ± 0.031  0.727 ± 0.051  SPG  0.288 ±0.036  0,815 ±0.093  Tumor bearing mice received 9 daily injections of SPG (15 mg/kg i.m.) or the control solvent. Photofrin (25 mg/kg) was administered one day after the last SPG treatment. The mice were sacrificed 24 hours after receiving Photofrin. The tumors were excised, minced and enzymaticaliy dissociated into single cell suspensions. Photofrin levels in the F c R and FcR" cell populations were determined as explained in Chapter 2. The results of a representative experiment (mean + SD, six mice per group) are shown. +  4.4.3  The effect  of SPG  on tumor  cell clonogenlcity  Survival of tumor cells determined by colony formation assay Photofrin based P D T  in vivo  after in vitro  PDT  after  is shown in Table 4.3. The tumors were excised  either immediately after the termination of the light treatment, or at 8 hours post PDT.  In the former case data reflect direct killing of tumor cells by PDT, while  the excision of tumors with 8 hour delay gives information on indirect lethal effects of P D T (Henderson et al. 1985). Direct killing: The cell yield with S C C V I I tumors excised immediately after the P D T was not different than with P D T non-treated tumors. However, the plating efficiency of these cells decreased from 0.26 to 0.13 due to the direct killing of tumor cells by PDT. The plating efficiency of tumor cells in S P G treated  S P G potentiation of PDT  90  group was not different than with S P G non-treated tumors; however, the yield of these cells was lower, which resulted in a somewhat lower value for the relative CFU/g of tumor. Indirect  killing:  Due to substantial decrease  in cell yield,  only  approximately 2 % of tumor cells from the S P G non-treated group survived at 8 h post PDT. The cell yield was even more drastically reduced in the S P G treated group, which resulted in the additional decrease in survival of tumor cells (p < 0.01, compared to the S P G non-treated group). This data suggests that the effect of S P G on PDT inflicted indirect killing of tumor cells is much more pronounced than on the direct killing. Table 4.3  Treatment  The effect of SPG pretreatment on clonogenicity of S C C V I I tumor cells isolated from PDT-treated subcutaneously growing tumors.  Plating efficiency  Non-treated controls S P G control  cell yield /g of tumor  0.26 ±0.04  1.3 ± 0 . 2 x 1 0  8  0.22 ±0.08  1.2 ± 0 . 3 x 1 0  8  0.78 ±0.1  PDT only, Oh  0.13 ±0.07  1.4 ± 0 . 2 x 1 0  8  0.54 ± 0.07  S P G + P D T , Oh  0.13 ±0.07  8.0 ± 2 . 0 x 1 0  7  0.39 ±0.12  PDT only, 8h  0.15 ±0.03  4.6 ± 2 . 5 x 1 0  8  SPG+PDT, 8h  0.10 ±0.02  1.2 ± 0.7x10 * 6  relative CFU/g of tumor 1.00  0.02 ± 0.011. 0.0036 ± 0.0022*  Tumor bearing mice received 9 daily injections of SPG (15 mg/kg i.m.). Photofrin (25 mg/kg) was administered one day after the last SPG treatment. Light treatment (60 J/cm ) was performed 24 hours after the Photofrin injection. Tumors were excised at 0 or 8 hours after PDT and enzymatically disaggregated as described in Materials and Methods. Known number of viable cells were plated for the soft agar clonogenic assay and the colonies were scored 2 weeks later. Twelve mice were included in each group. The results are mean ± SD. * = significantly different than the PDT only group (p < 0.01). 2  S P G potentiation of P D T 4.4.4  The  effect  on  tumor  91  recurrence  The effect of S P G therapy administered either before or after Photofrin based P D T with S C C V I I tumor regrowth or cure as endpoint is shown in Figure 4.2. The S P G therapy alone has no significant effect on tumor growth (Figure 4.2 insert).  The P D T treatment alone, under the conditions of this  experiment, gave a 1 7 % cure rate. The cure in this assay is defined as no sign of tumor regrowth at 90 days after the treatment. The experience with S C C V I I tumor model is that no tumor recurrence after this time period is equivalent to tumor cure. The S P G therapy administered before P D T markedly enhanced the effect of P D T , increasing the cure rate to around 5 0 % (p < 0.05, using Wilcoxon Rank Sum test).  In contrast, the S P G treatment administered after  PDT had no significant effect on the outcome of PDT.  S P G potentiation of P D T  92 1 000  CO  E E  100  " 1 0 0  r  CD  E  80 -  jmor  o >  10  I-  1  1  i . i .*. i . i . i . i . i . i 1 3 5 7 9 11131517  D a y s after  implant  CD O  60 CD CD  SPG + PDT ~  40 -  20 -  0  PDT only PDT + SPG 0  2  4  6  8  10 12 14 16 1 8 2 0 22  90  92  D a y s after P D T Figure 4.2 The effect of SPG treatment on tumor eradication by PDT. Mice bearing S C C V I I tumor received Photofrin (25 mg/kg, i.v.) followed 24 hours later by. 60 J/cm light treatment. The S P G therapy (9 daily injections of 15 mg/kg, i.m.) was administered either before PDT or it was initiated 24 hours after PDT. The PDT only group is also shown. The insert shows growth of non-treated tumors (*) and tumors treated with the SPG protocol only (+); the bars are + SD. Eighteen mice (pooled from the three experiments) were included in each treatment group. 2  S P G potentiation of PDT  93  The experimental evidence presented in this Chapter demonstrates that immunomodulating action of S P G potentiates the effect of PDT.  This agent  increased primarily the extent of indirect killing of tumor cells by PDT, probably by elevating the level of tumor infiltrating macrophages before and after PDT, which may have enhanced the tumoricidal activity of these cells and augmentated the non-specific immune reaction. This enhancement, however, appears to require prolonged treatment with S P G before PDT, as no effet could be detected when S P G was administered after the photodynamic treatment. The results of this work support the suggestions on the importance of immune reaction in tumor control by PDT.  Immunotherapy seems to be a  promising approach for improving the clinical effectiveness of P D T in cancer treatment.  The effect of GM-CSF on P D T  94  CHAPTER 5 Potentiation of photodynamic therapy elicited antitumor response by localized treatment with granulocytemacrophage colony stimulating factor 5.1  3  Summary Murine s q u a m o u s cell carcinoma ( S C C V I I ) cells were genetically  engineered to produce murine granulocyte-macrophage colony stimulating factor (GM-CSF). G M - C S F immunotherapy, based on the peritumoral injection of lethally irradiated G M - C S F producing cells, was examined as adjuvant to photodynamic therapy  (PDT) treatment  of this tumor.  The G M - C S F  immunotherapy administered 3 times in 48 h intervals starting 2 days before the light treatment substantially improved the curative effect of Photofrin mediated PDT.  A comparable effect of G M - C S F immunotherapy was observed in the  combination with benzporphyrin derivative mediated PDT. The tumor localized G M - C S F immunotherapy alone had no obvious effect on the growth of parental S C C V I I tumor.  This treatment did not significantly alter the differential  peripheral white blood cell count, and appeared not to affect tumor leukocyte infiltration.  However, G M - C S F treatment did increase the cytotoxic activity of  tumor associated macrophages against S C C V I I tumor cells.  It appears,  therefore, that tumor localized immune stimulation by G M - C S F amplifies P D T induced immune reaction, which has a potentiating effect on tumor control.  3  The results presented in this chapter have been published in following paper:  1.  Krosl, G., Korbelik, M., Krosl, J., and Dougherty G.J. (1996) Potentiation of photodynamic therapy-elicited antitumor response by localized treatment with granulocyte-macrophage colony stimulating factor. Cancer Res 56: 3281-3286.  The effect of GM-CSF on P D T 5.2  95  Introduction Eradication of tumors treated by P D T is a result of combined effects on both  tumor cells and various host derived cell types (Henderson and Dougherty 1992).  In addition to direct killing induced by photooxidative damage to vital  cellular structures (Penning et al. 1994), tumor cells appear to be inactivated not only by ischemia secondary to the damage to tumor vasculature, but also by the integrated tumoricidal activity of non-specific and specific immune effector cells (Korbelik and Krosl 1996). The host response triggered by the P D T treatment is dominated by a strong tumor localized acute inflammatory reaction associated with the functional activation of tumor resident and newly arrived leukocytes (Chapter 3 and (Krosl et al. 1995)).  Neutrophils, mast cells, monocytes and  macrophages have been suggested to participate in the antitumor activity in this early, phase post P D T treatment (Krosl e t a l . 1995; Korbelik and Krosl 1996). The inflammation of tumor tissue induced by P D T is accompanied by intense tumor destruction followed by the.release and phagocytosis of tumor cell debris. This creates conditions for the processing and presentation of tumor antigens by activated professional antigen presenting cells (macrophages) resulting in development of tumor specific immunity (Yamamoto et al. 1992; Korbelik and Krosl 1996).  Indeed, .experimental evidence obtained in our laboratory  (Korbelik et al. 1996) and elsewhere (Canti et al. 1994) supports the hypothesis that specific T cell mediated immune responses facilitate the eradication of tumors following PDT. Tumor regression induced by radiotherapy, chemotherapy or surgical excision is generally not associated with induction of systemic immunity.  In  contrast, P D T appears to have the capacity to reset the tumor-host relationship from tumor dominated to antitumor oriented. This justifies the development of specific strategies for the potentiation of the antitumor effect of P D T by adjuvant  The effect of GM-CSF on PDT immunotherapy.  9.6  One obvious type of immunofherapeutic intervention that  could be considered is to augment the activity of myeloid effector cells at the treated site.  Neutrophils which massively and rapidly accumulate in P D T  treated tumors (Krosl et al. 1995), have the capacity to inflict substantial damage on tumor tissue by. releasing reactive oxygen metabolites and a number of other tissue destructive mediators, or by attracting other immune cells to the tumor site.  Macrophages isolated from P D T treated tumors were shown to exhibit  elevated tumoricidal activity (Krosl et al. 1995). Increased macrophage activity after PDT in vitro has also been documented (Yamamoto et al. 1991; Yamamoto et al. 1992). The activation of these cells by systemic treatment by a specific macrophage activating factor generated from vitamin D 3 binding protein was shown to potentiate the curative effect of P D T  (Korbelik et al. 1995).  Macrophages were shown to release tumor necrosis factor-alpha (TNF-a) following PDT treatment (Evans et al. 1990). In addition, macrophages appear to preferentially recognize and destroy PDT treated tumor cell targets (Korbelik and Krosl 1994). Cross talk among granulocytes, macrophages and lymphocytes, in which the participants receive and/or deliver regulatory m e s s a g e s through the/ secretion of cytokines and other regulatory factors builds up and amplifies immune reaction (Colombo et al. 1992).  The localized production of some  cytokines within the tumor microenvironment can prevent or inhibit tumor growth by a T-cell independent mechanism, while other cytokines can stimulate a potent systemically-acting T cell mediated antitumor immune response (Tepper and Mule 1994). One of the latter cytokines is granulocyte-macrophage colony stimulating factor (GM-CSF), which is a key regulator controlling the maturation and function of granulocytes and monocytes/macrophages (Metcalf 1991), This glycoprotein stimulates the proliferation and differentiation of dendritic and other  The effect of GM-CSF on PDT  97  antigen presenting cells, and is a potent enhancer of antigen presentation by these cells (Grabbe et al. 1992; Grabbe et al. 1994; Sallusto and Lanzavecchia 1994).  The protection against challenge with parental tumor induced by  immunization with G M - C S F producing tumor cell vaccine was clearly shown to be mediated by CD4+ and CD8+ T cells (Dranoff et al. 1993; Levitsky. et al. 1994).  This cytokine is one of the immunotherapeutic agents  whose  effectiveness is currently under intense investigation both clinically and with in vivo tumor models (Dranoff et al. 1993; Tepper and Mule 1994). Since systemic treatment with high doses of G M - C S F may lead to profound perturbations in hemopoiesis and induce serious side effects (Metcalf 1991), and intravenously injected G M - C S F has relatively short half-life (~2 hours), it would be preferable if a means could be developed to achieve a sustained local release of this cytokine at the tumor site. This can be accomplished by the constitutive release of G M - C S F by peritumorally injected lethally irradiated tumor cells transfected with the gene encoding this cytokine (Dranoff et al. 1993). Using such an approach, we"introduced the murine G M - C S F c D N A into S C C V I I tumor cells (mouse squamous cell carcinoma) and, in combination with PDT, these genetically engineered cells were employed for the G M - C S F immunotherapy of mice bearing the parental non-infected S C C V I I tumor. -Data observed indicate that S C C V I I tumor localized G M - C S F treatment markedly elevates the effectiveness of PDT in this tumor model. 5.3  Materials and  5.3.1  Tumor  Methods  model,  cell  lines  The poorly immunogenic murine squamous cell carcinoma S C C V I I (Suit et al. 1985) growing in C3H/HeN mice (10-12 weeks old females) was used in this  The effect of GM-CSF on P D T study as a tumor model.  98  Maintenance and implantation of subcutaneously  growing S C C V I I tumors has been described in detail in Chapter 3. S C C V I I tumor cells were cultured in Dulbeco's modified Eagle's medium (DMEM) containing a high glucose concentration (4.5 g/L) with 10 % fetal bovine serum ( F B S ; HyClone Laboratories Inc., Logan, UT, U S A ) .  The  ecotropic GP+E-86 retrovirus packaging cell line (Markowitz et al. 1988) kindly provided by Dr. A. Banks (Columbia University, New York, NY, U S A ) was maintained in D M E M with high glucose content and 1 0 % newborn calf serum (HyClone), supplemented with 15 |j,g/mL hypoxanthine, 250 (ig/mL xanthine, and 25 |ig/mL mycophenolic acid (HXM selective medium).  B6SutA, an IL-3  and/or G M - C S F dependent murine hematopoietic cell line was grown in RPMI1640 media containing 1 0 % F B S (both HyClone) and 10 ng/mL of C O S cell derived IL-3 (produced in house at the terry Fox Laboratory). The F B S used for growing B6SutA cells was pretested for its ability to support growth and differentiation of murine bone marrow cells. 5.3.2  Generation  of GM-CSF  retroviral  vector  The murine retroviral vector used was based on upon the JzenTkneo vector described elsewhere (Damen et al. 1992). Briefly, a 495 base pair (bp) StulHinfl fragment containing the entire coding region of murine G M - C S F c D N A was isolated from the plasmid pGM19 GM-CSF (kindly provided by Dr. M Gorth; Ludwig Institute for Cancer Research, Melbourne, Australia), and blunted and subcloned into a Smal site of pAX114 (Kay and Humpries 1991). The G M - C S F c D N A was then reisolated as 507 bp S a i l fragment and subcloned into the Xhol site of JzenTkneo upstream of the n e o  r  gene, such that G M - C S F c D N A  expression is controlled by the myeloproliferative sarcoma long terminal repeat (LTR), with an expected chimaeric GM-GSF/neo m R N A of 3.5 kb. All restriction r  The effect of GM-CSF on PDT  99  enzymes used were from Canadian Life Technologies (Burlington, O N T , Canada). 5.3.3  Virus  production  and  infection  of  SCCVII  tumor  cells  The general strategy used to generate retrovirus producing cell lines was as outlined by Miller et al. (Miller et al. 1985). J z e n G M - C S F Tkneo plasmid DNA was transfected by calcium phosphate precipitation method (Ausubel et al. 1994) into GP+E-86 cells.  Transfected cells were selected based on their.  acquired resistance to neomycin by incubation in D M E M containing 0.8 mg/mL (active weight) of neomycin analog G-418 (Canadian Life Technologies) and were subsequently used as producers of recombinant retroviral particles encoding GM-CSF. Subconfluent monolayers of GP+E-86/JzGM-CSF and control GP+E86/Jzneo cells were washed twice with D M E M , overlaid with D M E M + 1 0 % F B S and irradiated to 12 Gy, using an x-ray source (Philips RT250, 250 kV, 0.5 mm Cu).  Virus containing cell culture supernatant was collected 24 hours later,  filtered through low protein binding filters (0.2 \im,  Millex-G;  Millipore,  Mississauga, ONT, Canada) and immediately used for infection of S C C V I I tumor cells. Low density cultures of S C C V I I tumor cells were infected by three consecutive 8 h incubations with virus containing supernatant in the presence of 6 u.g/mL polybrene. After the third incubation, the cells were washed twice with D M E M and cultured in D M E M + 1 0 % F B S for additional 24 h. The infected cells were then selected in medium containing 0.8 mg/mL of G-418. Individual antibiotic resistant colonies were scrapped off the dish, expanded in G-418 containing medium and tested for production of GM-CSF.  The effect of GM-CSF on PDT 5.3.4  Northern  blot  100  analysis  S C C V I I / J z G M - C S F cells (infected with JzenGM-CSFTkneo retrovirus) and S C C V I I / J z n e o cells (infected with JzenTkneo retrovirus) were grown in 10 cm tissue culture dishes in the absence of selection until they reached 8 0 - 9 0 % confluence.  The cells (approximately 5x10 ) were lyzed in TRIzol reagent 6  (Canadian Life Technologies) and total cellular R N A was isolated following the manufacturers recommendations. For Northern blot analysis, 10 jig of total R N A were separated on 1 % agarose, 5 % formaldehyde gel and transferred by blotting to a Zetaprobe nylon membrane (BioRad, Mississauga, ONT, Canada). The membrane was then prehybridized for 1 h in 5 0 % formaldehyde, 0.5 mmol/L N a H P 0 4 , 2.5 mmol/L EDTA, 5 % sodium dodecyl sulfate (SDS), and 1 2  mg/mL bovine serum albumin (BSA)  at 42°C and subsequently hybridized  overnight under the same conditions with c D N A probes that were by the random primer method (Feinberg and Vogelstein 1984).  3 2  P  labeled  Membranes  were washed twice at 55°C, first with 2 x S S P E , 0 . 3 % S D S ( 2 x S S P E : 0.3 mol/L NaCI, 20 mmol/L N a H P 0 2  SDS,  4 )  2 mmol/L EDTA; pH 7), then with 1x S S P E , 0 . 5 %  and finally with 0.3x S S P E , 1 % S D S .  The membranes were then  exposed to Kodak X-Omat A R film (Eastman-Kodak, Rochester, NY, USA). 5.3.5  GM-CSF  assay  1 x 1 0 S C C V I I / J z G M - C S F and SCCVII/Jzneo cells were incubated in 6 c m , 6  tissue culture dishes in 5 mL of D M E M + 1 0 % F B S in the absence of selection for 24 h. The media were then harvested, and filtered through 0.22 urn Millex-G filters.  Serial 5 0 % dilutions of this conditioned medium were prepared by  diluting the culture supernatant with RPMI medium containing 0 . 1 % B S A (Stem Cell Technologies, Vancouver, BC, Canada).  The effect of GM-CSF on PDT  101  Exponentially growing B6SutA cells were washed twice with RPMI medium containing 0 . 1 % BSA, and 2 x 1 0 cells in 80 uL of RPMI with 0 . 1 % B S A were 4  dispensed per U shaped well of 96 multiwell plate (Linbro: (CN, Mississauga, ONT, Canada).  Serial dilutions of conditioned media (20 u.L) were added to  duplicate wells to give a final volume of 0.1 mL/well. After 18 h incubation at 3 7 ° C , io |iL of a 50 uCi/mL solution of [ H]-thymidine (2.0 Ci/mmol; N E N , 3  DuPont C a n a d a Inc.) diluted in RPMI medium was added to each well to give the final activity of 1 u,Ci/well. After 2 h incubation at 37°C, the contents of the wells were harvested onto filtermats and counted using L K B  Betaplate  Harvester and Liquid Scintillation Counter (LKB Wallac, Turku, Finland). 5.3.6  Photodynamic  treatment  Tumors were used for experiments one week after inoculation, at which point their largest diameter was 5-6 mm. During the light treatment the mice were restrained unanasthetized in specially designed holders. Two different photosensitizers were used for photodynamic therapy of S C C V I I tumors. Photofrin based PDT consisted of intravenous administration of 10 mg/kg of Photofrin® (porfimer sodium) (QuadraLogic  Technologies  Phototherapeutics Inc., Vancouver, BC, Canada) followed by 150 J / c m of 630 2  nm light delivered 24 h later. Benzporphyrin derivative (BPD) based P D T was performed by intravenous administration of 2.5 mg/kg of B P D monoacid ring A (veterporfin, a liposomal preparation also from QuadraLogic) followed by 690 nm light (120 J/cm ) 4 hours later. 2  The light treatment for Photofrin-based PDT (630+10 nm) was delivered from a tunable light source equipped with 1 kW xenon bulb (model A 5000; Photon Technology International Inc.) through a 5 mm core diameter light guide (2000A, Luminex, Germany).  The. power density at the treatment area was 75  The effect of GM-CSF on P D T  102  mW/cm . The BPD-based P D T was performed using a 250 mW diode laser 2  (SDL7422-H1, Spectra Diode Labs, San Jose, C A , U S A ) , with 690 nm light delivered through a 2000A light guide. The power at the end of the light guide was 110 mW, and the power density at the irradiated area was 140 mW/cm . 2  The thickness of treated tumors never exceeded 3.5 mm, which ensured their transillumination by the monodirecfional light beams of 630 or 690 nm.  In  conjunction with the tissue light scattering, this achieved a high degree of light dose homogeneity within the treated lesions. The P D T light doses used with both photosensitizers were to assert, for the P D T alone groups, the level of tumor response that is close to the curative treshold (0-10% cures).  Tumor  temperature never reached more than 39°C during the light treatment as measured by a hypodermic thermocouple (YSI, Yellow Springs, O H , U S A ) . Mice were observed for tumor regrowth every second day. Three orthogonal tumor diameters were measured by a vernier caliper.  The mice were  considered cured if they were tumor free 90 days after the PDT. 5.3.7  GM-CSF  immunotherapy  The cultures of cytokine producing S C C V I I tumor cells were expanded and harvested when they reached approximately 80-90% confluence. Cells were then washed three times with 50 mL of cold (0°C) H B S S , to remove serum proteins. The cell concentration was adjusted to 1 x 1 0 cells/mL in H B S S . The 8  cell suspensions in 5 mL plastic tubes held.on ice were.then irradiated with xrays to 50 Gy. Aliquots (0.1 mL) of this suspension, containing 1 x 1 0 irradiated 7  cells were injected into each mouse. In all protocols, 1 x 1 0 irradiated SCCVII/JzGM-CSF or SCCVII/Jzneo cells 7  were injected per application. Mice were briefly anesthetized by inhalation of Metofane (Janssen Pharmaceutica, Mississauga, O N T , Canada), and the  The effect of GM-CSF on PDT  103  subcutaneously growing tumor was lifted and the cell suspension slowly injected under the tumor using 26 gauge needle. The tumor was then gently released such that no cells were lost through the needle track.  The first  treatment was given 48 hours before light treatment (i.e. 24 h before Photofrin administration), second treatment was immediately following the light delivery, and the last treatment was at 48 h after PDT.  When the tumor became  unpalpable at 48 h post PDT, the cells were injected subcutaneously as close as possible to the tumor site. 5.3.8  Macrophage  cytotoxicity  Mice bearing S C C V I I tumors were injected peritumorally with IxTO lethally 7  irradiated SCCVII/JzGM-CSF or SCCVII/Jzneo cells. The mice were sacrificed 48 hours later, tumors excised and dissociated into single cell suspension by an enzymatic procedure used routinely in our laboratory (Korbelik 1993).  Tumor  associated macrophages (TAMs) were isolated from this suspensions by a modification of the differential attachment procedure described previously (Korbelik et al. 1991; Krosl et al: 1995). Briefly, the ability of macrophages to attach firmly to a plastic substrate much more rapidly than the other cells present in S C C V I I tumor was exploited for obtaining highly purified T A M populations.  Tumor cell suspension was resuspended in RPMI medium  supplemented with 1 0 % F B S ,  and aliquots containing 6 . 9 x 1 0  5  (of which  approximately 2 x 1 0 were expected to be TAMs) were transferred into wells of 5  a 24-well plate. After 30 min. incubation at 37°C, the medium was replaced with 0.5 mL Trypsin-EDTA solution (Sigma Chemical Co., St. Louis, M O , USA) and incubated for 30 seconds at room temperature.  This was followed by  washing the attached cells vigorously three times with 1 mL of H B S S .  The  washout containing removed cells was collected and pooled for each sample.  The effect of GM-CSF on PDT  104  The number of T A M s remaining in wells was determined by subtracting the number of cells removed by washing from the number of plated cells. T A M s were then incubated with lipoplysaccharide (LPS)  from  E.  coli  The  011:b4  (Sigma) at 10 u.g/mL in RPMI + 1 0 % F B S for 24 h. The target cells ( S C C V I I tumor cells maintained  in vitro  for 6-8 weeks) were  added to the wells containing T A M s at a ration 20:1. Before that, the target cells were pre-labeled by exposure to [ H-methyl]thymidine (2.0 Ci/mmol, NEN) at 2 3  |iCi/mL for 24 h in cell growth medium and then pre-incubated for 4 h with Actinomycin-D (1.5 ixg/mL, Sigma).  The samples with effector and target cells  were incubated 72 h at 37°C and the supernatants were then collected for the measurement of radioactivity released from killed S C C V I I cells as described in detail earlier (Korbelik and Krosl 1994). All experiments were carried out in quadruplicate (four wells for each T A M population). 5.4  Results  5.4.1  GM-CSF  production  by SCCVII/JzGM-CSF  cells  Northern blot analysis of total R N A isolated from S C C V I I / J z G M - C S F and S C C V I I / J z n e o cells is shown in Figure 5.1.  The upper panel confirms the  presence of G M - C S F m R N A in S C C V I I cells transduced with the J z G M - C S F retrovirus, and shows that this message is not present in control cells infected with JzenTkneo virus.  The lower panel shows that in S C C V I I / J z G M - C S F  derived R N A the n e o probe recognized a transcript of approximately 3500 bp r  initiated within the retroviral LTR and encoding both G M - C S F  and n e o , r  whereas the S C C V I I / J z n e o cells expressed shorter n e o message initiated by r  the internal Tk promoter!  The effect of GM-CSF on PDT  A  105  A  GM-CSF n e o  Figure 5.1  Northern analysis of the total RNA isolated from SCCVII/JzGMCSF and SCCVII/Jzneo cells.  The production of GM-CSF protein by SCCVII/JzGM-CSF cells was tested by a bioassay using cytokine dependent B6SutA cells. The conditioned media from SCCVII/JzGM-CSF cells induced proliferative response of B6SutA cells, while the conditioned media from both, parental  SCCVII  cells and  SCCVII/Jzneo cells showed no support of the growth of B6SutA cells (Figure 5.2).  A comparison to the response achieved with known concentrations of  recombinant GM-CSF (Fig. 5.2  inset),  indicates that SCCVII/JzGM-CSF cell  conditioned medium contained approximately 400 ng/mL of GM-CSF released per 10 cells over a 24 h period. 6  The effect of GM-CSF on PDT  106  o  c  2000 1  CO  30000  2  3  ng GM-CSF  CD  § E  Q_ O  c o 2  o o o c  I  25000 20000 15000  SCCVII/JzGM-CSF SCCVII parental  1 0000  SCCVII/Jz neo  5000  CO  0  -  J  0.05  0.1  0.15  Conditioned medium (%  0.2  0.25  of total volume)  Figure 5.2 GM-CSF bioassay B6SutA cells were incubated overnight in serial dilutions of conditioned medium from 24 h culture of 1x10 SCCVII/JzGM-CSF, SCCVII/Jzneo, and parental SCCVII cells. The responder cells were then pulsed with [ H]-thymidine for 4 hours and the amount of incorporated nucleotide was registered on a scintillation counter. Inset: Proliferative response of B6SutA cells to recombinant GM-CSF. 6  3  The effect of GM-CSF on P D T 5.4.2  Blood  leukocyte  content  107  in GM-CSF  treated  mice  Blood smears were prepared at 2, 4, and 6 days following single or multiple treatment with 1 x 0 lethally irradiated G M - C S F producing S C C V I I cells 7  administered subcutaneously in the dorsal area of C3H/HeN mice (otherwise the site of S C C V I I tumor implantation). Following Wright staining, a differential white blood cell count was performed based on 200 nucleated cells per smear (five mice per group). The only difference noted (Table 5.1) was an increase in the average monocyte content from 7±3% in control mice to 13±6% in mice examined 6 days after the last of three injections of S C C V I I / J z G M - C S F cells that were given in 48 h intervals; this change however, w a s not statistically significant.  T h e blood content of neutrophils, other granulocytes a n d  lymphocytes were unchanged.  Injection of S C C V I I / J z n e o cells had no  detectable effect on total and differential blood cell counts.  Table 5.1  Treatment  Blood leukocyte content in GM-CSF treated mice Days  Lym %  SCCVII/JzGM-CSF 3x  Neutro  Mo  %  %  .  Baso & Eo %  -  22 ±7  7+3  1+2  c  69 ±9  21+5  8 +3  1.5+1  4  '. 71 ±7  21+4  7 +4  1±1  6  72 ±6  20 ± 5  6 ±3  1.5 ± 1  2  67 ± 7  22 + 3  10±5  4  67 + 9  23 ± 4  9±5  6  65 ±8  22 ± 5  13 ± 6  1± 1  2  66 + 6  22 ± 6  12 ± 5  4  60 + 4.  24 + 7  15 + 6  0.8 ± 1 1± 1  61 ±8  24 ±9  13 ± 6  2 +2  2  SCCVII/JzGM-CSF  .  70 + 6°  Control SCCVII/Jzneo  a  6  1+1 1 ± 1.5.  Mice were injected either with GM-CSF producing SCCVII cells or control SCCVII cells infected with JzenTkneo virus. Blood samples for Wright staining were taken at 2 days after the last injection. a  b  c  All differential counts were done manually on 200 cells. Results are the mean + SD for 5 mice per group.  Time after single GM-CSF treatment or after the last of three GM-CSF treatments.  108  The effect of GM-CSF on PDT 5.4.3  The  effect  of  GM-CSF  treatment  on  growth  of  SCCVII  tumor  Mice bearing a parental S C C V I I tumor were injected peritumorally with 1 x 1 0 lethally irradiated S C C V I I / J z G M - C S F cells at the time when the largest 7  tumor diameter reached 5-6 mm. The tumor volumes were then determined every second day. All treated mice developed edema around the tumor, which persisted for 2-4 days after the injection of G M - C S F releasing cells.  This  treatment, however, had no significant effect on the rate of growth of the S C C V I I tumor (Figure 5.3).  The injection of lethally irradiated S C C V I I / J z n e o or  parental S C C V I I cells also had no effect in the growth of S C C V I I tumor (data -not shown), In other experiments, 1 x 1 0 lethally irradiated S C C V I I / J z G M - C S F 7  cells were injected subcutaneously into the area of tumor implantation two days after the inoculation of parental S C C V I I cells. Even in this situation, when the tumor mass is very small (similarly as in the case with the reduced tumor burden after PDT) the GM-CSF treatment had no visible effect in tumor growth (Figure 5.4).  The effect of GM-CSF on P D T  0.1  I—i 4  •  1  6  •  • •  8  Days  1  10  i  109  l—i i i J i_J . I 12 14 16 18 2 0  after tumor implant  .  Figure 5.3  The effect of GM-CSF treatment on growth of established S C C V I I tumor. Mice bearing SCCVII tumors 5-6 mm in diameter were injected peritumorally with 1x10 lethally irradiated SCCVII/JzGM-CSF cells. Tumor volumes were determined every second day. Each group consisted of six mice. Bars are SD. 7  The effect of GM-CSF on PDT  0.1  I  1  4  I- ' • • ' i_J 6  8  •  10  I  12  i  I  14  i  I  16  i  110  I  18  i  I  20  D a y s after tumor implant Figure 5.4 Effect of GM-CSF treatment on inoculated S C C V I I tumor. Mice were injected subcutaneously with 1x10 lethally irradiated SCCVII/JzGM-CSF cells 2 days after the inoculation of parental SCCVII tumor. Tumor volume was determined every 2 days. Bars represent SD. 7  The effect of G M - C S F treatment on the levels of tumor infiltrating leukocyte populations in the S C C V I I tumor was also examined. Mice bearing S C C V I I tumors (of a similar size as used for PDT) were injected peritumorally with 1 x 1 0 lethally irradiated SCCVII/JzGM-CSF cells, the tumors were excised 48 h 7  later and analyzed for the content of malignant and other cell populations. This was determined by flow cytometry analysis of cells dissociated from the tumor tissue and stained with monoclonal antibodies against specific membrane markers which serve for the identification of various types of tumor infiltrating leukocytes.  The experimental protocols for such analysis of various tumor  models (including S C C V I I tumor) were developed in our earlier studies (Korbelik and Krosl 1995; Korbelik and Krosl 1996). A s previously reported (Korbelik and Krosl 1996), the majority of cells in S C C V I I tumor are cancerous  The effect of GM-CSF on P D T  111  (61%) i.e. CD45", the second largest population are T A M s (29%) i.e. F4/80+ while there are 5 % of other myeloid cells (GR1+F4/80 ) and 5 % T lymphocytes -  (CD3+).  These average values for the incidence of major cell populations in  S C C V I I tumor remained unchanged following the above described treatment with G M - C S F releasing cells. 5.4.4  The  effect  of  GM-CSF  treatment  on  cytotoxic  activity  of  TAM  Mice bearing S C C V I I tumor were injected peritumorally with 1 x 1 0 of 7  lethally irradiated SCCVII/JzGM-CSF of SCCVII/Jzneo cells. The tumors were excised 48 h later and T A M s were harvested for the analysis of their cytotoxicity against syngeneic in vitro cultured malignant S C C V I I cells. The measurement of [ H]thymidine released from killed target cells (Figure 5.5) revealed that, in 3  comparison to T A M s isolated from non-treated or S C C V I I / J z n e o  treated  S C C V I I tumors, the T A M s obtained following tumor localized G M - C S F treatment exhibit 3-4 fold increase in tumoricidal activity.  112  The effect of GM-CSF on P D T  30  r  25 -  'S 2 0 CO CD CD C TJ  15 -  >, 1 0 I  CO  0  Figure 5.5  Control  J z neo  Jz GM-CSF  The effect of tumor localized GM-CSF treatment activity of TAM.  on cytotoxic  S C C V I I tumor bearing mice were injected with 1 x 1 0 of lethally x-ray irradiated S C C V I I / J z G M - C S F of S C C V I I / J z n e o cells. The tumors were excised and T A M s isolated 48 h later. Cultured malignant S C C V I I cells were labeled with [ H]thymidine and admixed to T A M s at 1:20 ratio (1 x 1 0 S C C V I I cells vs. 2 x 1 0 T A M s per sample). Following 72 h incubation, the supernatants were collected for the measurement of radioactivity released from killed target cells. * = statistically significant difference compared to controls (p < 0.001). Bars indicate S D . 7  3  4  5.4.5 tumors  5  The to  effect  of  GM-CSF  treatment  on  the  response  of  PDT.  Three groups of 16 mice were included in the experiment designed to investigate the effect of GM-CSF immunotherapy on Photofrin mediated PDT. In two  groups,  1 x 10  7  lethally irradiated S C C V I I / J z G M - C S F  cells  or  S C C V I I / J z n e o cells were injected peritumorally 48 h before the photodynamic  The effect of GM-CSF on PDT  113  light delivery, immediately after the light treatment and 48 h later.  The third  group received PDT only. Complete tumor ablation was observed within 2 days after light delivery in all three groups (Figure 5.6).  However, the tumors  started to regrow in the PDT only group and the PDT+Jzneo group at 8-10 days post PDT.  By day 20, only one mouse (out of 16) showed no signs of tumor  recurrence in both these groups. In PDT+JzGM-CSF group, however, the tumor free period lasted at least two weeks.  Although tumor regrowth occurred  afterwards in some mice, the overall cure rate for this group was 7 5 % . Prolonged tumor free period and significantly increased survival of tumor bearing  mice  in  Photofrin  mediated  PDT  combined  with  GM-CSF  immunotherapy indicates that such a treatment modality offers increased effectiveness of tumor control.  The effect of GM-CSF on PDT  0  4  8  12  16  114  20  D a y s relative to  24  92  96  PDT  Fjgure 5.6  The effect of localized GM-CSF treatment on the control of S C C V I I tumor by Photofrin mediated PDT. Mice bearing S C C V I I tumor received Photofrin (10 mg/kg, i.v..) 24 hours before the light treatment with 150 J/cm . Some mice were also injected peritumorally with lethally x-ray irradiated SCCVII/JzGM-CSF or SCCVII/Jzneo cells in three 2 day intervals, i.e. at 48 h before PDT, immediately following light treatment, and 48 h after PDT. The mice were observed afterwards for signs of tumor recurrence. Each treatment group contained 16 mice. The difference of cure rate between GM-CSF+PDT and PDT alone groups is statistically significant (p < 0.0005).; / 2  The  same  GM-CSF  immunotherapy  protocol was  also e x a m i n e d in  combination with B P D mediated PDT of S C C V I I tumor. The result are depicted in Figure  5.7.  In all three groups, the tumors regressed and  unpalpable within several days after PDT.  become  However, visible signs of recurrence  appeared by day 8 and 10 in P D T only and PDT+Jzneo groups, respectively. All mice in these two groups showed tumor regrowth by day 18 after P D T .  In  The effect of G M - C S F on PDT  115  P D T + J z G M - C S F group, there was no tumor recurrence until day 12, with 5 0 % of animals remaining tumor free at the end of the observation period (96 days).  PDT PDT + Jz neo PDT + JzGM-CSF  I  I  I  I  0  2  4  6  I  L  L  I  L  I  I  l _  8 101 2 1 4 1 6 1 8 2 0 2 2 2 4 D a y s relative to  Figure 5.7  I  i  92  •  i 94  PDT  The effect of localized GM-CSF immunotherapy on the control of SCCVII tumor by BPD mediated PDT SCCVII tumor bearing mice received BPD (2.5 mg/kg, i.v.) at 4 h before the light treatment with 110 J/cm . Two groups of mice were treated with SCCVII/JzGM-CSF or SCCVII/Jzneo cells as described in Fig. 5.6. Other details were also as in Fig 5.6. The difference in the cure rate between GM-CSF and PDT alone groups is statistically significant (p < 0.0005). 2  The effect of GM-CSF on PDT  5.5  116  Discussion In order to investigate the effect of localized G M - C S F treatment on the  control of tumors treated with PDT, we introduced the gene for murine G M - C S F into S C C V I I tumor cells. Northern blot analysis and the bioassay with G M - C S F dependent B6SutA cells confirmed that G M - C S F transduced cells (denoted S C C V I I / J z G M - C S F ) express G M - C S F m R N A and secrete biologically active form of this cytokine. Stable secretion of relevant cytokines from infected tumor cells following antiproliferative doses of x-ray irradiation (as used in the present study) was reported to continue under in vitro conditions for at least 7-10 days (Tepper and Mule 1994). Single  o r . multiple s u b c u t a n e o u s  injections  of  lethally  irradiated  S C C V I I / J z G M - C S F cells exerted no significant effect on the leukocyte numbers in peripheral blood of treated mice.  The peritumoral injections of G M - C S F  releasing cells markedly increased cytotoxicity of T A M s against autochtonous S C C V I I cells (Figure 5.5), but this treatment had no obvious effect on the rate of growth of S C C V I I tumor (Figures 5.3 and 5.4). As demonstrated in the number of studies, a large tumor burden normally overcomes the immunostimulation induced by vaccination with cytokine gene-modified tumor cells (Tepper and Mule 1994). On the other hand, Dranoff era/. (Dranoff et al. 1993) showed that the vaccination of mice with G M - C S F producing B16 melanoma cells induces the rejection of B16 melanoma inoculum implanted 3 days earlier, while we were unable to demonstrate a similar effect with SCCVII/JzGM-CSF cells given two days after the S C C V I I tumor implant. This finding may reflect the lower antigenicity of S C C V I I tumor compared to the B16 melanoma. It should also be noted that the tumor inoculum used by Dranoff et al. (Dranoff et al. 1993) was lower than the inoculum used in the present study (5 x 1 0 vs. 5 x 1 0 cells). 4  5  The effect of GM-CSF on PDT  117  In preliminary studies (Krosl et a l , 1995), we examined a variety of treatment schedules with G M - C S F releasing cells in search for the most effective protocol for combined application with PDT.  Based on this evaluation, we opted for  three peritumoral injections of lethally irradiated S C C V I I / J z G M - C S F spaced in 48 h intervals and begun two days before PDT.  cells  It should be noted,  however, that even one such injection (given 48 h before PDT) proved effective in the enhancement of PDT related tumor control (Krosl et al. 1995). Much less effective was GM-CSF therapy initiated after PDT. , Since the cytokine production by S C C V I I / J z G M - C S F cells is mediated through their regular metabolic activity, there is no basis to expect an increased release of G M - C S F from these cells by a light-activated mechanism. On the contrary, photosensitizer accumulation in the cells subtumorally injected before its administration and consequent induction of PDT-mediated photodamage can negatively affect the metabolism of these cells, resulting in decreased G M - C S F release. The results presented in this Chapter demonstrate that tumor localized G M - C S F treatment substantially improves the curative effect of P D T in the S C C V I I tumor model.  This potentiating effect of G M - C S F was highly  pronounced irrespective of whether Photofrin of B P D were employed as photosensitizers for PDT.  The enhancement level with both photosensitizers  was equivalent to a -2.5 fold increase in the light dose for PDT used alone. The S C C V I I cells transfected with the control retroviral vector encoding for neo only r  were used to demonstrate that:  i)  peritumoral injections  perse  do not affect the  P D T response, and ii) localized treatment with lethally irradiated tumor cells transfected with the retroviral vector are not inducing an artifact in the evaluation of tumor response to PDT.  The effect of GM-CSF on PDT  118  B a s e d on available knowledge of the immunomodulating properties of G M - C S F , several putative mechanisms can be proposed to account for the observed effects of treatment with this cytokine on the antitumor activity of PDT. The increased local concentration of GM-CSF attained by the treatment protocol used in the present study may: i) upregulate the expression of leukocyte adhesion molecules and consequently the extravasation of inflammatory cells into tumor tissue; ii) potentiate specifically the tumoricidal activity of neutrophils and/or monocytes-macrophages; iii) induce release of a number of secondary cytokines and other molecules (including e.g. TNF-a and interleukin-2) involved in mediating the antitumor effect; iv) facilitate the presentation of tumor antigens released following P D T treatment and thereby activate specific T cell mediated immune responses; v) promote the inactivation of remaining islets of viable tumor cells, unhindered by the tumor burden, as P D T effectively de-bulked the tumor mass; vi) diminish the immunosuppressive effect (Bilyk and Holt 1993) induced by P D T (Lynch et al. 1989; Lynch et al. 1989). The ongoing research in our laboratory is designed to address specifically the contribution of the above listed mechanisms. The fact that the potentiation of the antitumor effect of P D T was observed with the S C C V I I tumor which is poorly immunogenic is particularly encouraging with respect to potential clinical ramifications.  It  remains to be determined whether the potentiating effect of G M - C S F treatment is equally pronounced or different with PDT treated immunogenic tumors. In Chapter 4 it was shown that the response of the S C C V I I tumor to P D T can be augmented by multiple intramuscular injections of glucan  SPG  administered before the light treatment. The response of tumors characterized by different degrees of immunogenicity was shown to be enhanced by a variety of other nonspecific immune stimulants, including B C G (Cho et al. 1992), Corynebacterium  parvum  vaccine (Myers et al. 1989), mycobacterial cell wall  The effect of GM-CSF on PDT  119  extract (Korbelik and Krosl 1996) and endotoxin (Dima et al. 1994), as well as with specific immune agents such as the macrophage activating factor G c M A F (Korbelik et al. 1995) and cytokines TNF-a (Bellnier 1991) and interleukin-7 (Dougherty et al. 1992).  It appears, therefore, that due to its unique  inflammatory/immune character,  PDT  is highly responsive to  adjuvant  immunotherapy. Immunotherapy regimens tailored and optimized for particular malignant lesions may produce outstanding gains in P D T mediated tumor control. The treatment with PDT, serving as a strong acute inflammatory insult associated with de-bulking of tumor mass,, may emerge as a model system of value for characterization of different aspects of the immune reaction.  Conclusions  120  CHAPTER 6 Conclusions and future directions 6.1  Conclusions The goal pursued in this research project was to provide a better insight into  the role of the host in the tumor response to PDT. The reports available at that time (Bugelski et al. 1981; Elmets and Bowen 1986; Lynch et al. 1989; Lynch et al. 1989; Myers et al. 1989; Evans et al. 1990) and the evidence the P D T induces release of vasoactive and proinflammatory mediators (Ben-Hur et al. 1988; Henderson and Donovan 1988; Henderson and Donovan 1989; Nseyo et al. 1990; Fingar et al. 1991; Fingar et al. 1992) indicated that cells of host immune system may be actively involved in the processes that lead to tumor destruction by PDT. This provided the rationale for initiating our studies on the role of host immune cells in the response of tumors to PDT. Our initial work concentrated on the distribution of Photofrin between the malignant and host cells of the murine S C C V I I tumor. The in vitro studies showed that not only the uptake of Photofrin by macrophages is markedly higher compared to S C C V I I cells, but also that influencing the phagocytic activity of macrophages affects their ability to accumulate the photosensitizer (Tables 2.1 and 2.2). A n interesting result from these studies w a s the demonstration of the inhibitory effect of serum and different plasma proteins on Photofrin  accumulation  in S C C V I I  cells as well as in macrophages  (Figure 2.3). W e interpreted this to be a consequence of disaggregation of Photofrin material by the serum components (Korbelik and Hung 1991). A n alternate explanation would invoke internalization of photosensitizer-serum protein complexes through specific endocytic receptors which are known to be abundant on macrophage surface membrane.  However, these in vitro results  Conclusions  121  do not support the hypothesis that macrophages accumulate mainly LDL bound Photofrin via the LDL and scavenger receptor pathways as proposed by Hamblin et al. (Hamblin and Newman 1994). The studies on the distribution of different photosensitizers in various tumor models that were done in our laboratory after the initial experiments described in Chapter 2 (Korbelik and Krosl 1995; Korbelik and Krosl 1995; Korbelik and Krosl 1996)  support the  hypothesis that the state of macrophage activation determines the accumulation of Photofrin in these cells. This is also in concordance with the observations of porphyrin accumulation in areas of inflammation, atherosclerosis and healing wounds (Figge et al. 1948; Spears et al. 1983; Nseyo et al. 1985). It is now established that an intense inflammatory reaction follows P D T treatment of solid tumors. The release of pro-inflammatory mediators such as metabolites of arachidonic acid, cytokines and degradation products of membranous lipids have been implicated in this process (Pass 1993). We have shown that Photofrin-based PDT initiated a massive and regulated infiltration of inflammatory cells into the treated tumor. Such an infiltration could facilitate the effect of PDT by several interconnected mechanisms. The swift and massive infiltration of neutrophils is probably the initiating event in the host response to PDT. The ability of activated neutrophils to kill tumor cells is well known (Fady et al. 1990; Midorikama et al. 1990). The release of superoxide by neutrophil membrane-associated  NAPDH  oxidase (Rossi  1986) and liberation of  proteases and non-oxidative toxins by these cells is likely to play an important role in the, observed blood vessel damage and the resulting hemorrhagic necrosis (Gallin 1989). Although the numbers of infiltrating mast cells observed in P D T treated S C C V I I tumors are much lower than those determined for neutrophils, mast cells are known to produce a variety of cytokines such as IL-4, IL-5, IFN-y, and TNF-a (Harvima et al. 1994). The macrophages that were  Conclusions  122  recovered from the tumor site after PDT showed markedly increased cytotoxicity against tumor cells (see Figure 3.6).  The intense tumor cell destruction and  release of dead cell fragments, that are likely phagocytized by resident and infiltrating macrophages, build up the conditions for the efficient presentation of tumor antigens to T lymphocytes.  The pro-inflammatory cytokines mentioned  above, documented to be released after P D T (Nseyo et al. 1990), and mediators released by infiltrating neutrophils and macrophages may provide an appropriate milieu for T cell activation (Colombo et al. 1992; LLoyd and Oppenheim 1992). This proinflammatory and immunostimulatory nature of P D T was exploited in the experiments with combined PDT-immunotherapy treatment that are described in Chapter 4 and Chapter 5.  Significantly enhanced tumor control  obtained with P D T in combination with G M - C S F and S P G  immunotherapies  indicates that the immune system can be induced to eradicate tumor cells that would otherwise escape PDT treatment. The constituitive release of cytokines by genetically engineered tumor cells, as was used in the immunotherapy with G M - C S F (Chapter 5), is an intensely researched area in tumor biology (Colombo et al. 1992; Tepper and Mule 1994). Localized treatment of tumors with exogenous cytokines was shown to induce antitumor reaction which can lead to tumor regression (Pericle et al. 1992). In our experimental system, the treatment with either of the tested immunotherapies alone did not affect tumor progression (Figure 4.1 and Figure 5.3).  The enhanced  tumor control that was  achieved  with the  PDT-  immunotherapy combinations compared to PDT alone is probably the result of a stronger PDT-immunotherapy induced host response. The results presented in Table 4.2 clearly show that the S P G immunotherapy significantly enhanced the secondary effects of PDT. In the experiments with both immunotherapies it was  Conclusions  123  shown that the timing of immunotherapy relative to P D T is of a critical importance. S P G requires repeated administration for priming of macrophages (Sugawara et al. 1984; Tsuchiya et al. 1989), and is therefore ineffective if given after PDT. G M - C S F enhances proliferation and antigen presentation of A P C s (Heufler et al. 1987; Witmer-Pack et al. 1987; Grabbe et al. 1992; Grabbe et al. 1994) and together with TNF-a induces the increased expression of M H C class II and costimulatory molecules on A P C s (Grabbe et al. 1992; Sallusto and Lanzavecchia 1994). Continuous presence of G M - C S F during and after P D T (Figure 4.6) seemed to have a stronger potentiating effect on P D T compared to the single GM-CSF treatment (Figure 4.5) It has been reported that curative P D T can induce a protective immunity against the secondary challenge with the same tumor (Canti et a|. 1994), while Myers et al. (Myers et al. 1989) observed that the treatment with low dose Corynebacterium  parvum  vaccine which induces primarily lymphocyte  infiltration in tumor site amplifies the effect of P D T .  Therefore, it can be  hypothesized that G M - C S F immunotherapy enhances the specific immune response against the tumor cells which was initiated by PDT. 6.2  Future  directions  The role of the inflammatory reaction in P D T mediated tumor control is well established but it needs to be better characterized. It is known that treatment with inhibitors of inflammation, such as drugs that block the metabolism of arachidonic acid, reduce the tumor cure (Fingar et al. 1993). Additional studies in our laboratory will focus on the importance of leukocyte-endothelial cell interactions in tumor control by PDT. Antibodies that can block leukocyteendothelial cell adhesion (Albelda et al. 1,994) will be used in order to manipulate inflammatory cell extravasation pathways.  These results may  Conclusions provide important information about the development of P D T  124 induced  inflammatory reaction and its importance for PDT-mediated tumor cure. Results of enhanced tumor control with PDT-immunotherapy combination compared to PDT alone, presented in this thesis warrant additional studies on the role of immune system in the response to PDT. The possible involvement of specific immunity in the curative potential of G M - C S F immunotherapy adjuvant to P D T can be inferred from the fact that G M - C S F induces T-cell mediated immunity against the tumors (Dranoff e t a l . 1993; Levitsky et al. 1994).  Our  observation that the anitumor effect of PDT is greatly diminished in the severe combined immunodeficient (SCID) mice, which lack the specific immune response mediated by T and B lymphocytes, in comparison to syngeneic Balb/c mice provide an additional support for this hypothesis. Adoptive transplantation of T lymphocytes or their subsets from normal mice into SCID mice at different times relative to P D T will give us more specific answers in regard to the involvement of specific effector cells in PDT tumor control. The depletion of T lymphocyte subsets in normal mice before or after PDT will provide additional data with respect to the importance of T cells during and after PDT. We expect that at least for some tumors the presence of specific immune cells will be shown to be of a crucial importance for tumor control. A better knowledge about the contribution of these cells in the processes that lead to PDT-mediated tumor destruction will help in designing more effective immunotherapy protocols for combination with PDT.  References  125  CHAPTER 7 References Abramson, A. L , M. J . Shikowitz, V. M. Mullooly, B. M. Steinberg, C. A. Amelia and H. R. Rothstein (1992). "Clinical effects of photodynamic therapy on recurrent laryngeal papillomas."  Arch.  Otolar.  Head  Neck  Surg  118: 25-  9. Abramson, A. L , M. J . Shikowitz, V. M. Mullooly, B. M. Steinberg and R. B. Hyman (1994). "Variable light-dose effect on photodynamic therapy for laryngeal papillomas."  Arch.  Otolar.  Head  Neck  Surg.  120: 852-5.  Agarwal, M. L , H. E. Larkin, S. I. A. Zaidi, H. Mukhtar and N. Oleinick (1993). "Phospholipase activation triggers apoptosis in photosensitized mouse lymphoma cells."  Cancer  Res.  53: 5897-5902.  Albelda, S. M., C. W. Smith and P. A. Ward (1994). "Adhesion molecules and inflammation injury."  FASEB  8: 504-512.  J.  Andersson-Engels, S., R. Berg, J . Johansson, S. Svanberg, U. Stenram and K. Svanberg (1992). Laser spectroscopy in medical diagnostics. Photodynamic  Therapy,  Basic  Principles  and Clinical  1  Applications.  (B.  W.  Henderson and T. J . Dougherty, ed.) New York, Marcel Dekker Inc. pp. 387-424. Atlante, A., S. Passarella, E. Quagliariello, G . Moreno and C. Salet (1989). "Haematoporphyrin derivative (Photofrin II) photosensitization of isolated mitochondria: inhibition of ADP/ATP translocator." Photobiol.  B: Biol.  J.  Photochem.  4: 35-46.  Atlante, A., S. Passarella, E. Quagliariello, G . Moreno and C. Salet (1990). "Carrier thiols are targets of Photofrin II photosensitization of isolated rat liver mitochondria."  J. Photochem.  Photobiol.  B: Biol.  7: 21-32.  References  126  Auler, H. and G . Banzer (1942). "Untersuchungen uber die rolle der porphyrine bei geschwulstkranken menshen und tieren."  Z. Krebsforsch.  53: 65-68.  Ausubel, F. M., R. Brent, R.'E. Kingston, D. D. Moore, J . G. Seidman, J . A. Smith and K. Struhl, Ed. (1994).  Transfection  of DNA  into eukaryotic  cells.  Current protocols in molecular biology. New York, Greene Publishing Associates and Wiley-lnterscience. Axline, S. G . and E. P. Reaven (1974). "Inhibition of phagocytosis and plasma membrane mobility of the cultivated macrophage by cytohalasin B." B. J. Cell  Biol.  62: 647-659.  Bellnier, D. A. (1991). "Potentiation of photodynamic therapy in mice with recombinant human tumor necrosis factor-oc." J. Biol.  Photochem.  Photobiol.  B:  8: 203-210.  Bellnier, D. A. and T. J . Dougherty (1989). "The time course of cutaneous porphyrin photosensitization in the murine ear."  Photochem.  Photobiol.  49: 369-372. Bellnier, D. A. and B. W. Henderson (1992). Determinants of photodynamic tissue destruction: Applications.  Photodynamic  Therapy,  Basic  Principles  and  Clinical  (B. W. Henderson and T. J . Dougherty, ed.) New York,  Marcel Dekker Inc. pp. 117-127. Ben-Hur, E., E. Heldman, S. E. Crane and I. Rosenthal (1988). "Release of clotting factors from photosensitized endothelial cells: a possible trigger for blood vessel occlusion by photodynamic therapy."  FEBS  Lett  236:  105-108. Berg, K. and J . Moan (1992). "Mitotic inhibition by phenylporphines and tetrasulfonated aluminium phthalocyanine in combination with light." Photochem.  Photobiol.  56: 333-339.  References  127  Berg, K., J . Moan, JVC. Bommer and J . W. Winkelman (1990). "Cellular inhibition of microtubule assembly by photoactivated sulphonated mesotetraphenylporphines."  Int. J  r  Radial  Biol.  58: 475-487.  Bilyk, N. and P. G. Holt (1993). "Inhibition of the immunosuppressive activity of resident pulmonary macrophages by granulocyte/macrophage colonystimulating factor." J. Exp. Med. 177: 1773-1777. Bonnett, R. and M. Berenbaum (1989). "Porphyrins as photosensitizers." Found.  Symp.  CIBA  146: 40-53.  Brown, S. B. and D. I. Vernon (1990). The quantitative determination of porphyrins in tissues and body fluids: applications in studies of photodynamic therapy.  Photodynamic  therapy  of neoplastic  disease.  (D.  Kessel, ed.) Boca Raton, C R C Press, Inc. pp. 109-128. Bucana, C D , A. Fabra, R. Sanchez and I. J . Fidler (1992), "Different patterns of macrophage infiltration into allogenic-murine and xenogenic-human neoplasms growing in nude mice."  Am.  J.  Pathol.  141: 1225-1236.  Bugelski, P. J . , C. W. Porter and T. J . Dougherty (1981). "Autoradiographic distribution of hematoporphyrin derivative in normal and tumor tissue of the mouse."  Cancer  Res.  41: 4606-4612.  Cairnduff, F., M. R. Stringer, E. J . Hudson, D. V. Ash and S. B, Brown (1994). "Superficial photodynamic therapy with topical 5-aminolaevulonic acid for superficial primary and secondary skin cancer."  Br. J.  Cancer  69: 605-  608. Candide, C , J . C. Maziere, R. Santus, C. Maziere, P. Morliere, J . P. Reyftmann, S. Goldstein and L Dubertret (1989). "Photosensitization of Wi26-VA4 transformed human fibroblasts by low density lipoprotein loaded with the anticancer porphyrin mixture photofrin II: evidence for endoplasmic reticulum alteration."  Cancer  Lett.  44: 157-161.  128  References  Canti, G., D. Lattuada, A. Nicolin, P. Taroni, G. Valentini and R. Cubeddu (1994). "Antitumor immunity induced by photodynamic therapy with aluminum disulfonated phthalocyanines and laser light." Anti-Cancer  Drugs  5: 443-  447. Chan, W.-S., J . F. Marshall, G. J . F. Lam and I. R. Hart (1988). "Tissue uptake, distribution, and potency of the photoactive dye chloraluminum , sulfonated phthalocyanine in mice bearing transplantable tumors." Cancer  Res.  48: 3040-3044.  Chaplin, D. J . , R. E. Durand, I. J . Stratford and T. C. Jenkins (1986). "The radiosensitizing and toxic effects of RSU-1069 on hypoxic cells in a murine tumor."  Int. J. Radiation  Oncology  Biol. Phys.  12: 1091-1095.  Chaplin, D. J . , P. L. Olive and R. E. Durand (1987). "Intermittent blood flow in a murine tumour: radiobiological effects."  Cancer  Res.  47: 597-601.  Chapman, M. J . (1986). "Comparative analysis of mammalian plasma lipoproteins."  Methods  Enzymol.  128: 569-573.  Chien, K. R., J . Abrams, A. Serioni, J . T. Martin and J . K. Farber (1978). "Accelerated phospholipid degradation and association membrane dysfunction in irreversible ischemic liver cell injury."  J. Biol.  Chem.  256:  4809-4817. Cho, Y., R. C. Straight and J . H. Smith (1992). "Effects of photodynamic therapy in combination with intravesical drugs in a murine bladder tumor model." Journal  of Urology  147: 743-746.  Colombo, M. P., A. Modesti, G. Parmiani and G. Forni (1992). "Perspectives in Cancer research: local cytokine availability elicits tumor rejection and systemic immunity through granulocyte-T-lymphocyte cross-talk." Res.  52: 1-5.  Cancer  References  129  Cortese, D. A., E. S. Edell, M. D. Silvastrein, K. Offord, V. F. Trastek, P. C. Pairolero, M. S. Allen and C. Dechamps (1992). An evaluation of the effectiveness of photodynamic therapy (PDT) compared to surgical resection in early stage roentgenographically occult lung cancer. Photodynamic  Therapy  and Biomedical  Lasers.  (P. Spinelli, M. Dal Fante  and R. Marchesini, ed.) Amsterdam, Elsevier Science Publishers B. V. pp. 15-22. Damen, J . , A. L. F. Mui, P. Hughes, K. Humpries and G. Krystal (1992). "Erythropoeitin-induced tyrosine phosphorylation in a high erythropoeitin receptor-expressing lymphoid cell line."  Blood  80: 1923-1932.  Darling, G., D. L. Fraker, J . C. Jensen, C. M. Gorschboth and J . A. Norton (1990). "Cachectic effects of recombinant human tumor necrosis factor in rats." Cancer  Res.  50: 4008-4013.  DeLaney, T. F., W. G. Sindelar, Z. Tochner, P. D. Smith, W. S. Friauf, G. Thomas, L. Dachowski, J . W. Cole, S. M. Steinberg and E. Glatstein (1993). "Phase I study of debulking surgery and photodynamic therapy for disseminated intraperitoneal tumors." Phys.  Int. J. Radiation  Oncology  Biol.  25: 445-457.  Dima, V. F., V. Vasiliu, D. Laky, M. D. lonescu and S. V. Dima (1994). "Treatment of rat Walker-256 carcinosarcoma with photodynamic therapy and endotoxin irradiated with high energy electrons."  SPIE  2078: 547-557.  Dougherty, G. J . , C. A. Allen and N. M. Hogg (1986). Applications of immunological techniques to the study of the tumour-host relationship. Handbook  of Experimental  Immunology.  (D. M. Weir, L. A. Herzenberg,  C. Blakwell and L. A. Herzenberg, ed.) Oxford, Blackwell Scientific Publications Ltd. pp. 125.1-125.12. Dougherty, G. J . , S. T. Dougherty, R. J . Kay, P. Lansdorp and R. K. Humphries (1989). "Identification and characterization^ 114/A10, an antigen highly expressed on the surface of murine myeloid and erythroid progenitor cells and IL-3 dependent cell lines."  Exp.  Hematol.  17: 877-882.  References  130  Dougherty, G. J . , J . D. Thecker, W. H. McBride, G. Krosl and M. Korbelik (1992). "Effect of immunization with genetically modified tumor cells on tumor recurrence following photodynamic therapy." Dougherty, T. J . (1984). "Photoradiation therapy."  Lasers  Med.  Urol. Supl.  Sci.  7: 226.  23: 61.  Dougherty, T. J . (1987). "Photosensitizers: Therapy and detection of malignant tumors."  Photochem.  Photobiol.  45: 874-889.  Dougherty, T. J . (1989). "Photodynamic therapy: Status and potential." Oncology  3: 67-78.  Dougherty, T. J . , D. Boyle, K. R. Weishaupt, C. Gomer, D. Borcicky, J . H. Kaufman and G. Grindey (1977). Phototherapy of human tumors. \  Research  (A. Castellani, ed.) New York, Plenum  in Photobiology.  Publishing Corp. pp. 435-466. Dougherty, T. J . , G. Lawrence, J . H. Kaufman, D. Boyle, K. R. Weishaupt and A. Gbldfarb (1979). "Photoradiation in the treatment of recurrent breast carcinoma." JNCI62:  231-237.  Dougherty, T. J . , T. S. Mang, A. M. Regal, H. Takita, Z. Bernstein, B. D. Wilson and M. McAuley (1992). "New potential clinical applications of photodynamic therapy: Intrathoracic P D T and treatment of AIDS-related Kaposi's sarcoma."  Lasers  Med.  Sci.  7: 215.  Dougherty, T. J . , W. R. Potter and K. R. Weishaupt (1984). The structure of the active component of hematoporphyrin derivative. and  treatment  of tumors.  Porphyrin  localization  (D. R. Dorion and C. J . Gomer, ed.) New York,  Alan R Liss. pp. 301-314.  References  131  Dranoff, G., E. Jaffee, A. Lazehby, P. Golumbek, H. Leyitsky, K. Brose, V. Jackson, H. Hamada, D. Pardoll and R. C. Mulligan (1993). "Vaccination with irradiated tumor cells engineered to secrete murine granulocytemacrophage colonyTStimulating factor stimulates potent, specific, and long-lasting anti-tumor immunity."  Proc.  Natl. Acad.  Sci.  90: 3539-  USA  3543. Eddel, E. S. and D, A. Cortese (1992). "Photodynamic therapy in the management of early superficial squamous cell carcinoma as an alternative to surgical resection."  Chest  102: 1319-1322.  Elmets, C. A. and K. D. Bowen (1986). "Immunological supression in mice treated with hematoporphyrin derivative photoradiation."  Cancer  Res.  46:  1608-1611. Evans, S., W. Matthews, R. Perry, D. Fraker, J . Norton and H. I. Pass (1990). "Effect of photodynamic therapy oh tumor necrosis factor production by murine macrophages." JNCI82:  34-39.  Fady, C , D. Reisser and F. Martin (1990). "Non-activated rat neutrophils kill syngeneic colon tumor cells by the release of low molecular wight factor." lmmunobiology\8~\:  1-12.  Feinberg, A. P. and B. Vogelstein (1984). "A technique for radiolabelling D N A restriction endonuclease fragments to high specific, activity." Biochem.  Anal.  132: 6-13.  Ferrario, A. and C. T. Gomer (1990). "Systemic toxicity in mice induced by localized porphyrin photodynamic therapy."  Cancer  Res.  50: 539-543.  Figge, F. H. J . , G. S. Weiland and M. L. O. J . (1948). "Cancer detection and therapy. Affinity of neoplastic, embryonic and traumatized tissue for porphyrins and metalloporphyrins." 641.  Proc.  Soc.  Exp.  Biol.  Med.  68: 640-  References  132  Fingar, V. H., K. A. Siegel, J . T. Wieman and K. W. Doak (1993). "The effects of thromboxane inhibitors on the microvasculature and tumor response to photodynamic therapy."  Photochem.  Photobiol.  58: 393-399.  Fingar, V. H., T. J . Weiman, S. A. Wiehle and P.'.B. Cerrito (1992). "The role of microvascular damage in photodynamic therapy: The effect of treatment on vessel constriction, permeability and leukocyte adhesion."  Cancer  Res. 52; 4914-4921. Fingar, V. H , T. J . Wieman and k. W. Doak (1990), "Role of thromboxane and prostacyclin release on photodynamic therapy-induced tumor destruction."  Cancer  50: 2599-2603.  Res.  Fingar, V. H., T. J . Wieman and K. W. Doak (1991). "Machanistic studies of P D T induced vascular damage: evidence that eicosanoids mediate the . process."  Int.J.  Radial  Biol.  60: 303-309.  Foote, C. S. (1984). Mechanisms of photooxygenation. and  treatment  of tumors.  Porphyrin  localization  (D. R. Dorion and C. J . Gomer, ed.) New York,  Alan R. Liss Inc. pp. 3-18. Foster, T. H., R. S. Murant, R. G. Bryant, R. S. Knox, S. L. Gibbson and R. Hilf (1991). "Oxygen consumption and diffusion effects in photodynamic therapy."  Radial  Res.  126: 296-303.  Furuse, K., M. Fukuoka, H. Kato, T. Horai, K. Kubota, N. Kodama, Y. Kusunoki, N. Takifuji, T. Okunaka and C. Konaka (1993). "A prospective phase II study on photodynamic therapy with photofrin II for centrally located early-stage lung cancer. The Japan Lung Cancer Photodynamic Therapy Study Group [see comments]." Gallin, J . I. (1989). Inflammation.  J. Clin.  Fundamental  New York, Raven Press, pp. 721-733.  Oncol.  11: 1852-1857.  Immunology.  (W. E. Paul, ed.)  References  133  Gomer, C. J . and T. J . Dougherty (1979). "Determination of [ H]- and 3  [ C]Hemathoporphyrin derivative distribution in malignant and normal 14  tissue."  Cancer  Res.  39: 146-151.  Grabbe, S . , S . Bruvers, S. Beissert and R. D. Granstein (1994). "Interferon-y inhibits tumor antigen presentation by epidermal antigen-presenting cells."  J. Leukoc.  Biol.  55: 695-701.  Grabbe, S., S. Bruvers, A. M. Lindgren, J . Hosoi, K. C. Tan and R. D. Granstein (1992). "Tumor antigen presentation by epidermal antigen-presenting .  cells in the mouse: modulation by granulocyte-macrophage colonystimulating factor, tumor necrosis factor a, and ultraviolet irradiation." J . Leukoc.  Biol.  52: 209-217.  Grant, W. E., P. M. Speight, A . J . MacRobert, C. Hopper and S. G. Bown (1994). "Photodynamic therapy of normal rat arteries after photosensitization , using disulphonated aluminum phthalocyanine and 5-aminblaevulonic acid."  Br. J. Cancer  Grossweiner, L. I. (1989).  70:  72-78.  The Science  of Photobiology.  New.York, Plenum  Press. •' ' Grossweiner, L. I. (1994).  :  The Science  of Phototherapy.  Boca Raton, C R C  Press, Inc. Hamblin, M. R. and L. E. Newman (1994). "On the mechanism of the tumourlocalising effect in photodynamic therapy."  J. Photochem:  Photobiol.  B:  Biol. 2 3 : 3-8"  Hampton, J . A. and S. H. Selman (1992). "Mechanisms of cell killing in photodynamic therapy using a novel system."  Photochem.  Photobiol.  in vivo drug/in  vitro  light culture  56: 235-243.  Harvima, I. T., L. Horsmanheimo, A. Naukkarinen and M. Horsmanheimo (1994). "Mast cell proteinases and cytokines in skin inflammation. [Review]."/Arc/7. Dermato/. Res. 287: 61-67, ;  rf  References  134  Henderson, B. W. (1989). "Photodynamic therapy: coming of age." 6: 200-211.  Photodermathology  Henderson, B. W. and D. A. Bellnier (1989). "Tissue localization of photosensitizers and the mechanism of photodynamic tissue destruction. [Review]."  CIBA  Found.  146: 112-25.  Symp.  Henderson, B. W., D. A. Bellnier, B. Ziring and T. J . Dougherty (1983). Aspects of the cellular uptake and retention of hematoporphyrin derivative and their correlation with the biological response to P R T in vitro. Photosensitization.  Porphyrin  (D. Kessel and T. J . Dougherty, ed.) New York,  Plenum Publishing Corporation, pp. 129-137. Henderson, B. W. and J . M. Donovan (1988). "Prostaglandin release from peritoneal macrophages and tumor cells after photodynamic therapy." Photochem.  Photobiol.  47:  76S.  Henderson, B. W. and J . M. Donovan (1989). "Release of prostaglandin E2 from cells by photodynamic treatment in vitro."  Cancer  Res.  49: 6896-6900.  Henderson, B. W. and T. J . Dougherty (1992). "How does photodynamic therapy work?. [Review]."  Photochem.  Photobiol.  55: 145-157.  Henderson, B. W. and V. H. Fingar (1987). "Relationship of tumor hypoxia and response to photodynamic treatment in an experimental mouse tumor." Cancer  Res.  47: 3110-3114.  Henderson, B. W. and V. H. Fingar (1994). "The role of vascular photodamage in photodynamic therapy."  Photochem.  Photobiol.  59: 1S-2S.  Henderson, B. W., B. Owczarczak, J . Sweeney and T. Gessner (1992). "Effects of photodynamic treatment of platelets or endothelial cells in vitro on platelet aggregation."  Photochem.  Photobiol.  56: 513-521.  135  References  Henderson, B. W., A. B. Sumlin, B. L. Owczarczak and T. J . Dougherty (1991). "Bacteriochlorophyll-a as photosensitizer for photodynamic treatment of transplantable murine tumors."  J. Photochem.  Photobiol.  10: SOS-  B: Biol.  SIS. Henderson, B. W., S. M. Waldow, T. S. Mang, W. R. Potter, P. B. Malone and T. J . Dougherty (1985). "Tumor destruction and kinetics of tumor cell death in two experimental mouse tumors following photodynamic therapy." Cancer  Res.  45: 572-576.  Heufler, C , F. Koch and G . Schooler (1987). "Granulocyte/macrophage colony stimulating factor and interleukins mediate the maturation of murine epidermal Langerhans cells into potent immunostimUlatory dendritic cells." J . Exp. Med. 167: 700-705. Hier, S. K., K. Rotham, L. M. Hier and W. S. Rosenthal (1993). "Phototherapy of esophageal malignancies."  Lasers  Surg.  Med.  Suppl.  5: 51 (Abstract).  Hilf, R., R. S. Murant, U. Narayanan and S. L. Gibson (1986). "Relationship of mitochondrial function and cellular adenosine triphosphate levels to hematoporphyrin derivative-induced photosensitization in R3230AC mammary tumors."  Cancer  Res.  46: 211-217.  Hilf, R., D.-B. Smail, R. S. Murant, P. B. Leakey and S. L. Gibson (1984). "Hematoporphyrin derivative-induced photosensitivity of mitochondrial succinate dehydrogenase and selected cytosolic enzymes of R3230AC mammary adenocarcinomas of rats."  Cancer  Res.  44: 1483-1488.  Hilf, R., N. W. Warne, D. B. Smail and S. U Gibson (1984). "Photodynamic inactivation of selected intracellular enzymes by hematoporphyrin derivative and their relationship to tumor cell viability in vitro." Lett.  24: 165-172.  Cancer  .  Howard, B. V., H. P. Morris and J . M. Bailey (1972). "Ether-lipids, glycerol phosphate dehydrogenase and growth rate in tumors and cultured cells." Cancer  Res.  32: 1533-1538.  136  References  Hruza, L , H. Lui, N. Kollias, J . Winberly, P. Dwyer, M. Gagel, V. Salvatori and R. Anderson (1993). "Photodynamic therapy of psoriasis using benzoporphyrin derivative monoacid ring A (BPD-MA): Preliminary observations."  Photochem,  Photobiol.  BIS:  A  09S.  Inomata, T., Y. Ogawa, F. Hamada, S. Yoshida, T. Maeda and H. Seguchi (1987). "Effects of radiotherapy and Sizophyllan (SPG) on MM46 tumor " inoculated into C3H/He mice."  Radiation  System  Research  (Tokyo)  2:  216-219. Jain, R. K. (1989). "Delivery of novel therapeutic agents in tumors: physiological barters and strategies." JNCI81: Jori, G . (1989).  "In vivo  570-576.  transport and pharmacokinetic behaviour of tumor  photosensitizers."  CIBA  Found.  Symp.  146: 78-86.  Jori, G., M. Beltramini, E. Reddi, B. Salvato, A. Pagnan* L. Ziron, L. Tomio and T: Tsanov (1984). "Evidence for a major role of plasma lipoproteins as hematoporphyrin carriers in vivo."  Cancer  Lett.  24: 291-297.  Kay, R. and R. K. HUmpries (1991). "New.vectors and procedures for isolating c D N A s encoding cell surface proteins by epression in C O S cells." Molec.  Cell.  Biol.  Meth.  2: 254-265.  Kelly, J . F., M. E. Snell and M. C. Berenbaum (1975). "Photodynamic destruction of human bladder carcinoma."  Br. J. Cancer  31: 237-244.  Kennedy, J . C. and R. H. Pottier (1992). "Endogenous protoporphyrin IX, a clinically useful photosensitizer for photodynamic therapy. [Review]." J. Photochem.  Photobiol.  B: Biol.  14: 275-92.  Kennedy, J . C , R. H. Pottier and D. C. Pross (1990). "Photodynamic therapy with endogenous protoporphyrin I X : basic principles and present clinical experience."  J. Photochem.  Photobiol.  B: Biol.  6: 143-148.  References Kerdel,  F.  A., N. A. Soter and H. W. Lim (1987).  137 "In vivo  mediator release and  degranulation of mast cells in hematoporphyrin derivative-induced phototoxicity in mice."  J. Invest.  Dermatol.  88: 277-280.  Kessel, D. (1986). "Porphyrin-lipoprotein association as a factor of porphyrin localization."  Cancer  Lett.  33: 183-188.  Kessel, D. (1986). "Proposed structure of the tumor localizing fraction of hematoporphyrin derivative."  Photochem.  Photobiol.  44: 193-196.  Kick, G., G. Messer, A. Goetz, G. Plewig and P. Kind (1995). "Photodynamic therapy induces expression of interleukin 6 by activation of AP-1 but not NF-KB  DNA binding." Cancer  Res.  55: 2373-2379.  Kongshaug, M., J . Moan and S. B. Brown (1989). "The distribution of porphyrins with different tumour localising ability among human plasma proteins." Br. J. Cancer59:  184-188.  Korbelik, M. (1993). "Distribution of disulfonated and tetrasulfonated aluminum phthalocyanine between malignant and host cell populations of a murine fibrosarcoma." J .  Photochem.  Photobiol.  B: Biol.  20: 173-181.  Korbelik, M. and J . Hung (1991). "Cellular delivery and retention of Photofrin II: the effects of interaction with human plasma proteins." Photobiol.  Photochem.  53: 501-510.  Korbelik, M., J . Hung, S. Lam and B. Palcic (1990). "The effects of low density lipoproteins on uptake of Photofrin II into cultured cells." Photobiol.  Photochem.  51: 191-196.  Korbelik, M. and G. Krosl (1994). "Cellular levels of photosensitisers in tumours: the role of proximity to the blood supply."  Br. J. Cancer  70:  604-10.  Korbelik, M. and G. Krosl (1994). "Enhanced macrophage cytotoxicity against tumor cells treated with photodynamic therapy." 60: 497-502.  Photochem.  Photobiol.  References  138  Korbelik, M. and G. Krosl (1995). "Accumulation of benzoporphyrin derivative in malignant and host cell populations of the murine RIF tumor." Lett.  Cancer  97: 249-254.  Korbelik, M. and G. Krosl (1995). "Photofrin accumulation in malignant and host cell populations of murine fibrosarcoma."  Photochem.  Photobiol.  62:  162-168. Korbelik, M. and G. Krosl (1995). "Tumor associated macrophages (not tumor cells) are the determinants of photosensitizer tumor localization."  SPIE  2 3 7 1 : 344-346. Korbelik, M. and G. Krosl (1996). "Photofrin accumulation in malignant and host cell populations of various tumours."  Br. J. CancerlZ:  506-513.  Korbelik, M. and G. Krosl (1996). Photosensitizer distribution and photosensitized damage of tumor tissues. Phototherapy.  Basic  principles  of  (G. Jori, H. Young and H. Honigsman, ed.) Berlin, Springer  Verlag. pp. in press. Korbelik, M., G. Krosl and D. J . Chaplin (1991). "Can P D T be potentiated by immunotherapy?"  SPIE  1616: 192-198.  Korbelik, M., G. Krosl and D. J . Chaplin (1991). "Photofrin uptake by murine macrophages."  Cancer  Res.  51: 2251-2255.  Korbelik, M., G. Krosl and D. J . Dougherty (1993). "PDT elicited tumoricidal activity of tumor associated macrophages."  Photochem.  Photobiol.  91S. . Korbelik, M., G. Krosl, G. J . Dougherty and J . D. Chaplin (1992). "Host cell infiltration into PDT treated tumor."  SPIE  1645: 124-130.  57:  References  139  Korbelik, M., G. Krosl, J . Krosl and G. J . Dougherty (1996). "Modulation of tumor response to photodynamic therapy in severe combined immunodeficient (SCID) mice by adoptively transferred lymphoid cells."  2675: 156-  SPIE  162. Korbelik, M., G. Krosl, V. R. Naraparayu and N. Yamamoto (1995). "The effect of enzymatically generated macrophage activating factor (GcMAF) on the tumor response to photodynamic therapy."  Photochem.  61:  Photobiol.  97S. Korbelik, M., G. Krosl, P. L. Olive and D. J . Chaplin (1991). "Distribution of. Photofrin between tumour cells and tumour associated macrophages." Br. J. Cancer64:  508-512.  Krosl, G. and M. Korbelik (1994). "Potentiation of photodynamic therapy by immunotherapy: the effect of schizophyllan (SPG)."  Cancer  Lett.  84: 43-  49. Krosl, G., M. Korbelik and G. J . Dougherty (1995). "Induction of immune cell infiltration into murine SCCVII tumour by photofrin-based photodynamic therapy,"  Br. J. Cancer  71: 549-555.  . Krosl, G., M. Korbelik, J . Krosl and G. J . Dougherty (1995). "Potentiation of photodynamic therapy by granulocyte-macrophage colony stimulating factor immunotherapy." SP/E 2371: 347-350.  .  Lam, S. (1994). "Photodynamic therapy of lung cancer. [Review]." 21 (6  Oncology  Seminars  in  Suppl 15): 15-19.  Lam, S., C. MacAulay, J . C. LeRiche, J . Qu, G. Krosl, H. Zeng, M. Korbelik and B. Palcic (1993). "Fluorescence imaging of pre-malignant and malignant tissue."  SPIE  1881: 160-167.  Lam, S., B. Palcic, D. McLean, J . Hung, M. Korbelik and A. E. Profio (1990). "Detection of lung cancer using low dose Photofrin II." 337.; •  Chest  97:  333-  140  References  Lee See, K., I. J . Forbes and W. H. Betts (1984). "Oxygen dependency of photocytotoxicity with haematoporphyrin derivative." Photobiol.  Photochem.  39: 631-634.  Levitsky, H. I., A. Lazenby, R. J . Hayashi and D. M. Pardoll (1994).  "In  vivo  priming of two distinct antitumor effector populations: the role of M H C Class I expression." J. Exp. Med. 179: 1215-1224. Lim, H. W. (1989). "Role of mediators of inflammation and cells in porphyrininduced cytotoxicity." SPIE1065:  28-33.  Lim, H. W., M. Hagan and I. Gigli (1986). "Phototoxicity induced by  hematoporphyrin derivative in C5- defficient, mast cell-defficient, and leukopenic mice."  Photochem.  Photobiol.  44: 175-180.  Lin, C.-W. (1989). Selective localization of photosensitizers in tumors: a review of the phenomenon and possible mechanisms. neoplastic  Photodynamic  therapy  of  (D. Kessel, ed.) Boca Raton, FL, C R C Press, Inc. pp.  disease.  79-101. Lindsay, J . M., L. Manning and G. W. Wood (1982). "Exclusive binding of immunoglobulin to Fc gamma receptors on macrophages in 3methylcholanthrene-induced murine tumors."  UNCI  69: 1163-1174.  Lipson, R. L. and E; J . Baldes (1960). "The photodynamic properties of a particular hematoporphyrin derivative."  Arch.  Dermatol.  82: 508-516.  Lipson, R. L., M. J . Gray and E. J . Baldes (1966). Hematoporphyrin derivative for detection and management of cancer. Ninth Internat. Cancer Congr. Tokyo, Japan, 393. Lipson, R. L., B. E. J . and A. M. Olsen (1961). "Hematoporphyrin derivative: A new aid for endoscopic detection of malignant disease." Cardiovasc.  Surg.  42:623-629.  J.  Thorac.  References  141  LLoyd, A. R. and J . J . Oppenheim (1992). "Poly's lament: the neglected role of the polymorphonuclear neutrophil in the efferent limb of the immune system."  Immunol.  Today  13: 169-171.  Lui, H. (1994). "Photodynamic therapy in dermatology with porfimer sodium and benzporphyrin derivative: an update."  Seminars  21 (6): 11-  in Oncology  14. Lui, H., L. Hruza, N. Kollias, J . Wimberly, M. Gagel, D. McLean, V. Salvatori and R. Anderson (1993). "Photodynamic therapy of malignant skin tumors with benzporphyrin derivative monoacid ring a (BPD-MA)." Photobiol.  57:  Photochem.  109S.  Lynch, D. H., S. Haddad, C. J . Jolles, V. J . King, M. J . Ott, B. Robertson and R. C. Straight (1989). "Immunologic effects of peritoneal photodynamic treatment."  SPIE  1065: 55-65.  Lynch, D. H., S. Haddad, K. J . Vernon, M. J . Ott, R . C Straight and C. J . Jolles (1989). "Systemic immunosupression induced by photodynamic therapy (PDT) is adoptively transferred by macrophages."  Photochem.  Photobiol.  49: 453-458. Ma, L. W., J . Moan and Q. Peng (1992). "Effects of light exposure on the uptake of photofrin II in tumors and normal tissues."  120-123.  Int. J. Cancer52:  Marcon, N. R. (1994). "Photodynamic therapy and cancer of the esophagus." Seminars  in  Oncology 21 (6 Suppl 15): 20-23.  Markowitz, D., S. Goff and A. Bank (1988). "A safe packaging line for gene transfer: separating viral genes on two different plasmids."  J.  Virol.  62:  1120-1124. McBride, W. H., J . D. Thacker, S. Comora, J . Economou, D. Kelley, S. M. Dubinett, D. Hogge and G. J . Dougherty (1992). "Genetic modification of a murine fibrosarcoma to produce IL7 stimulates host immune infiltration and tumor immunity."  Cancer  Res.  52: 3931-3937.  References  142  Metcalf, D. (1991). "Control of granulocytes and macrophages: molecular, cellular and clinical aspects."  Science  254: 529-533  Midorikama, Y., T. Yamashita and F. Sendo (1990). "Modulation of the immune response to transplanted tumors in rats by selective depletion of neutrophils  in vivo  using a monoclonal antibody: aborgation of specific  transplantation resistance to chemical neutrophils  in vivo."  Cancer  Res.  50: 6243-6247. Miller, A. D., M. F. Law and I. M. Verma (1985). "Generation of helper-free amphotropic retroviruses that transduce a dominant-acting, methotrexate-resistant dihydrofolate reductase gene." "  Mol.  Cell.  Biol.  5:  431-437.;  Mitchell, J . B., S. McPherson, W. DeGraff, J . Gamson, A. Zabell and A. Russo (1985). "Oxygen dependence of hematoporphyrin derivative-induced photoinactivation of Chinese-hamster cells."  Cancer  Res.  45: 2008-2011.  Moan, J . and K. Berg (1991). "The photodegradation of porphyrins in cells can be used to estimate the lifetime of singlet 53: 549-553.  oxygen."  Photochem.  Photobiol.  .  Moan, J . , K. Berg, E. Kvam, A. Western, Z. Malik, A. Ruck and H. Schneckenburger (1989). "Intracellular localization of photosensitizers. [Review]."  CIBA  Found.  Symp.  146: 95-107.  Moan, J . , K. Berg, E. Kvam, A. Western, Z. Malik, A. Ruck and H. Schnekenburger (1989). Intracellular localization of photosensitizers. • Photosensitizing  compounds:  their  chemistry,  biology  and  clinical  use.  (G. Bock and S. Harnett, ed.) Chicester, UK, Wiley Interscience. pp. 95.  107.  Moan, J . , J . V. Johannessen, T. Christehsen, T. Espevik and J . B. McGhie (1982). "Porphyrin-sensitized photo-inactivation of human cells Am.  J.  Pathol.  109: 184-192.  in vitro."  143  References  Moan, J . and S. Sommer (1983). "Uptake of the components of hematoporphyrin derivative by cells and tumours."  Cancer  Lett.  21: 167-  174. Morgan, A. R., G. M. Garbo, R. W. Keck, L. D. Eriksen and S. H. Selman (1990). "Metallopurpurins and light: Effect on transplantable rat tumors and murine skin."  Photochem.  Photobiol.  51: 589-592.  Mulroney, C. M., S. Gluck and A. D. Ho (1994). "The use of photodynamic therapy in bone marrow purging. [Review]."  Seminars  in  Oncology  21(Suppl 15): 24-27. Myers, R. C., B. H. S. Lau, D. Y. Kunihira, R. R. Torrey, J . L. Woolley and J . Tosk (1989). "Modulation of hematoporphyrin derivative-sensitized phototherapy with corynebacterium parvum in murine transitional cell carcinoma."  Urology  3: 230-235.  Nakano, T., K. Oka, T. Sugita and H. Tsunemoto (1993). "Antitumor activity of Langerhans cells in radiation therapy for cervical capcer and its modulation with S P G administration."  In Vivo  7: 257-264.  Nelson, J . S., L H. Liaw, A. Orenstein, W. G. Roberts and M. W. Berns (1988). "Mechanism of tumor destruction following photodynamic therapy with, hematoporphyrin derivative, chlorin, and phthalocyanine." 1599-605.  JNCI80: ;'  Nelson, J . S., W. G. Roberts and M. W. Berns (1987). "In vivo studies on the  utilization of mono-L-aspartyl chlorin (NPeg) for photodynamic therapy." Cancer  Res.  47: 4681-4685.  Ngwenya, B. Z. and N. Yamamoto (1986). "Effects of inflammation products on immune systems: lysophosphatidylcholine stimulates macrophages." Cancer  Immunol.  lmmunother.2"\:  174-182.  References  144  Norisuye, K., T. Yanaki and H. Fujita (1980). "Triple helix of Schizophyllum communae polysaccharide in aqueous solution." J.  Polym.  Sci.  18: 547-  558. Nseyo, U. O., T. J . Dougherty, D. Boyle, W. Potter, L. S. Englander, R. P. Huben and J . E. Pontes (1985). "Experimantal photodynamic therapy of canine bladder."  J.  Urol A  33: 311-315.  Nseyo, U. O., R. K. Whalen, M. R. Duncan, B. Berman and S. L. Lundahl (1990). "Urinary cytokines following photodynamic therapy for bladder cancer." Urology  36: 167-171.  Okamura, K., M. Suzuki, T. Chihara and 1. others (1986). "Clinical evaluation of Schizophyllan combined with irradiation in patients with cervical cancer. A randomized control study."  58: 865-872.  Cancer  Olive, P. L. (1989). "Distribution, oxygenation, and clonogenicity of macrophages in a murine tumor."  Cancer  Commun.  1: 93-97.  Olive, P. L , D. J . Chaplin and R. E. Durand (1985). "Pharmacokinetics, binding and distribution of Hoechst 33342 in spheroids and murine tumors." Br. J. Cancer  52: 739-746.  Orenstein, A., J . S. Nelson, L. H. Liaw, R. Kaplan, S. Kimel and M. W. Berns (1990). "Photochemotherapy of hypervascular dermal lesions: a possible alternative to photothermal therapy?"  Lasers  in Surgery  & Medicine  10:  334-343. Parker, J . G. (1986). "Optical detection of the photodynamic production of singlet oxygen  in vivo." Lasers.  Surg.  Med.  6: 258.  Pass, H. I. (1993). "Photodynamic therapy in oncology: Mechanisms and clinical use." JNCI85:  443-456.  145  References  Peng, Q., J . Moan and L. S, Cheng (1991). "The effect of glucose administration on the uptake of photofrin II in a human tumor xenograft."  Cancer  Lett:  58: 29-35. Peng, Q., J . Moan, G. Farrants, H. E. Danielsen and C. Rimington (1991). "Localization of potent photosensitizers in human tumor L O X by means of laser scanning microscopy."  Cancer  Lett.  58(1-2): 17-27.  Penning, L. C , K. Tijssen, P. J . Boegheim, J . van Steveninck and T. M. A. R. Dubbleman (1994). "Relationship between photodynamically induced, damage to various cellular parameters and loss of echogenicity in different cell types with hematoporphyrin derivative as sensitizer." Biochem.  Biophys.  Acta  1221: 250-258.  Pericle, F., F. Di Pierro and G. Forni (1992). Clinical trials with local administration of lymphohaematopoietic growth factors. Lymphohaematopoietic  Growth  Factors  II.  (R. Martelmasnn, ed.) Berlin,  Springer-Verlag. pp. Policard, A. (1924). "Etudes sur le aspects offerts par des tumeurs experimentales examinees a la lumiere de Woods."  CR  Soc.  Biol.  91:  1423-1425. Pottier, R. and J . C. Kennedy (1990). "The possible role of ionic species in selective biodistribution of photochemotherapeutic agents toward neoplastic tissue."  J. Photochem.  Photobiol  8:1-1.6.  Reed, M. W., D. A. Schuschke, D. M. Ackermann, J . I. Harty, T. J . Wieman and F. N. Miller (1989). "The response of the rat urinary bladder microcirculation to photodynamic therapy." J .  Urol.  142(3): 865-868.  Reed, M. W., T. J . Wieman, K. W. Doak, C. G. Pietsch and D. A. Schuschke (1989). "The microvascular effects of photodynamic therapy: evidence for a possible role of cyclooxygenase products." 419-423.  Photochem.  Photobiol.  50:  References  146  Reed, M. W., T. J . Wieman, D. A. Schuschke, M. T. Tseng and F. N. Miller (1989); "A comparison of the effects of photodynamic therapy on normal and tumor blood vessels in the rat microcirculation."  Radial  Res.  119:  542-552. Richter, A. M., S. Yip, E. Waterfield, P. M. Logan, C. E. Slonecker and J . G. Levy (1991). "Mouse skin photosensitization with benzoporphyrin derivatives and Photofrin: macroscopic and microscopic evaluation." Photobiol.  SZ:  Photochem.  281-6.  Ris, H.-B., H. J . Altermatt, B. Nachbur, J . C. M. Stewart, Q. Wang, C. K. Lim, R. Bonnett and U. Althus (1992). Clinical evaluation of photodynamic therapy with m T H P C for chest malignancies. biomedial  lasers.  Photodynamic  therapy  and  (P. Spinelli, M. Dal Fante and R. Marchesini, ed.)  Amsterdam, Elsevier Science Publishers B. V. pp. 421-425. Roberts, W. G. and M. W. Berns (1989). "In vitro photosensitization I. Cellular uptake and subcellular localization of mono-L-aspartyl chlorin e6, chloroaluminum sulfonated phthalocyanine, and photofrin II."  Lasers.  Surg.  Med. 9: 90-101. Roberts, W. G., L. H. Liaw and M. W. Berns (1989). "In vitro photosensitization II. An electron microscopy study of cellular destruction with mono-L-aspartyl chlorin e6 and photofrin II."  Lasers.  Surg.  Med.  9: 102-108.  Rossi, F. (1986). "The superoxide forming N A P D H oxidase of phagocytes: nature, machanisms of activation and function."  Biochim.  Biophys.  Acta  8 5 3 : 65-69. Rotomskis, R., S. Bagdonas and G. Streckyte (1996); "Spectroscopic studies of photobleaching and photoproduct formation of porphyrins used in tumour therapy."  J.  Photochem.  Photobiol.  B: Biol.  33: 61-67.  References  147  Russell, S. W., G. Y. Gillespie and J . L. Pace (1980). "Evidence for mononuclear phagocytes in solid neoplasms and appraisal of their nonspecific cytotoxic capabilities."  Contemporary  Topics  143-  in ImmunobiologylO:  "166. Salet, C , and G . Moreno (1990). "New trends in photobiology. . Photosensitization of mitochondria. Molecular and cellular aspects." J . Photochem.  Photobiol.  B: Biol.  5: 133-150.  Sallusto, F. and A. Lanzavecchia (1994). "Efficient presentation of soluble antigen by cultured human dendritic cells is maintained by granulocyte/macrophage colbny-stimulating factor plus interleukin 4 and downregulated by tumor necrosis factor a." J. Exp. Med. 179: 11091118. Samuelsson, B. (1982). Prostaglandins, thromboxanes and leukotrienes: biochemical pathways.  Prostaglandins  and related  lipids.  (T..J. Powles,  R. S. Bockman, K. V. Honn and P. Ramwell, ed.) New York, Alan R. Liss. pp. 1-19. Shumaker, B. P. and F. W. Hetzel (1987). "Clinical laser photodynamic therapy in the treatment of bladder carcinoma."  Photochem,  Photobiol.  4: 899-  901. Snyder, F. and R. Wood (1969). "Alkylalk-1-enyl-ethers of glycerol in lipids from normal and neoplastic tissues."  Cancer  Res.  29: 251-257.  Spears, J . R., J . Serur, D. Shropshire and S. Paulin (1983). "Fluorescence of experimental atheromatous plaques with hematoporphyrin derivative." J. Clin.  Invest.  71: 395-399:  Specht, K. G . and M. A. J . Rodgers (1990). "Depolarization of mouse myeloma cell membranes during photodynamic action." 319-324.  Photochem.  Photobiol.  51:  References  148  Sporn, L. A. and T. H. Foster (1992). "Photofrin and light induce microtubule depolymerization in cultured human endothelial cells."  Cancer  Res.  52:  3443-3448. Star, W. M.j P. A. Marjnissen, S. van den Berg-Blok, J . A. C. Versteeg, K. A. P. Franken and H. S. Reinshold (1986). "Destruction of rat mammary tumor and normal tissue microcirculation by hematoporphyrin derivative photoradiation observed Cancer  Res.  in vivo  in sandwich observation chambers."  46: 2532-2540.  Sugawara, I., K. Lee and M. Wong (1984). "Schyzophyllan (SPG)-treated macrophages and anti-tumor activities against syngeneic and allogeneic tumor cells. I. Characteristics of S P G treated macrophages." Immunol.  Immunother.  16:  Cancer  137-144.  Suit, H. D., R. S. Sedlacek, G. Silver and D. Dosoretz (1985). "Pentobarbital anesthezia and the response of tumor and normal tissue in the C3Hf/Sed mouse to radiation."  Radial  Res.  104: 47-65.  Svennevig, J . and H. Svaar (1979). "Content and distribution of macrophages and lymphocytes in solid malignant tumors."  Int. J.  Cancer  24: 754-758.  Tappenier, H. and A. Jesionek (1903). "Therapeutische versuche mit fluoreszirenden stoffen."  Muench  Med.  Wochenschr.  1: 2042-2044.  Tarlau, C. J . , H. Barr, A. J . MacRobert and S. G. Brown (1990). Relative merits of porphyrin and phthalocyanine sensitization for photodynamic therapy. Photodynamic  Therapy  of Neoplastic  Disease.  (D. Kessel, ed.) Boca  Raton, FL, C R C Press, pp. 263-277. Tepper, R. I. and J . J . Mule (1994). "Experimental and clinical studies of cytokine gene-modified tumor cells. [Review]." HGT5:  153-64.  Thomas, J . P., R. D. Hall and A. W. Girotti (1987). "Singlet oxygen intermediacy in the photodynamic action of membrane bound hematoporphyrin derivative."  Cancer  Lett.  36: 295-302.  References  149  Tian, M. E., S. L. Qui and Q. Ji (1985). "Preliminary results of hematoporphyrin derivative-laser treatment for 13 cases of early esophageal carcinoma." Adv.  Exp.  Med.  Biol.  193: 21-25.  Tromberg, B. J . , S. Kimel, A. Orenstein, S. J . Barker, J . Hyatt, J . S. Nelson, W. G . Roberts and M. W. Berns (1990). "Tumor oxygen tension during photodynamic therapy."  J. Photochem.  Photobiol.  B: Biol.  5(1): 121-126.  Tsuchiya, Y., M. Igarashi, M. Inoue and K. Kumagai (1989). "Cytokine ralated immunomodulationg activities of an anti-tumor glucan, Sizofiran (SPG)." J.  12: 616-625.  Pharamcobio-Dyn.  Volz, W. and R. Allen (1992). Cutaneous phototoxicity of N P e g in man. Photodynamic  therapy  and biomedical  lasers.  (P. Spinelli, M. Dal Fante  and R. Marchesini, ed.) Amsterdam, Elsevier Science Publishers B. V. pp. 446-448. Witmer-Pack, M. D. W. Oliver, J . Valinsky, G. Schulerand R. M. Steinman s  (1987). "Granulocyte/macrophage colony stimulating factor is essential for the viability and function of cultured mouse Langerhans cells." J. Exp. Med. 166: 1484-1489. Wood, G . W. and K. A. Gollahon (1977). "Detection and quantitation of macrophage infiltration into primary human tumors with the use of cell-, surface markers."  JNCI59:  1081-1087.  Yamamoto, K. and S. Kawanishi (1991). "Oxidation of specific S H protein of mitochondria by photodynamic action of hematoporphyrin. Relevance to uncoupling of oxidative phosphorylation."  Biochem.  Pharmacol.  42(5):  1087-1092. Yamamoto, N., S. Homma, T. W. Sery, L. A. Donoso and K. J . Hoober (1991). "Photodynamic immunopotentiation:  in vitro  activation of macrophages  by treatment of peritoneal cells with haematoporphyrin derivative and light." Eur. J. Cancer27(4):  467-471.  References  150  Yamamoto, N., K. Hoober, N..Yamamoto and S. Yamamoto (1992). "Tumoricidal capacities of macrophages photodynamically activated with hematoporphyrin derivative."  Photochem.  Photobiol.  56(2): 245-250,  Yamamoto, N. and B. Z. Ngwenya (1987). "Activation of mouse peritoneal macrophages by lysophospholipids and ether derivatives of neutral lipids . and phospholipids."  Cancer  Res.  47: 2008-2013.  Yamamoto, N., D. A. S T Claire, S. Homma and B. Z. Ngwenya (1988). "Activation of mouse macrophages by alkylglycerols, inflammation products of cancerous tissues."  Cancer  Res.  48:6044-6049.  Yanhua, D., O. Xiaolin, L. Zongkang and L. Hong (1990). "Scanning electron microscopic observations on photodynamic effects  in vitro."  Laser  Med.  Sci. 5: 375-379. Zurier, R. B. (1982). Prostaglandins and inflammation. Lee, ed.) New York, Elsevier, pp. 91-112.  Prostaglandins.  (J. B.  

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