SignificanceIndia has one of the highest rates of oral squamous cell carcinoma (OSCC) in the world, with an incidence of 15 per 100,000 and more than 70,000 deaths per year. The problem is exacerbated by a lack of medical infrastructure and routine screening, especially in rural areas. New technologies for oral cancer detection and timely treatment at the point of care are urgently needed.AimOur study aimed to use a hand-held smartphone-coupled intraoral imaging device, previously investigated for autofluorescence (auto-FL) diagnostics adapted here for treatment guidance and monitoring photodynamic therapy (PDT) using 5-aminolevulinic acid (ALA)-induced protoporphyrin IX (PpIX) fluorescence (FL).ApproachA total of 12 patients with 14 buccal mucosal lesions having moderately/well-differentiated micro-invasive OSCC lesions (<2 cm diameter and <5 mm depth) were systemically (in oral solution) administered three doses of 20 mg / kg ALA (total 60 mg / kg). Lesion site PpIX and auto-FL were imaged using the multichannel FL and polarized white-light oral cancer imaging probe before/after ALA administration and after light delivery (fractionated, total 100 J / cm2 of 635 nm red LED light).ResultsThe handheld device was conducive for access to lesion site images in the oral cavity. Segmentation of ratiometric images in which PpIX FL is mapped relative to auto-FL enabled improved demarcation of lesion boundaries relative to PpIX alone. A relative FL (R-value) threshold of 1.4 was found to segment lesion site PpIX production among the patients with mild to severe dysplasia malignancy. The segmented lesion size is well correlated with ultrasound findings. Lesions for which R-value was >1.65 at the time of treatment were associated with successful outcomes.ConclusionThese results indicate the utility of a low-cost, handheld intraoral imaging probe for image-guided PDT and treatment monitoring while also laying the groundwork for an integrated approach, combining cancer screening and treatment with the same hardware.
India has one of the highest rates of oral squamous cell carcinoma (OSCC) in the world, with an incidence of 15 per 100,000 and more than 70,000 deaths per year. The problem is exacerbated by lack of medical infrastructure and routine screening, especially in rural areas. This collaboration recently developed, and clinically validated, a low-cost, portable and easy-to-use platform for intraoral photodynamic therapy (PDT) specifically engineered for use in global health settings. Here, we explore the implementation of our low-cost PDT system in conjunction with a small, handheld smartphone-coupled, multichannel fluorescence and white-light oral cancer imaging probe, which was also developed for global health settings. Our study aimed to use this mobile intraoral imaging device for treatment guidance and monitoring PDT using 5-aminolevulinic acid (ALA)-induced protoporphyrin IX (PS; PpIX) fluorescence. A total of 12 patients with 14 lesions having moderately/well-differentiated micro-invasive OSCC lesions (<2 cm diameter, depth <5 mm) were systemically administered with three doses of 20mg/kg ALA (total 60mg/kg). Lesion site PpIX and auto fluorescence was analyzed before/after ALA administration, and again after light delivery (fractionated, total 100 J/cm2 of 630nm red LED light). Quantification of relative PpIX fluorescence enables lesion area segmentation to improve guidance of light delivery and reports extent of photobleaching. These results indicate the utility of this approach for image-guided PDT and treatment monitoring while also laying groundwork for an integrated approach, combining cancer screening and treatment with the same hardware.
Significance: India has one of the highest rates of oral cancer incidence in the world, accounting for 30% of reported cancers. In rural areas, a lack of adequate medical infrastructure contributes to unchecked disease progression and dismal mortality rates. Photodynamic therapy (PDT) has emerged as an effective modality with potential for treating early stage disease in resource-limited settings, while photosensitizer fluorescence can be leveraged for treatment guidance.
Aim: Our aim was to assess the capability of a simple smartphone-based device for imaging 5-aminolevulinic acid (ALA)-induced protoporphyrin IX (PpIX) fluorescence for treatment guidance and monitoring as part of an ongoing clinical study evaluating low-cost technology for ALA-based PDT treatment of early oral cancer.
Approach: A total of 29 subjects with <2 cm diameter moderately/well-differentiated microinvasive ( < 5 mm depth) oral squamous cell carcinoma lesions (33 lesions total, mean area ∼1.23 cm2) were administered 60 mg / kg ALA in oral solution and imaged before and after delivery of 100 J / cm2 total light dose to the lesion surface. Smartphone-based fluorescence and white light (WL) images were analyzed and compared with ultrasound (US) imaging of the same lesions.
Results: We present a comparative analysis of pre- and post-treatment fluorescence, WL, and US images of oral lesions. There was no significant difference in the distribution of lesion widths measured by fluorescence and US (mean widths of 14.5 and 15.3 mm, respectively) and linear regression shows good agreement (R2 = 0.91). In general, PpIX fluorescence images obtained prior to therapeutic light delivery are able to resolve lesion margins while dramatic photobleaching (∼42 % ) is visible post-treatment. Segmentation of the photobleached area confirms the boundaries of the irradiated zone.
Conclusions: A simple smartphone-based approach for imaging oral lesions is shown to agree in most cases with US, suggesting that this approach may be a useful tool to aid in PDT treatment guidance and monitoring photobleaching as part of a low-cost platform for intraoral PDT.
Oral cancers are among the most prevalent malignancies in males. In developing countries like India where chewing tobacco and other carcinogen containing mixtures is common, incidence of oral cancers is high. Photodynamic therapy is emerging as a promising method for non-disfiguring treatment for early malignant lesions of the buccal mucosa with relatively few effects and potential for implementation in settings with limited medical infrastructure
We evaluate ultrasonography as an approach for assessment of PDT response in oral malignancies.In our study we selected stage 1 malignancy of the buccal mucosa using both ultrasonography followed by histopathology.The criterion for selection on USG was lesion length of 2cm or less and depth of 5mm confirmed by biopsy and histopathology analysis. Subsequently, the patients found positive on biopsy were treated with ALA PDT with a LED light source. Following treatment these patients were reassessed with ultrasound at day 10. The images obtained were compared and evaluated for change in the size of the lesion, their echopattern, vascularity, mucosal status etc.
It was found, lesions completely hypoechoic signifying necrosis came out negative on biopsy every single time, confirming hypoechogenecity as the single best indicator for success of PDT treatment. However, those lesions which did not develop necrosis but were negative on biopsy, the indirect markers were small initial size of the lesion, a lack of vascularity within the lesion and surrounding inflammation.
To conclude, ultrasonography is a convenient, reliable and radiation free method for post PDT evaluation of lesions of buccal mucosa.
Oral cancers are the 8th most common cancer among males. In India, this corresponds to almost 80,000 new cases per year. With such a disease burden, oral cancers are a prime cause of morbidity and functional disability.
Conventional treatment for oral cancers is surgery and radiation therapy which are fraught with physical and functional side effects, and the high cost and infrastructure requirements present barriers to timely intervention for patients in rural and/or resource-limited areas. Motivated by these considerations we sought to evaluate photodynamic therapy (PDT) as an approach which is inherently conducive to adaptation for resource-limited settings and has previously shown promising clinical results for early stage oral lesions. In this study we evaluate a low-cost platform for aminolevulinic acid (ALA)-based PDT consisting of a portable 635nm fiber-coupled LED light source integrated with 3D printed applicators for stable intraoral light delivery and smartphone-based fluorescence imaging for treatment guidance.
Using this technology, we treated 18 subjects with histologically confirmed T1N0M0 lesions of the buccal mucosa with a mean diameter of 1.38 cm2 and micro-invasive (≤ 5mm depth) disease. A total light dose of 100 J/cm2 was delivered in 3 to 5 fractions to the buccal mucosa after oral administration of 60mg/kg ALA (in 3 aliquots of 20mg/kg). The post-PDT investigations showed a 72% success rate (no residual malignancy in follow-up biopsy).
The treatment was very well tolerated and has potential for broader dissemination into primary care sites and as an early intervention for pre-malignant conditions including submucous fibrosis and leucoplakia.
A range of cellular, architectural, and physical cues in the tumor microenvironment influence the intrinsic and acquired resistance mechanisms that lead to treatment failure. Strategies that leverage photodynamic therapy (PDT), a photochemistry-based biophysical treatment modality, to regionally target and prime stubborn tumor populations may be essential to realizing durable improvements in cancer management while minimizing toxicity from traditional agents. Capturing these attributes in rationally-designed combinations has shown promise by synergistically reducing tumor area in 3D models, and durably controlling tumor burden in vivo. Among the areas that remain understudied is the influence of mechanical forces, such as hydrodynamic shear stress, on resistance, and the development of 3D tumor models and in vivo models that account for physical stress. To evaluate and optimize PDT regimens, and PDT-based combinations, designed to overcome resistance to conventional therapies due to physical stress, a multi-faceted approach is needed. Here the impact of hydrodynamic stress is evaluated in bioengineered 3D tumor models in the context of ovarian cancer. The potential value of using biologically inspired in vitro models to guide customized, rationally-designed PDT-based combination regimens will be presented.
Oral cancer represents over 30% of cancers reported in low middle-income countries (LMIC), like India and is the leading cause of cancer death among Indian men. Surgery, radiation and chemo therapies are the mainstay of management but are either too expensive, unavailable for people or have extensive side effects. An alternate effective therapy for oral cancer is photodynamic therapy (PDT), a light based spatially targeted cytotoxic therapy that has shown excellent healing of the oral mucosa post treatment. We here combined engineering, optics and biochemistry to produce a low-cost, mobile LED-based light source with 3D printed light applicators for smart phone-based, image-guided PDT. After validating the devices in preclinical models, we performed an ergonomics study on 10 healthy volunteers at the MGH, where the comfort level of the applicators (anterior buccal cheek, posterior buccal cheek and retromolar positions) and presence of fatigue or numbness in the mouth due to the applicators was evaluated. We found that the retromolar and posterior applicators were the most comfortable and well tolerated. After these initial steps, the device was tested in clinical studies of early oral cancer in India. We observe in subjects with T1N0M0 oral lesions that our applicator and light system combination delivered light to cover the entire lesion area and yielded effective PDT response. Of the 18 treatments so far, 14 subjects have responded, with no residual/recurrent disease in follow-up biopsy. The significance of this work is that it offers an alternative treatment modality for early disease without associated morbidities.
India has one of the highest rates of oral cancer incidence in the world, with an estimated 80,000 new cases per year, accounting for 30% of reported cancers. In rural areas, a lack of adequate medical infrastructure contributes to unchecked disease progression and dismal mortality rates. PDT emerges as a potential modality which can be implemented in resource limited settings, while photosensitizer fluorescence can be leveraged for treatment guidance. Here, as part of an ongoing clinical study evaluating low-cost technology for ALA PDT treatment, we evaluated the capability of a simple smartphone-based device for imaging ALA-induced PpIX fluorescence. The imaging device itself consists of an annulus of 405nm LEDs for PpIX excitation with emission filter in the center mounted over the phone camera. 18 subjects having <2 cm diameter (mean size; ~1.38 cm2) lesions with micro-invasive (≤5 mm. depth) moderately/well-differentiated squamous cell carcinoma were administered 60 mg/kg ALA in oral solution and imaged before and after delivery of 100 J/cm2 total light dose to the lesion surface. We will present comparative analysis of pre-and post-treatment fluorescence, white light, and ultrasound images. In general, PpIX fluorescence images obtained prior to therapeutic light delivery are able to resolve lesion margins while dramatic photobleaching in post-treatment images confirms the irradiated zone. Overall this approach is able to generate sufficient fluorescence contrast for treatment guidance and monitoring photobleaching while the use of a smartphone-based device provides a low-cost, widely available platform with potential for telemedicine integration.
Biomodulation of cancer cell metabolism represents a promising approach to overcome tumor heterogeneity and poor selectivity, which contribute significantly to treatment resistance. To date, several studies have demonstrated that modulation of cell metabolism including the heme synthesis pathway serves as an elegant approach to improve the efficacy of aminolevulinic acid (ALA) based photodynamic therapy (PDT). However, the ability of biomodulation-enhanced PDT to improve outcomes in low resource settings and to address challenges in treating lethal tumors with exogenous photosensitizers remains underexplored. The ability of vitamin D or methotrexate to enhance PDT efficacy in a carcinogen-induced hamster cheek pouch model of oral squamous cell carcinoma and in 3D cell-based models for pancreatic ductal adenocarcinoma is evaluated. Challenges associated with adapting PDT regimens to low resource settings, understanding the effects of biomodulatory agents on the metabolism of cancer cells, and the differential effects of biomodulatory agents on tumor and stromal cells will be discussed.
Photodynamic therapy (PDT) is a photochemistry based cytotoxic technique that imparts cellular damage via excitation of a photosensitizer with drug-specific wavelength of light. The dose at the treatment site for type II PDT is determined by three factors: photosensitizer (PS) concentration, oxygenation status and delivered light irradiance. Most of the FDA approved photosensitizers in their triplet-excited state generate cytotoxic species by reacting with the ground state oxygen that is available in the surrounding environment. Given the inter- and intra-subject variability in the uptake of the photosensitizer and the distribution of oxygen in the tumor, understanding the interplay between these dose parameters could aid in determining photodynamic therapy efficacy. Previously several studies have discussed the interplay between the dose parameters using shown point measurements and 2D imaging systems. Using various subcutaneous and orthotopic mouse models we will demonstrate the utility of a non-invasive non-ionizing photoacoustic imaging modality to determine efficacy and predict treatment response in Benzoporphyrin derivative (BPD) or Aminolevulinic acid (ALA) based PDT. We further compare the predictive capability of photoacoustic imaging with the more predominantly used fluorescence imaging and immunohistochemistry techniques.
Photodynamic therapy (PDT) is a light-based modality that shows promise for adaptation and implementation as a cancer treatment technology in resource-limited settings. In this context PDT is particularly well suited for treatment of pre-cancer and early stage malignancy of the oral cavity, that present a major global health challenge, but for which light delivery can be achieved without major infrastructure requirements. In recent reports we demonstrated that a prototype low-cost batterypowered 635nm LED light source for ALA-PpIX PDT achieves tumoricidal efficacy in vitro and vivo, comparable to a commercial turn-key laser source. Here, building on these reports, we describe the further development of a prototype PDT device to enable intraoral light delivery, designed for ALA- PDT treatment of precancerous and cancerous lesions of the oral cavity. We evaluate light delivery via fiber bundles and customized 3D printed light applicators for flexible delivery to lesions of varying size and position within the oral cavity. We also briefly address performance requirements (output power, stability, and light delivery) and present validation of the device for ALA-PDT treatment in monolayer squamous carcinoma cell cultures.
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