Photodiagnosis and Photodynamic Therapy (2006) 3, 132—133
HOW-TO-DO-IT
Photodynamic diagnosis (PDD) and photodynamic therapy (PDT) in dermatology: ‘‘How we do it’’ A. Siero´ n MD, PhD ∗, A. Kawczyk-Krupka, M. Adamek, W. Cebula, W. Ziele´ znik, K. Niepsuj, G. Niepsuj, A. Pietrusa, M. Szyguła, T. Biniszkiewicz, S. Mazur, J. Małyszek, A. Roma´ nczyk, A. Ledwo´ n, A. Frankiewicz, A. Zybura, E. Koczy, B. Birkner Center for Laser Diagnostics and Therapy, Silesian Medical University, Department and Clinic of Internal Diseases and Physical Medicine, 15 Batory Street, PL-41902 Bytom, Poland
KEYWORDS Dermatology; Actinic keratoses; Basal cell carcinomas; Bowen’s disease; Superficial squamous cell carcinomas
Summary In dermatology PDT has been proven to be effective in the treatment of actinic keratoses, basal cell carcinomas (BCC), Bowen’s disease, superficial squamous cell carcinomas (SCC). © 2006 Published by Elsevier B.V.
Patients and methods Patient population We have the Ethical committee approval for PDT in dermatology, and every patient is informed of the nature of our treatment and sign a consent form. Indications for PDT were primary or secondary treatment following the previous cryosurgery, surgical excision, and electrodissection. The indications for PDT in our patients (number 315) were superficial BCC, nodular BCC, exulcerans BCC, with actinic keratoses, and with superficial SCC and with Bowen’s disease. Treated lesions were located on the neck, the trunk, the legs, the hands, the penis, and on the face and on the head. The extent of the lesions ∗
Corresponding author. Tel.: +48 32 786 16 30; fax: +48 32 786 16 30. E-mail address: [email protected] (A. Siero´ n). 1572-1000/$ — see front matter © 2006 Published by Elsevier B.V. doi:10.1016/j.pdpdt.2006.03.009
ranged from 2 mm to 5 cm (median diameter was 1.28 cm). Biopsies were taken from lesions in all patients prior to PDT. In the patients with multiple lesions, a biopsy was performed for every lesion.
Drug application In our study ␦-aminolevulinic acid (ALA) (Medac GmbH, Wedel, Germany) was used as a precursor in the biosynthesis of haem. A thin layer of an oilin-water emulsion containing 20% ALA was applied topically to the tumors with a margin of 4 mm of surrounding normal tissue.
PDT light source For the treatment Diomed 630 PDT semiconductor laser is used, at fluence rate 700 mW/cm2 . The delivery fiber optic terminated in a microlens that
Photodynamic diagnosis (PDD) and photodynamic therapy (PDT) in dermatology
133
focused the laser radiation on to the circular field. The energy density of the laser irradiation was 100—125 J/cm2 .
Treatment procedure The 20% ALA was applied topically to the lesion sites. The sites were then covered with a selfadhesive foil, kept in place for 10 h. Patients, in majority of cases, were hospitalized for 2 days for the treatment and to avoid light-related adverse events. Prior to light treatment the tumor fluorescence was assessed by a CCD-based imaging system (Xillix Technologies Corp., Richmond, BC, Canada, excitation wavelength 442 nm). Tissue accumulation of PpIX showed a red fluorescence. Once the extent of the lesion was determined, Irradiation was performed using light from Diomed 630 PDT in the wavelength 630 nm giving a radiation dose of 100—125 J/cm2 . We included at least a 10—20% margin around the lesions in the field of irradiation. The treatment time was about 15 min, at a low fluence rate interrupted periodically. About 90% of the patients received local anaesthesia (10% Lidocaine hydrochloride) and 30% needed analgesic drugs (Paracetamol, Metamizole sodium). All patients were reviewed at 2-week intervals and treatments were repeated if required. The number of treatment sessions was from 2 to 12 (median: 6).
Follow-up study The post-treatment observation period ranged from 10 months to 6 years. Recurrences were observed mostly: in nodular BCC and in SCC. When clinical absence of the tumor was found, the lesion’s fluorescence was assessed 3 h after topical 20% ALA cream application. Complete responses were judged as clinical absence of palpable or visible lesions, which corresponded with green fluorescence of the tissue. Sometimes, when there was even the slightest clinical or photodynamic diagnostic’s (PDD) doubt, response was confirmed by the biopsy. Partial response was defined as a reduction of half (between 50% and 100%) in the lesion area. There were nonresponders, when after 10 treatment sessions a response has not been noted, or at least half reduction of the initial tumor’s size had not been noted.
Results Evaluation A complete response was recorded in 79% of patients. The response rates for different lesions
Figure 1 Tumor response to PDT.
were superficial BCC (94%), nodular BCC (60%), exulcerans BCC (80%), actinic keratoses (100%), superficial SCC (60%), and in morbus Bowen’s disease (100%). Actinic keratoses and superficial BCC are ideally suited for PDT with topical application of ALA (Fig. 1).
Adverse reaction The treatment was well tolerated by the majority of patients. Moderate pain during treatment, localized erythema and oedema were observed immediately after illumination and for 1—2 days later. The discomfort of the patients from pain was graded as none, moderate and severe. Ten percent of patients had acute pain at the beginning of the treatment, which became moderate during the treatment. When the temperature of the air near the end of fiber optic turned colder, the pain diminished. Sometimes PDT-treatment was associated with secondary erythema (40%) and secondary infection (5%).
Cosmetic results Following light exposure, skin lesions became necrotic and showed hemorrhagic crusts. In our patients’ good cosmetic results of PDT after topical application of ALA in the treatment of superficial BCC, actinic keratoses and Bowen’s disease were observed.
HOW-TO-DO-IT
Photodynamic diagnosis (PDD) and photodynamic therapy (PDT) in dermatology: ‘‘How we do it’’ A. Siero´ n MD, PhD ∗, A. Kawczyk-Krupka, M. Adamek, W. Cebula, W. Ziele´ znik, K. Niepsuj, G. Niepsuj, A. Pietrusa, M. Szyguła, T. Biniszkiewicz, S. Mazur, J. Małyszek, A. Roma´ nczyk, A. Ledwo´ n, A. Frankiewicz, A. Zybura, E. Koczy, B. Birkner Center for Laser Diagnostics and Therapy, Silesian Medical University, Department and Clinic of Internal Diseases and Physical Medicine, 15 Batory Street, PL-41902 Bytom, Poland
KEYWORDS Dermatology; Actinic keratoses; Basal cell carcinomas; Bowen’s disease; Superficial squamous cell carcinomas
Summary In dermatology PDT has been proven to be effective in the treatment of actinic keratoses, basal cell carcinomas (BCC), Bowen’s disease, superficial squamous cell carcinomas (SCC). © 2006 Published by Elsevier B.V.
Patients and methods Patient population We have the Ethical committee approval for PDT in dermatology, and every patient is informed of the nature of our treatment and sign a consent form. Indications for PDT were primary or secondary treatment following the previous cryosurgery, surgical excision, and electrodissection. The indications for PDT in our patients (number 315) were superficial BCC, nodular BCC, exulcerans BCC, with actinic keratoses, and with superficial SCC and with Bowen’s disease. Treated lesions were located on the neck, the trunk, the legs, the hands, the penis, and on the face and on the head. The extent of the lesions ∗
Corresponding author. Tel.: +48 32 786 16 30; fax: +48 32 786 16 30. E-mail address: [email protected] (A. Siero´ n). 1572-1000/$ — see front matter © 2006 Published by Elsevier B.V. doi:10.1016/j.pdpdt.2006.03.009
ranged from 2 mm to 5 cm (median diameter was 1.28 cm). Biopsies were taken from lesions in all patients prior to PDT. In the patients with multiple lesions, a biopsy was performed for every lesion.
Drug application In our study ␦-aminolevulinic acid (ALA) (Medac GmbH, Wedel, Germany) was used as a precursor in the biosynthesis of haem. A thin layer of an oilin-water emulsion containing 20% ALA was applied topically to the tumors with a margin of 4 mm of surrounding normal tissue.
PDT light source For the treatment Diomed 630 PDT semiconductor laser is used, at fluence rate 700 mW/cm2 . The delivery fiber optic terminated in a microlens that
Photodynamic diagnosis (PDD) and photodynamic therapy (PDT) in dermatology
133
focused the laser radiation on to the circular field. The energy density of the laser irradiation was 100—125 J/cm2 .
Treatment procedure The 20% ALA was applied topically to the lesion sites. The sites were then covered with a selfadhesive foil, kept in place for 10 h. Patients, in majority of cases, were hospitalized for 2 days for the treatment and to avoid light-related adverse events. Prior to light treatment the tumor fluorescence was assessed by a CCD-based imaging system (Xillix Technologies Corp., Richmond, BC, Canada, excitation wavelength 442 nm). Tissue accumulation of PpIX showed a red fluorescence. Once the extent of the lesion was determined, Irradiation was performed using light from Diomed 630 PDT in the wavelength 630 nm giving a radiation dose of 100—125 J/cm2 . We included at least a 10—20% margin around the lesions in the field of irradiation. The treatment time was about 15 min, at a low fluence rate interrupted periodically. About 90% of the patients received local anaesthesia (10% Lidocaine hydrochloride) and 30% needed analgesic drugs (Paracetamol, Metamizole sodium). All patients were reviewed at 2-week intervals and treatments were repeated if required. The number of treatment sessions was from 2 to 12 (median: 6).
Follow-up study The post-treatment observation period ranged from 10 months to 6 years. Recurrences were observed mostly: in nodular BCC and in SCC. When clinical absence of the tumor was found, the lesion’s fluorescence was assessed 3 h after topical 20% ALA cream application. Complete responses were judged as clinical absence of palpable or visible lesions, which corresponded with green fluorescence of the tissue. Sometimes, when there was even the slightest clinical or photodynamic diagnostic’s (PDD) doubt, response was confirmed by the biopsy. Partial response was defined as a reduction of half (between 50% and 100%) in the lesion area. There were nonresponders, when after 10 treatment sessions a response has not been noted, or at least half reduction of the initial tumor’s size had not been noted.
Results Evaluation A complete response was recorded in 79% of patients. The response rates for different lesions
Figure 1 Tumor response to PDT.
were superficial BCC (94%), nodular BCC (60%), exulcerans BCC (80%), actinic keratoses (100%), superficial SCC (60%), and in morbus Bowen’s disease (100%). Actinic keratoses and superficial BCC are ideally suited for PDT with topical application of ALA (Fig. 1).
Adverse reaction The treatment was well tolerated by the majority of patients. Moderate pain during treatment, localized erythema and oedema were observed immediately after illumination and for 1—2 days later. The discomfort of the patients from pain was graded as none, moderate and severe. Ten percent of patients had acute pain at the beginning of the treatment, which became moderate during the treatment. When the temperature of the air near the end of fiber optic turned colder, the pain diminished. Sometimes PDT-treatment was associated with secondary erythema (40%) and secondary infection (5%).
Cosmetic results Following light exposure, skin lesions became necrotic and showed hemorrhagic crusts. In our patients’ good cosmetic results of PDT after topical application of ALA in the treatment of superficial BCC, actinic keratoses and Bowen’s disease were observed.
