Patent Application
20110040170
The present invention relates to an endoscopic imaging photodynamic therapy system for focused tissue ablation and methods of use.
Ablation, as used in Medicine, is defined as removal or excision of a body part or tissue or its function and is usually carried out surgically. Ablation may also be performed by the administration of hormones, drugs, radiofrequency, heating, freezing and/or any other suitable method for performing ablation. For example, surface ablation in the skin can be carried out by chemicals (peeling) or by lasers in order to remove skin spots, aged skin or wrinkles, and in otolaringology for several kinds of surgery, such as prevention of snoring. Surface ablation of the cornea for several types of eye refractive surgery is now common, using laser ablation, for example, to remodel the cornea refractive properties in order to correct refraction errors, such as astigmatism, myopia and hyperopia.
Radiofrequency ablation (RFA) is the most popular minimally invasive thermal ablation technique worldwide. RFA employs radiofrequency energy to destroy abnormal electrical pathways in heart tissue and is used, for example, to cure a variety of arrhythmias such as supraventricular tachycardia, WPW syndrome, ventricular tachycardia and atrial fibrillation. The energy emitting probe (electrode) is placed into the heart through a catheter. New ablation techniques include cryoablation, microwave ablation, and high intensity focused ultrasound (HIFU) ablation, in which acoustic energy is used.
RFA expanded the treatment options for certain oncology patients. Minimally invasive, image-guided therapy may now provide effective local treatment of isolated or localized neoplastic disease, and can also be used as an adjunct to conventional surgery, systemic chemotherapy, or radiation. Other clinical applications of RFA include treatment of patients with liver cancers, kidney, adrenal, and prostate tumors; benign prostatic hyperplasia; painful or abnormal neural tissue; and painful soft tissue or bone masses that are unresponsive to conventional therapy.
Photodynamic therapy (PDT) is a relatively new treatment modality best known for its applications in the therapy of cancer and macular degeneration. PDT is rapidly maturing in the clinic with the development of new photosensitizers, treatment protocols and additional clinical applications as well as increasing basic understanding of this technique. In the US, several FDA approved PDT drugs are in use and others are in various stages of preclinical and clinical trials.
PDT involves two non-toxic components that are combined at the treatment site to induce cellular and tissue damage in an oxygen-dependent manner: a non-toxic photosensitizer drug, administered systemically or locally, and non-hazardous light of a matched wavelength that is delivered locally to the treatment site. The photosensitization of the drug elicits the transfer of energy or an electron to molecular oxygen resulting in instant local generation of cytotoxic reactive oxygen species (ROS). Depending on the drug and the treatment protocol, phototoxicity can be directed toward the targeted tissue or tumor cells or towards the respective vasculature. The half-life of these radicals in the biological milieu is extremely short (<0.04 μs) restricting their diffusion distance to <0.02 μm, practically confining the damage to the illuminated area. Compared to surgical resection of tumors, PDT following I.V. administration of the photosensitizer can be delivered to internal lesions via optic fibers. Thus, PDT can be defined as a highly controlled, minimally-invasive, local treatment. In contrast to other clinical laser-ablation techniques, in PDT low energy lasers are commonly used, which deliver a few hundred mW/treatment site.
Devices and methods for photodynamic ablation of tissues have been described. U.S. Pat. No. 6,811,562 discloses procedures and devices for photodynamic cardiac ablation therapy for treating cardiac tissue by forming lesions in that tissue using said PDT techniques. WO 97/06797 discloses PDT using green porphyrins such as BPD for endometrial ablation to treat endometrial disorders such as dysfunctional uterine bleeding, menorrhagia, endometriosis, endometrial neoplasia, sterilization and termination of early pregnancy. No device is disclosed.
Extrauterine pregnancy (EUP)
Extrauterine pregnancy (EUP) in humans is the abnormal implantation of an embryo outside the uterus. The prevalence of EUP is about 10-20 cases per 1000 pregnancies. During the 1980's and 1990's there has been a 3-4 fold increase in EUP incidence in developed countries due to increase in the use of assisted reproductive technology and prevalence of pelvic inflammatory disease. Other risk factors include infertility, previous EUP and pelvic surgery. The high occurrence rate of EUP makes it the second leading cause of overall pregnancy-related maternal mortality in the USA and the leading cause of pregnancy-related maternal death during the first trimester.
Early diagnosis is the key to successful treatment of EUP. Intervention prior to Fallopian tube rupture allows conservative treatment and enhances fertility preservation. Today most cases are diagnosed early in the first trimester of pregnancy by a combination of transvaginal ultrasonography and determination of serum β-human chorionic gonadotropin (β-hCG) levels.
Current treatment options for EUP consist of medical or surgical therapy. Medical therapy with methotrexate is aimed against the rapidly dividing cells of the placenta and embryo. Methotrexate, a chemotherapeutic drug, is a powerful anti-metabolite that inhibits dihydrofolate reductase, inhibiting DNA replication and cell division. The adverse effects of methotrexate include acute abdominal pains, impaired liver function, stomatitis, cytopenia and rarely, pneumonitis. However, medical therapy is an established treatment of EUP only in selected patients (e.g., embryonic mass size of less than 4 cm, absence of fetal heart beat and low blood β-hCG levels), with a success rate of 70-95%.
A large proportion of patients with EUP will require surgical treatment, either conservative (salpingostomy) or radical (salpingectomy). Conservative surgery aims at preserving the Fallopian tube and consequent fertility by removing only the implanted embryo and placenta. The main risk factor associated with this technique is incomplete removal of the placenta, which can result in persistent disease, necessitating further surgery or methotrexate treatment and constituting treatment failure (˜15% of patients). Radical surgery involves the resection of the Fallopian tube with the pregnancy, ending the medical emergency with high certainty, but usually resulting in impaired fertility. In addition, surgery entails other risks such as infection, hemorrhage and anesthesia, as well as a risk for pelvic adhesions and mechanical infertility. Prolonged hospitalization and recovery times make surgery significantly more costly when compared to medical treatment.
The high prevalence of EUP, as well as the drawbacks and limitations of current treatment options, prompt a search for novel treatment modalities.
The similarities between tumors and newly implanted pregnancies are striking: both develop on the basis of a rapidly dividing cell mass that invades surrounding tissues and induce angiogenesis by establishing a neo-vascular system. In spite of this similarity, a single study attempting photo-ablation of EUP was not successful (Yang et al., 1993). In this study, Yang et al. attempted photo-ablation of EUP in the pregnant rat using systemic administration of 5-aminolevulinic acid (5-ALA) combined with illumination of an entire uterine horn. This resulted in the termination of all pregnancies in the treated horn, as well as subsequent high infertility rates (only 66.2% of treated animals developed pregnancies in the treated horn, presenting ˜28% fewer implanted embryos) indicative of lasting endometrial damage. A subsequent study by the same group reported the non-selective ablation of all the embryos in a rat uterine horn following systemic injection of 5-ALA and illumination (Yang et al., 1994). Although reviewed as recently as 2000 by the same group (Reid et al, 2000), no follow up in the direction of EUP ablation has been published, but rather the group's attention has shifted to endometrial ablation as a potential treatment for endometriosis by 5-ALA PDT (Yang et al., 1996; Krzemien, 2002).
The present invention is directed toward a novel technological platform designed for optimal delivery of minimally invasive internal treatments by photodynamic means under controlled real-time imaging.
In one aspect, the present invention relates to an endoscopic imaging photodynamic therapy system for focused tissue ablation by illumination of a photosensitizer drug in a target tissue, said system comprising an endoscopic assembly, a real-time imaging component for locating the target tissue and monitoring the ablation intervention, a therapeutic light system and, optionally, a drug delivery module, wherein said imaging component comprises a flexible transducer with an operative channel for insertion of a flexible light guide of the therapeutic light system and, optionally, a flexible drug delivery catheter of the drug delivery module.
In another aspect, the invention provides a method for focused tissue ablation in a target tissue of an individual in need using the endoscopic imaging photodynamic therapy system of the invention.
The system and method of the present invention can be used for treatment of various diseases, disorders and conditions by focused tissue ablation and, particularly, for photodynamic ablation of the fetoplacental unit(s) in the treatment of extrauterine pregnancy (EUP).
In the accompanying drawings, like reference characters relate to similar features in the different views to facilitate comparison.
The present invention provides a technological platform based on an endoscopic imaging photodynamic therapy system (EIPS) designed for optimal delivery of minimally invasive internal treatments by photodynamic means under controlled real-time imaging, in which the photosensitizer administration can be done locally or systemically.
The EIPS of the present invention generally consists of three major components that act in concert to provide the tasks needed to perform the procedure accurately and safely while the various instruments, control panels and monitor(s) are placed at the patient's bedside, conveniently situated for controlled operation by the physician.
The EIPS of the invention is suitable for transvaginal focused tissue ablation, particularly for ablation of the feto-placental unit in ectopic location in cases of extrauterine pregnancy (EUP). Such a system is described hereinbelow wherein the intravaginally inserted assembly contains the respective front-end components for controlled interactive function at the treatment site. However, with appropriate modifications, the EIPS can also become instrumental in other medical applications where PDT may be applied for treatment such as, but not limited to, malignant and pre-malignant lesions, gynecological diseases, cardiology and other cardiovascular diseases, gastrointestinal tract lesions, respiratory system diseases, urinary tract diseases, musculo-skeletal diseases, head and neck or neuronal and brain treatments.
In one aspect of the invention, an endoscopic imaging photodynamic therapy system is provided for focused tissue ablation by illumination of a photosensitizer drug in a target tissue, said system comprising an endoscopic assembly, a real-time imaging component for locating the target tissue and monitoring the ablation intervention, a therapeutic light system and, optionally, a drug delivery module, wherein said imaging component comprises a flexible transducer with an operative channel for insertion of a flexible light guide of the therapeutic light system and, optionally, a flexible drug delivery catheter of the drug delivery module.
As defined herein, the term “target tissue” refers to any biological tissue or a part thereof, including blood and/or lymph vessels, which is the object of focused tissue ablation and includes, for example, a group of cells, a tissue, a body part or an organ. The target tissue may also be an embryo/fetus or a placenta or part thereof when EUP is treated.
In one embodiment, the present invention provides an EIPS wherein:
(a) said endoscopic assembly comprises a control handle, an operation handle and an application adaptor;
(b) said real-time imaging component comprises means for guidance for location of said target tissue and monitoring of the ablation intervention in said target tissue, and a flexible transducer with an operative channel;
(c) said therapeutic light system consists of a light source, a flexible light guide and an operating switch for the light system; and
(d) said drug delivery module, if present, comprises a flexible drug delivery catheter adapted for injecting a photosensitizer drug to the target tissue, a drug delivery means and a photosensitizer drug in an injectible form.
According to one embodiment of the invention, the flexible light guide of the therapeutic light system and the flexible drug delivery catheter of the drug delivery module, if present, are inserted into the operative channel of the flexible transducer of the real-time imaging component, for example, via a flexible service catheter.
The control handle of the endoscopic assembly (a) may be manual or computer-controlled and comprises a proximal grip and at least one service opening. When there are two service openings, one is used for insertion of the flexible transducer of the real-time imaging component, as described below, and the other may be used, for example, for washing the tissue, suction from the tissue, insertion of needle biopsies to sample cells from an abnormal area for laboratory testing, removal of a piece of a polyp, a gallstone, a foreign object, or a stent, etc.
The operation handle of the endoscopic assembly preferably comprises means for aiming and bending the flexible transducer with the flexible drug delivery catheter, if present, and the flexible light guide towards the target tissue. Said means may be mechanical such as a navigator dial or computer-aided, computer-controlled, computer-operated or wireless.
The real-time imaging component for locating the target tissue and monitoring the ablation intervention may be any imaging component such as, without limitation, ultrasound (US), magnetic resonance imaging (MRI), computerized tomography (CT), positron emission tomography (PET), light-based video, or any combination thereof, or any other or future imaging technique, and may also be used to measure the size of the target tissue, when appropriate.
Any appropriate light source may be used in the therapeutic light system such as a diode laser, preferably with several variable output channels. Preferably, the diode laser emits a light beam with a wavelength that matches one or more of the absorption peaks of the photosensitizer drug. The operating switch for the therapeutic light system may be a pedal.
In one embodiment of the invention, the flexible light guide of the therapeutic light system is equipped with front-end optics to improve viewing and location of the target tissue.
According to one embodiment of the invention, the flexible light guide of the therapeutic light system is inserted into the target tissue or to its close proximity simultaneously with the flexible drug delivery catheter of the drug delivery module via the operative channel of the flexible transducer. In another embodiment, the flexible light guide is inserted into the target tissue or to its close proximity following the insertion of the flexible drug delivery catheter, which needs retraction of the flexible drug delivery catheter prior to insertion of the flexible light guide.
The service openings may also be in different positions depending on the engineering of the device, for example, one to the left and the other to the right. One of the service openings is used for insertion of the flexible transducer of the real-time imaging component while the other service opening may be used for different purposes as described above.
The operation handle 20 of the endoscopic assembly 100 may comprise a navigator dial 21 that allows aiming and bending of the flexible service catheter 70 and the real-time imaging component 40 towards the target tissue. The application adaptor 30 described is designed for reproductive tract intervention and is connected to the operation handle 20 through a connecting screw 31 and to a flexible guide 33 through the non-flexible guide 32. However, the size and shape of the application adaptor 30 may be modified according to the specific use and the target tissue and location involved in the procedure.
According to the present invention, the real-time imaging component 40 for locating the target tissue and monitoring the ablation intervention, may be an ultrasound (US), magnetic resonance imaging (MRI), computerized tomography (CT), positron emission tomography (PET), light-based video, and any other known imaging component or developed in the future that is suitable for imaging biological material, or any combination thereof In one preferred embodiment, the real-time imaging component is Doppler ultrasound (US Doppler) that can detect and measure vascular blood flow. The real-time imaging component 40 may also be used for measuring the size of the target tissue, for example, the size of the embryo when the procedure is used for ablation/treatment of extrauterine pregnancy.
The photosensitizer drug used in the invention may be any known photosensitizer as well as any photosensitizer to be developed that is suitable for PDT, and is chosen according to the target tissue to be treated. The photosensitizer drug may be systemically injected to the patient, in which case the drug delivery module function may be either absent in the system or it is present in the system, but is not used in the intervention.
The light source 61 may be any suitable light source and is preferably a diode laser that emits a light beam with a wavelength that matches one of the absorption peaks of the photosensitizer drug, preferably a diode laser with several variable output channels. In a specific embodiment, the diode laser is a standard PDT diode-laser (optionally with several 0.05-4W variable output channels) as used, for instance, in clinical PDT of prostate cancer treatment, situated at the patient bedside. The therapeutic light dose is delivered via one or more flexible light guides 62 equipped with optional front-end optics (diffuser or lens 63 for interstitial light delivery), integrated in the light system for optimal function and represented at the assembly tip for optimal insertion and delivery of the therapeutic light dose. In an internal body space like bladder (e.g., inflated bladder), non-interstitial illumination is provided using a light beam originating from the optic fiber tip. When the procedure is transvaginal for treatment of EUP, the flexible light guide 62 is best situated to guide the intervention towards the target tissue to be ablated, located for example, in the Fallopian tube, uterine isthmus or cervix for maximal efficacy and safety of the treatment. The therapeutic illumination time is estimated to be a matter of minutes.
The wavelength of the laser is matched with one of the absorption peaks of the selected photosensitizer (presently estimated in the range of 500-850 nm). Light in this spectral range and used intensities is not hazardous to the fetus or patient. The estimated light intensity to be delivered is in the range of 50-500 mW/1-5 min exposures, depending on the flexible light guide 62, the mode of illumination used, the nature of the target tissue and the objective of the treatment.
In one embodiment, the flexible light guide 62 of the therapeutic light system 60 is equipped with front-end optics. The flexible light guide 62 may be inserted to the target tissue or to its close proximity, according to the treated target and the objective of the treatment, and it may be inserted simultaneously with or following the insertion of the flexible drug delivery catheter 51 (see
Any suitable operating switch 64 may be used according to the invention such as foot-operated, hand-operated, motion-operated or computer-operated switches. In a preferred embodiment of the invention, the operating switch 64 for the therapeutic light system 60 is a foot-operated switch, most preferably a pedal, as shown in
According to the invention, the real-time imaging component 40 comprises a flexible transducer 42 with an operative channel 43 through which the flexible service catheter 70 is inserted. Several possibilities are envisaged by the invention for positioning of the flexible transducer 42 and the operative channel 43 containing the inserted flexible service catheter 70. In principle, the operative channel 43 may be internal, namely, positioned within the transducer 42, or external, positioned in different positions, as depicted in
In
In
When the operative channel 43 is positioned inside the flexible transducer 42, the size of both the operation channel 43 and of the flexible service catheter 70 is inherently predetermined by the size of the flexible transducer 42. When the operative channel 43 is external, as depicted in
The endoscopic imaging photodynamic therapy system (EIPS) of the invention is designed for optimal delivery of minimally invasive internal treatments by photodynamic means, by local or systemic photosensitizer administration, under controlled real-time imaging. The EIPS of the invention can be used in various medical applications which require tissue ablation and where PDT may be applied such as, but not limited to, for treatment of reproductive tract diseases, disorders or lesions; gastrointestinal tract lesions; cardiological diseases, e.g., atrial arrhythmia, atrial fibrillation and ventricular tachycardia; respiratory system diseases; urinary tract diseases; musculo-skeletal diseases; central nervous system (CNS) diseases; pre-malignant and malignant lesions; benign tumors such as benign prostatic hyperplasia (BPH) and angiomas; and malignant tumors and neoplasms in all organs, including the brain.
It is to be understood that all operations of the EIPS of the invention can also be software-controlled and operated, for example, by a personal computer or a dedicated device and these embodiments are encompassed by the present invention.
The EIPS illustrated in
In one preferred embodiment, the EIPS of the invention is for use in the treatment of diseases, disorders or lesions of the reproductive tract, particularly in the treatment of gynaecological diseases, disorders and abnormalities such as, but not limited to, extrauterine pregnancy (EUP), ovarian pathologies, uterine fibroids (intramural, submucose or subserous) and other uterine lesions and tumors, pelvic endometriosis, and cervical, vaginal or vulvar lesions.
In a more preferred embodiment, the EIPS of the invention is for use in the treatment of extrauterine pregnancy (EUP).
The description below illustrates the use of the EIPS of
The flexible drug delivery catheter 51 of the drug delivery module 50 is inserted through the flexible service catheter 70 and guided to the target EUP, thus bringing the needle 53 to the target EUP to permit the photosensitizer drug (in an injectable form) injection by the delivery means 52 (
When appropriate, the flexible drug delivery catheter 51 of the drug delivery module is retracted and the flexible light guide 62 of the therapeutic light system 60 with an optic lens/diffuser 63 are inserted through the flexible service catheter 70 and placed in position (
The device and technology described in
The present invention further provides endoscopic methods for focused tissue ablation of a target tissue using an endoscopic imaging photodynamic therapy system according to the invention. In these methods, the photosensitizer drug may be injected either by local injection using a drug delivery module as described herein, or systemically, e.g., by intravenous infusion. The photosensitizer drug can be injected either before the EIPS is inserted or after the device is in place and ready for operation/illumination. In a preferred embodiment, the photosensitizer drug is administered by continuous infusion throughout the illumination step.
In one embodiment, the present invention provides an endoscopic method for focused tissue ablation of a target tissue of an individual using an endoscopic imaging photodynamic therapy system according to the invention, said method comprising:
(i) inserting the endoscopic assembly (a) into a cavity of the individual's body that leads to the target tissue;
(ii) inserting the flexible transducer of the real-time imaging component (b) through a service opening of the endoscopic assembly;
(iii) guiding the flexible transducer to the target tissue and locating the target tissue with the aid of said real-time imaging component;
(iv) inserting the flexible drug delivery catheter of the drug delivery module (d) through the operative channel of the flexible transducer, pushing towards the target tissue, and positioning and aligning the flexible drug delivery catheter with a navigator dial or computer-operated means under real-time imaging guidance to the appropriate injection site at or close to the target tissue;
(v) injecting a photosensitizer drug directly into or close to the target tissue with the drug delivery means;
(vi) retracting the flexible drug delivery catheter;
(vii) inserting the flexible light guide of the therapeutic light system (c) through the operative channel of the flexible transducer and positioning the flexible light guide adjacent to the target tissue;
(viii) delivering a therapeutic light dose to the target tissue, thus inducing photodamage and tissue ablation in the target tissue; and
(ix) retracting the endoscopic imaging photodynamic therapy system.
In another embodiment, the invention provides an endoscopic method for focused tissue ablation of a target tissue of an individual using an endoscopic imaging photodynamic therapy system according to the invention, said method comprising:
(i) inserting the endoscopic assembly (a) into a cavity of the individual's body that leads to the target tissue;
(ii) inserting the flexible transducer of the real-time imaging component (b) through a service opening of the endoscopic assembly;
(iii) guiding the flexible transducer to the target tissue and locating the target tissue with the aid of said real-time imaging component;
(iv) inserting the flexible drug delivery catheter of the drug delivery module (d) and the flexible light guide of the therapeutic light system (c) concomitantly through the operative channel of the flexible transducer, pushing towards the target tissue, and positioning and aligning the flexible drug delivery catheter with a navigator dial or computer-operated means under real-time imaging guidance to the appropriate injection site at or close to the target tissue;
(v) injecting a photosensitizer drug directly into or close to the target tissue with the drug delivery means;
(vi) positioning the flexible light guide adjacent to the target tissue;
(vii) delivering a therapeutic light dose to the target tissue, thus inducing photodamage and tissue ablation in the target tissue; and
(viii) retracting the endoscopic imaging photodynamic therapy system.
In one embodiment, the flexible drug delivery catheter of the drug delivery module and the flexible light guide of the therapeutic light system are inserted through the flexible service catheter inserted into the operative channel of the flexible transducer.
As used herein, the term “cavity of an individual's body” refers to any cavity, lumen or other inner space of an organ or tissue into which an endoscopic system of the invention can be inserted in order to effect the ablation treatment in the target tissue.
The invention further provides an endoscopic method for focused tissue ablation of a target tissue of an individual using an endoscopic imaging photodynamic therapy system according to the invention comprising an endoscopic assembly (a), a real-time imaging component (b), and a therapeutic light system (c), said method comprising:
(i) injecting/infusing a photosensitizer drug systemically to the individual;
(ii) inserting the endoscopic assembly (a) into a cavity of the individual's body that leads to the target tissue;
(iii) inserting the flexible transducer of the real-time imaging component (b) through a service opening of the endoscopic assembly;
(iv) guiding the flexible transducer to the target tissue and locating the target tissue with the aid of said real-time imaging component;
(v) inserting the flexible light guide of the therapeutic light system (c) through the operative channel of the flexible transducer, pushing towards the target tissue, and positioning the flexible light guide adjacent to the target tissue;
(vi) delivering a therapeutic light dose to said target tissue, thus inducing photodamage and tissue ablation in the target tissue; and
(vii) retracting the endoscopic imaging photodynamic therapy system.
In a preferred embodiment, the invention provides a method for focused tissue ablation of a feto-placental unit in an extrauterine pregnancy (EUP) in a female patient using an endoscopic imaging photodynamic therapy system comprising an endoscopic assembly, a real-time imaging component, a drug delivery module, and a therapeutic light system, said method comprising:
(i) inserting the endoscopic assembly into the vaginal tract of the female patient with EUP;
(ii) inserting a flexible transducer with an operative channel of the real-time imaging component through a service opening of the endoscopic assembly;
(iii) guiding the flexible transducer to the target EUP through the vaginal tract and locating the target EUP with the aid of said real-time imaging component;
(iv) inserting a flexible drug delivery catheter of the drug delivery module through the operative channel of the flexible transducer, pushing towards the target EUP, and positioning and aligning the flexible drug delivery catheter with a navigator dial or computer-operated means under real-time imaging guidance to the appropriate injection site at or close to the target EUP;
(v) injecting a photosensitizer drug directly into the target EUP with a drug delivery means of the drug delivery module;
(vi) retracting the flexible drug delivery catheter;
(vii) inserting a flexible light guide of the therapeutic light system through the operative channel of the flexible transducer, pushing towards the target EUP, and positioning the flexible light guide adjacent to the target EUP;
(viii) delivering a therapeutic light dose to said target EUP, thus inducing photodamage and tissue ablation of the feto-placental unit in the target EUP; and
(ix) retracting the endoscopic imaging photodynamic therapy system.
In another preferred embodiment, the invention provides a method for focused tissue ablation of a feto-placental unit in an extrauterine pregnancy (EUP) in a female patient using an endoscopic imaging photodynamic therapy system comprising an endoscopic assembly, a real-time imaging component, a drug delivery module, and a therapeutic light system, said method comprising:
(i) inserting the endoscopic assembly into the vaginal tract of the female patient with EUP;
(ii) inserting a flexible transducer with an operative channel of the real-time imaging component through a service opening of the endoscopic assembly;
(iii) guiding the flexible transducer to the target EUP through the vaginal tract and locating the target EUP with the aid of said real-time imaging component;
(iv) inserting a flexible drug delivery catheter of the drug delivery module and a flexible light guide of the therapeutic light system concomitantly through the operative channel of the flexible transducer, pushing towards the target EUP, and positioning and aligning the flexible drug delivery catheter with a navigator dial or computer-operated means under real-time imaging guidance to the appropriate injection site at or close to the target EUP;
(v) injecting a photosensitizer drug directly at the target EUP with a drug delivery means of the drug delivery module;
(vi) positioning the flexible light guide adjacent to the target EUP;
(vii) delivering a therapeutic light dose to said target EUP, thus inducing photodamage and tissue ablation of the feto-placental unit in the target EUP; and
(viii) retracting the endoscopic imaging photodynamic therapy system.
The Examples hereinbelow were carried out in a rat model of EUP. Since EUP is not a natural or inducible condition in laboratory animals, it was necessary to find a suitable model for this study. The rat model selected in this study for in utero photodynamic feto-placental ablation yielded encouraging results, showing promise for clinical EUP treatment, in spite of the fact that the rat was exposed to far greater risks than foreseen in pregnant women: (i) the rat underwent abdominal surgery with trans-uterine PDT, whereas in pregnant women a minimally invasive trans-vaginal approach is suggested; (ii) a single, selected feto-placental unit (in a litter of 7-12) has been safely ablated without detectable lateral or collateral damage, while the ectopic pregnancy in women will be the sole target, without need to spare any neighboring embryos; (iii) there was no alternative to trans-uterine administration of PDT in the rat while the minimally invasive trans-vaginal approach proposed for EUP-PDT in women will allow direct delivery of the treatment into the placenta (by endoscopic means); and (iv) using the rat uterus as model for the Fallopian tube (that is not homologous), while reasonable, entails higher risks when preservation of functional integrity following PDT is obligatory, especially during muscle stress expected during parturition.
In summary, the intervention in the rat is significantly more severe, morbid and potentially damaging to the uterus than the proposed trans-vaginal approach proposed according to the invention for female patients. It is important to note the normal completion of gestation (evidence for uterine integrity as well as normal smooth muscle strength) with conservation of fertility potential, in all the tested rats (
As for the photodynamic damage inflicted upon feto-placental units, histological analysis of feto-placental units subjected to PDT demonstrated dramatic effects in the severely damaged targeted feto-placental units, while the uterine tissues remained intact (
The size of the rat embryonic sac at the time of the photodynamic intervention (approximately 2 cm in diameter at E14) is similar to the size of human extrauterine pregnancies eligible for conservative treatment (<4 cm in diameter). In contrast to humans where pregnancy termination results in abortion, in rodents mortality of embryos culminates with gradual absorption in utero, permitting their post treatment examination.
As stated above, the only previously reported attempt to address the problem of EUP by means of PDT (Yang et al., 1993, 1994) was in the early 90's employing a very different approach. The photosensitizer 5-ALA, which suffers from both a slow clearance rate as well as inferior photochemical properties, was systemically administered to the pregnant rat on E10 and the entire uterine horn was illuminated up to 30 min later, resulting in massive endometrial ablation and loss of all embryos in the treated uterine horn when examined on E17. Furthermore, one third of the treated animals did not conceive following PDT and the unlikely re-conception in the treated uterine horns was not reported. Pregnancy termination in this case was probably the result of an anti-endometrial effect and not due to direct damage to any single specific embryo. No subsequent follow up of these studies was reported by these or other investigators. Subsequent reports of this group focused on endometrial ablation by 5-ALA-PDT as a potential treatment for endometriosis (Krzemien et al., 2002).
The procedure disclosed in the Examples hereinafter overcame the adverse effects (endometrial damage, infertility, systemic photosensitivity) caused by the above attempts of pregnancy termination by PDT with 5-ALA. The novel photosensitizer used in the examples herein (PMRDA), like other bacteriochlorophyll-derived PDT drugs, has several important advantages over the previously used 5-ALA: (i) spectral absorption in the NIR, allowing deeper tissue penetration of light with larger treatment volume; (ii) PMRDA can be photosensitized immediately upon administration, not requiring prior metabolic conversion into a photosensitive form like 5-ALA, allowing intra-operative application and shortening the procedure; (iii) rapid clearance results in little to no skin phototoxicity (not relevant to this procedure because of local administration of the drug); and (iv) local administration of low doses as performed in this study reduces eventual photodamage to neighboring tissues and organs by restricting damage solely to the photosensitizer-containing tissue and sparing damage from the trans-illuminated uterine wall.
The nearly 80% success rate of pregnancy termination with PDT disclosed in the Examples herein is consistent with the range of success rates obtained with PDT in several tumor models in mice and rats (69-92% tumor free following a single treatment session) using other bacteriochlorophyll derived photosensitizers including WST09 and WST11 (Zilberstein et al., 2001; Koudinova et al., 2003; Preise et al., 2003; Mazor et al., 2004; Plaks et al., 2004; Kelleher et al., 2003; Kelleher et al., 2004).
Potentially, the gynaecological applications of PDT with bacteriochlorophyll derived photosensitizers like PMRDA and others may extend beyond EUP treatment, e.g., pelvic endometriosis, uterine fibroid tumors, ovarian, vulvar, vaginal and cervical lesions, pre-cancerous, and malignant tumors of the reproductive system. As recently reviewed by Allison et al. (2005), the major hurdles in PDT applications in gynecology with 5-ALA, Foscan® or Photofrin® as photosensitizers are insufficient depth of treatment and skin phototoxicity. Applying Pd-bacteriochlorophyll based photosensitizers holds great promise of circumventing these shortcomings due to their superior properties, as demonstrated in cancer therapy (Koudinova et al., 2003; Weersink et al., 2005).
In summary, this study demonstrates for the first time that placental-PDT is an applicable, highly efficient, fertility-preserving intervention, able of selective ablation of a specific rat feto-placental unit, without significant local or systemic adverse effects, and indicates its possible clinical translation for treatment of women suffering from extrauterine pregnancy, offering a highly controlled, local, short and cost effective minimally-invasive modality.
The proposed intervention procedure according to the invention in the rat model of extrauterine pregnancy is local, highly accurate allowing for specific ablation of a selected embryo in the litter, and is short (a few minutes). In addition, the provided method has no deleterious effects on the treated dam and neighboring embryos with complete preservation of fertility.
In one embodiment of the present invention, the photosensitizer drug and the therapeutic light are delivered locally into the feto-placental unit by the endoscopic imaging photodynamic therapy system of the invention, thereby enabling a focused ablation of the abnormal pregnancy, without causing mechanical damage to the Fallopian tube. Thus, the method of the present invention offers higher success rates and maximal fertility preservation. In addition, the separation of fetal from systemic maternal blood systems offers a potential confinement of the PDT agent to the target (placenta), thus preventing maternal exposure and adverse effects.
Any photosensitizer suitable for PDT can be used in the present invention such as the approved photosensitizers Photofrin and 5-aminolevulinic acid (5-ALA), the second generation photosensitizers in the investigational stage and, particularly, the chlorophyll and bacteriochlorophyll derivatives disclosed in the following patents and patent applications of the applicant: EP 0584552, WO 97/19081, WO 00/33833, WO 01/40232, WO 2004/045492 and WO 2005/120573, all incorporated herewith by reference as if fully disclosed herein. The invention will now be illustrated by the following non-limiting examples.
Materials and Methods (i) Animals. Pregnant 10-week old female Wistar rats (litter sizes of 10±2) (Harlan Laboratories, Rehovot, Israel) were delivered to the lab on embryonic day 7-12 (E7-E12) and allowed acclimatization of at least 48 h. All animal protocols were approved by the Weizmann Institutional Animal Care and Use Committee (IACUC).
(ii) Photosensitizer. Palladium 31-oxo-15 -methoxycarbonylmethylrhodobacterio-chlorin-131,173-di(2-N2-dimethylaminoethyl) amide (PMRDA), a water-soluble positively charged Pd-bacteriochlorophyll derivative disclosed in WO 2005/120573, was either synthesized in the inventor's laboratory by known methods or kindly provided by Steba Laboratories Ltd. (Israel), and used as a photosensitizer. The PMRDA was obtained as powder and kept under Argon (Ar) at −20° C. in the dark. Thereafter it was dissolved in methanol (MeOH) and, following spectrophotometric determination of concentration, was divided into aliquots, dried under Ar and kept at −20° C. in the dark until use.
(iii) Light source. A 1W 755 nm laser (CeramOptec, Bonn, Germany) was used. Light was delivered via a diffuser tipped optic fiber (Medlight S.A., Ecublens, Switzerland).
(iv) In vivo PDT protocol. A pregnant rat (E14) was anesthetized by isoflurane inhalation using the IMPAC6 system (VetEquip Inc., Pleasanton, Calif., USA) and placed on its back; the lower abdomen was shaved, washed with 70% ethanol and draped with sterile gauze. A midline incision (approximately 2 cm in length) in the lower abdomen was performed by cutting the skin and abdominal-muscle layers separately. Using round forceps, the uterus was gently drawn out from the abdominal cavity and placed on the gauze. The exposed uterus was continuously irrigated with sterile 0.9% NaCl solution during the procedure (for layout, see
(v) Euthanasia. Animals were sacrificed by CO2 inhalation, in accordance with IACUC guidelines.
(vi) Post PDT fertility assessment. Treated rats were allowed to reach parturition and pup weaning (P21). Fertile males were then introduced into the cages and rats were allowed to mate until pregnancy could be verified by daily vaginal smears and palpation. Pregnancy in both uterine horns was verified by magnetic resonance imaging (MRI) and/or by animal sacrifice and macroscopic examination. To fully prove fertility of rats post PDT, the MRI examined rats were allowed to bear the second litter to parturition and pup-weaning.
(vii) In vivo MRI of pregnant rats. The pregnant female rats (E12-E16) were anesthetized by intra-peritoneal injection of ketamine/diazepam (1:1 v/v). MR images were acquired on a horizontal 4.7 T Bruker-Biospec spectrometer using a volume coil. Gradient echo 3D T2 weighted sequence was acquired with 10 ms repetition time, 3.5 ms echo time, 5° flip angle, 2 scans, 128×128×128 matrix size, 8×4×4 cm3 field of view.
(viii) Histology. Following animal sacrifice, the abdomen was surgically opened, the uterus was tied-off at the cervix, removed and placed in Carnoy's fixative (6:3:1 ethanol, chloroform and acetic acid, by vol.), or Tris-buffered Zn fixative (2.8 mM calcium acetate, 22.8 mM zinc acetate, and 36.7 mM zinc chloride in 0.1M Tris buffer, pH 7.4) for 48-72 h. Fixed tissue samples were placed in 70% ethanol, paraffin embedded and slides were prepared. Slides were stained with hematoxylin and eosin (H&E) Immunohistochemical staining of the specific cell markers was done using the following antibodies: sheep anti-von Willebrand Factor (vWF)] (Serotec, Oxford, UK), mouse anti-pancytokeratin (clone AE1/AE3, Zymed, San-Francisco, USA) and mouse anti-human smooth muscle actin (SMA) (a SMC marker) (clone 1A4, Serotec, Oxford, UK).
(ix) Light microscopy. Microscopic images were taken using a Nikon ECLIPSE E600 microscope equipped with a Nikon DXM1200F digital camera (Nikon Instech Co., Kanagawa, Japan).
(x) Photography. Macroscopic images were taken using a Fujifilm MX-2900 ZOOM digital camera (Fuji Photo Film Co., Tokyo, Japan).
In order to assess the feasibility of employing PDT for the ablation of a single embryo in a litter, a novel procedure of placental-PDT with PMRDA as photosensitizer was developed and tested.
The photodynamic treatment protocol was carried out in the pregnant rat on E14 (see Materials and Methods and layout,
Photodynamic treatment of a single embryo in the pregnant rat with PMRDA resulted in pregnancy termination in 11/14 embryos (78.6%). In control rats (one LC embryo and one DC embryo per litter, one treated embryo per uterine horn), embryo mortality rates were 1/8 (12.5%) for LC and 3/8 (37.5%) for DC. In a total of 22 litters (14 PDT and 8 control rats) the death rate of UN embryos was 13/230 (5.7%) (
These results clearly demonstrate that the developed photodynamic feto-placental ablation procedure can induce loss of the targeted embryo (terminating the pregnancy) without significantly affecting other embryos in the litter. Furthermore, this protocol did not result in noticeable morbidity to the treated pregnant rat and appeared efficient and reproducible, justifying further examination.
The fixed feto-placental units with the surrounding uterine wall were next examined histologically.
In post-PMRDA-PDT placentas severe damage was observed. A fully necrotic embryo was observed, presenting ill-defined structures, in a state of disintegration and necrosis, undergoing absorption (
Importantly, the uterus adjacent to the treated placenta appeared viable (
In conclusion, placental PDT is shown to induce a high rate of severe and significant photodamage in placental and embryonic tissues, which includes various degrees of hemorrhage (vascular damage), inflammation (immune response) and necrosis (cellular damage) of embryo and placental components, while sparing the uterine tissues from discernable damage. The absence of any apparent injury or damage to the uterus lead us to further examine the functional integrity of the reproductive system following PDT.
In order to examine the possible functional effects of PMRDA-PDT on the fertility of treated pregnant rats, two parameters were examined: (i) the ability of treated rats to achieve successful parturition of the remaining pups of the litter (indicative of the functional integrity of the uterine wall) and (ii) the ability of the post-PDT rat to conceive with implantation in the photodynamically treated uterine horn (indicative of uterine patency). To this end, six pregnant rats were treated and allowed to achieve parturition: four received PDT and two the respective control manipulations (one DC and one LC embryo per rat, one treatment per uterine horn). All six rats achieved normal parturition, delivering 6 to 11 pups without post-parturition maternal or pup mortality. The newborn pups were followed till P21 (weaning) and found to develop normally. This result suggested that placental PDT of a selected single feto-placental unit has no adverse effect on the remaining litter and subsequent parturition.
Following pup separation (P21), the resumption of normal estrus cycle in the rats was examined by sequential vaginal smearing. Once estrus cycle commenced, a fertile male was introduced into the cage and rats were allowed to mate, with the aim of examining these post-PDT rats for their ability to conceive and achieve parturition. Results were conclusive, with all six rats pregnant (litter sizes 6-11). Once pregnancy was confirmed, the rats were subjected to MRI examination in order to verify ongoing pregnancy in both treated and untreated uterine horns (5/6 rats were examined by MRI) (
Following verification of the functional integrity of post-PDT rat uteri, histological analysis was conducted in order to identify possible long-term damage resulting from the treatment. For this purpose, uteri in post-PDT and control manipulated rats were examined approximately 10 days after parturition (17-18 days after treatment). The respective uteri were stained by standard H&E (
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| Filing Document | Filing Date | Country | Kind | 371c Date |
|---|---|---|---|---|
| PCT/IL09/00108 | 1/28/2009 | WO | 00 | 10/5/2010 |
| Number | Date | Country | |
|---|---|---|---|
| 61023912 | Jan 2008 | US |
