U.S. patent application number 17/613788 was filed with the patent office on 2022-07-21 for sonosensitization.
The applicant listed for this patent is SONALASENSE,INC.. Invention is credited to Stuart L. MARCUS.
Application Number | 20220226471 17/613788 |
Document ID | / |
Family ID | |
Filed Date | 2022-07-21 |
United States Patent
Application |
20220226471 |
Kind Code |
A1 |
MARCUS; Stuart L. |
July 21, 2022 |
SONOSENSITIZATION
Abstract
An improved method for MRI-guided sonosensitized focused
ultrasound treatment of malignant tissue is disclosed herein.
Inventors: |
MARCUS; Stuart L.;
(Berkeley, CA) |
|
Applicant: |
Name |
City |
State |
Country |
Type |
SONALASENSE,INC. |
Berkeley |
CA |
US |
|
|
Appl. No.: |
17/613788 |
Filed: |
May 28, 2020 |
PCT Filed: |
May 28, 2020 |
PCT NO: |
PCT/US2020/034944 |
371 Date: |
November 23, 2021 |
Related U.S. Patent Documents
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Application
Number |
Filing Date |
Patent Number |
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62853853 |
May 29, 2019 |
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International
Class: |
A61K 41/00 20060101
A61K041/00; A61K 31/197 20060101 A61K031/197; A61M 37/00 20060101
A61M037/00; A61N 7/00 20060101 A61N007/00; A61K 9/00 20060101
A61K009/00; A61P 35/00 20060101 A61P035/00 |
Claims
1. A method for selectively inducing a directly cytotoxic effect
within malignant tissue in a subject, the method comprising: a)
providing an effective amount of 5-aminolevulinic acid, or a
pharmaceutically acceptable salt or ester thereof, to the malignant
tissue; and b) exposing the tissue to ultrasound energy
("sonicating") using a focused ultrasound device, at a frequency of
about 0.1 MHz to about 3 MHz, at an intensity at the ultrasound
beam focus of about 3 W/cm.sup.2 to about 100 W/cm.sup.2.
2. A method for selectively inducing apoptosis within malignant
tissue in a subject, the method comprising: a) providing an
effective amount of 5-aminolevulinic acid, or a pharmaceutically
acceptable salt or ester thereof, to the malignant tissue; and b)
exposing the tissue to ultrasound energy ("sonicating") using a
focused ultrasound device, at a frequency of about 0.1 MHz to about
3 MHz, at an intensity at the ultrasound beam focus of about 3
W/cm.sup.2 to about 100 W/cm.sup.2.
3. The method of claim 1 or 2, wherein the 5-aminolevulinic acid
comprises gamma-irradiated 5-aminolevulinic acid.
4. The method of any one of claims 1 to 3, wherein the malignant
tissue is exposed to ultrasound for a duration of about 1 min to
about 6 hours.
5. The method of any one of claims 1 to 4, wherein the malignant
tissue is exposed to ultrasound for a duration of about 1 min to
about 180 min.
6. The method of any one of claims 1 to 5, wherein the intensity is
from about 5 W/cm.sup.2 to about 80 W/cm.sup.2.
7. The method of any one of claims 1 to 6, wherein the intensity is
from about 5 W/cm.sup.2 to about 60 W/cm.sup.2.
8. The method of any one of claims 1 to 7, wherein the energy
applied at the focus is between 10 J and 2000 J.
9. The method of any one of claims 1 to 8, wherein the energy
applied at the focus is between 10 J and 2000 J.
10. The method of any one of claims 1 to 9, wherein there is an
incubation period between providing 5-aminolevulinic acid and
soniciating the malignant tissue.
11. The method of claim 10, wherein the incubation period is from
about 1 hour to about 72 hours.
12. The method of claim 10 or 11, wherein the incubation period is
about 3 hours.
13. The method of any one of claims 1 to 12, wherein the malignant
tissue comprises tumor tissue.
14. The method of claim 13, wherein the tumor tissue comprises
glioblastoma multiforme, optical pathway glioma, diffuse intrinsic
pontine glioma, astrocytoma, ependymoma, medulloblasoma,
oligodendroglioma, hemangioblastoma, rhabdoid tumor, brain
metastases from another cancer (selected from breast
adenocarcinoma, small cell lung carcinoma, non-small cell lung
carcinoma, squamous cell lung carcinoma, metastatic malignant
melanoma, and prostate carcinoma), meningioma, primary pituitary
gland malignancy, malignant nerve sheath tumor, neurofibroma,
cutaneous T-cell lymphoma (CTCL), noncutaneous peripheral T-cell
lymphoma, lymphomas associated with human T-cell lymphotropic virus
(HTLV), adult T-cell leukemia/lymphoma (ATLL), acute lymphocytic
leukemia, acute nonlymphocytic leukemias, chronic lymphocytic
leukemia, chronic myelogenous leukemia, Hodgkin's Disease,
non-Hodgkin's lymphomas, multiple myeloma, neuroblastoma,
retinoblastoma, Wilms' Tumor, bone tumors, soft-tissue sarcomas,
infiltrating or metastatic squamous cell carcinoma, salivary gland
tumors, nasopharyngeal carcinomas, oral, laryngeal, esophageal
tumors, urethral cancer, ureteral cancer, renal cell cancer,
bladder carcinoma, bladder carcinoma in situ, metastatic carcinoma
of the prostate, bladder, renal, uterine, ovarian, testicular,
cancers, uterine, cervical, and uterine carcinoma, rectal or colon
cancer, lung cancer, mesothelioma, small cell lung carcinoma,
non-small cell lung carcinoma, squamous cell lung carcinoma, breast
cancer, gastric cancer, esophageal cancer, and colon carcinoma,
cholangiocarcinoma, hepatic carcinoma, pancreatic adenocarcinoma,
melanoma, infiltrating basal cell carcinomas, other skin cancers,
liver cancer or thyroid cancer.
15. The method of any one of claims 1 to 14, wherein the tumor
tissue comprises glioblastoma.
16. The method of any one of claims 1 to 15, wherein the malignant
tissue is sonicated at a plurality of individual points.
17. The method of any one of claims 1 to 16, further comprising
locating the malignant tissue by magnetic resonance imaging prior
to sonicating.
18. The method of any one of claims 1 to 17, wherein the tissue
sonicated comprises malignant tissue and non-malignant tissue.
19. The method of any one of claims 1 to 18, wherein the tissue
sonicated comprises malignant tissue and a margin around the
malignant tissue.
20. The method of claim 19, wherein the outer edge of the margin is
0.2 cm to 5 cm from the malignant tissue.
21. The method of claim 19 or 20, wherein the outer edge of the
margin is 1 cm to 3 cm from the malignant tissue.
22. The method of any one of claims 1 to 18, wherein the tissue
sonicated comprises a margin around a resection location after
resection of malignant tissue.
23. The method of claim 22, wherein the outer edge of the margin is
0.2 cm to 5 cm from the malignant tissue resection site.
24. The method of any one of claims 1 to 18, wherein the tissue
sonicated comprises a complete anatomic region of the brain.
25. The method of claim 30, wherein the complete anatomic region of
the brain is a temporal lobe, a parietal lobe, a frontal lobe, an
occipital lobe, the thalamus, the pituitary gland, the pons, the
corpus callosum, the basal ganglia, the brainstem, a hemisphere,
the supratentorial region, or the infratentorial region.
26. The method of claim 30, wherein the complete anatomic region of
the brain is the brain FLAIR region.
27. The method of any one of claims 1 to 26, wherein less than
about 25% of non-malignant tissue in the ultrasound beam focus is
damaged.
28. The method of any one of claims 1 to 27, wherein less than
about 10% of the non-malignant tissue in the ultrasound beam focus
is damaged.
29. The method of any one of claims 1 to 28, wherein less than
about 5% of the non-malignant tissue in the ultrasound beam focus
is damaged.
30. The method of any one of claims 1 to 29, wherein the
temperature of the malignant tissue is raised by sonication no more
than about 10.degree. C.
31. The method of any one of claims 1 to 30, wherein the
temperature of the malignant tissue is raised by sonication no more
than about 5.degree. C.
32. The method of any one of claims 1 to 30, wherein the
temperature of the malignant tissue is raised by sonication no more
than about 2.degree. C.
33. The method of any one of claims 1 to 32, wherein the
5-aminolevulinic acid is provided to the malignant tissue by oral
administration of an oral formulation, or intravenous
administration of an i.v. formulation, to the subject.
34. The method of any one of claims 1 to 33, wherein the
5-aminolevulinic acid is provided by intravenous
administration.
35. The method of any one of claims 1 to 34, wherein the subject is
human.
36. The method of any one of claims 1 to 35, further comprising
providing an effective amount of a 5-ALA potentiating agent to the
malignant tissue.
37. The method of claim 36, wherein the potentiating agent is
selected from the group consisting of doxycycline, methotrexate,
minocycline, and Vitamin D.sub.3 or a derivative thereof.
38. The method of any one of claims 1 to 37, further comprising
providing an effective amount of microbubbles to the malignant
tissue.
39. The method of claim 38, wherein the microbubbles are enhanced
contrast ultrasound microbubbles.
40. The method of claim 38 or 39, wherein the microbubbles comprise
sulfur hexafluoride or a perfluorocarbon.
41. The method of any one of claims 1 to 40, wherein the
5-aminolevulinic acid is provided in a container, the container
further comprising a machine-readable identifier, wherein the
machine-readable identifier identifies the source of the
5-aminolevulinic acid, the amount of 5-aminolevulinic acid, the
subject to which the 5-aminolevulinic acid is to be administered,
the focused ultrasound treatment parameters prescribed for the
subject, an identification code or serial number, or a combination
thereof.
42. The method of claim 41, wherein the focused ultrasound
treatment parameters comprise the ultrasound frequency, power,
energy, duration, or a combination thereof.
43. The method of claim 41 or 42, wherein the focused ultrasound
device comprises a scanning element capable of scanning the
machine-readable identifier, wherein the treatment parameters of
the focused ultrasound device are set in response to the
machine-readable identifier.
44. The method of any one of claims 41 to 43, wherein the focused
ultrasound device is locked in the absence of a machine-readable
identifier.
45. The method of any one of claims 1 to 44, wherein the effective
amount of 5-ALA is between about 1 mg/kg body weight and 1000 mg/kg
body weight.
46. The method of any one of claims 1 to 45, wherein the effective
amount of 5-ALA is between about 10 mg/kg body weight and 750 mg/kg
body weight.
47. The method of any one of claims 1 to 46, wherein the effective
amount of 5-ALA is between about 20 mg/kg body weight and 500 mg/kg
body weight.
48. The method of any one of claims 1 to 47, wherein steps a)
through b) are repeated at a treatment interval of about 1 day to
about 60 days.
49. The method of any one of claims 1 to 48, wherein the ultrasound
exposure duration comprises at least one rest period.
50. The method of any one of claims 1 to 49, wherein the ultrasound
exposure duration comprises rest periods of about 10 seconds to
about 120 seconds, separated by sonication periods of about 10
seconds to about 180 seconds.
51. The method of claim 50, wherein the sonication periods are
about 60 to about 90 seconds, and the rest periods are about 45 to
about 75 seconds.
52. A dosage form for use with a FUS device in the treatment of a
subject in need of treatment, the dosage form comprising: a) a
container, comprising an effective amount of 5-aminolevulinic acid
sufficient to treat the subject; and b) a machine-readable
identifier readable by the FUS device, wherein the machine-readable
identifier identifies the source of the 5-aminolevulinic acid, the
amount of 5-aminolevulinic acid, the subject for which the
5-aminolevulinic acid has been prescribed, the FUS treatment
parameters prescribed for the subject, an identification code or
serial number, or a combination thereof.
53. The dosage form of claim 52, wherein the machine-readable
identifier is encrypted, and comprises information for
automatically programming the FUS.
54. A system for treating malignant tissue in a subject, the system
comprising: a) an effective amount of 5-aminolevulinic acid; and b)
a focused ultrasound (FUS) device.
55. The system of claim 54, further comprising: c) an effective
amount of a potentiating agent and/or an effective amount of
microbubbles.
56. The system of claim 54 or 55, further comprising a container
sufficient to contain the effective amount of 5-aminolevulinic
acid, an effective amount of a potentiating agent, and/or an
effective amount of microbubbles; wherein the container comprises a
machine-readable identifier readable by the FUS device, wherein the
machine-readable identifier identifies the source of the
5-aminolevulinic acid, the amount of 5-aminolevulinic acid, the
subject for which the 5-aminolevulinic acid has been prescribed,
the FUS treatment parameters prescribed for the subject, an
identification code or serial number, or a combination thereof.
57. The system of claim 56, wherein the machine-readable identifier
is encrypted, and comprises information for automatically
programming the FUS device.
58. The system of any one of claims 54 to 57, wherein the FUS
device is locked in the absence of the machine-readable
identifier.
59. The system of any one of claims 54 to 58, wherein the FUS
device is a magnetic resonance-guided FUS device (MRgFUS).
Description
FIELD
[0001] The disclosures provided herein relate generally to medical
treatments. More particularly, the disclosures relate to medical
treatments using ultrasound and an ultrasound sensitizer.
BACKGROUND
[0002] Hematoporphyrins and their derivatives were described as
accumulating preferentially in tumor cells in 1942 (H. Auler et
al., Z. Krebsforsch. (1942) 53:65-68). The fluorescent property of
the compound is employed to mark tumor tissue, as a surgical aid
and as a diagnostic (R. Vansevi te et al., Medicina (2014)
50:137-43; J. Zhang et al., Acta Pharm Sinica B (2018) 8:137-46).
In 1972, it was demonstrated that hematoporphyrins could be used to
selectively sensitize tumor cells to light in the presence of
oxygen (the "photodynamic effect"), resulting in reduction in size
of the tumor, a procedure now known as photodynamic therapy (I.
Diamond et al., Lancet (1972) 2:1175-77). Hematoporphyrins in most
organisms are converted to heme and related molecules. It is
believed that hematoporphyrins accumulate in certain tumor tissues
due to lack of iron, or dysfunction of metabolic enzymes (W. Song
et al., Anticancer Res (2011) 31:39-46; C. J. Gomer et al., Cancer
Res (1979) 39:146-51). This permits the selective destruction of
tumor cells using light, leaving healthy nearby tissue relatively
unaffected. It was also discovered that when one administers
exogenous 5-aminolevulinic acid ("5-ALA"), the first committed
molecule in the heme pathway, the photosensitizing porphyrin
protoporphyrin-IX accumulates and allows tissue photosensitization
within a few hours (C. Perotti et al., Br J Cancer (2004)
90:1660-65). Photodynamic therapy, however, is limited by the
opacity of tissue: effective treatment tumors not accessible from
the body surface or lumen can require surgical access to the tumor
site.
[0003] Sonodynamic therapy ("SDT") is a method for destroying cells
using focused ultrasound (FUS) after sensitization with a
sonosensitizer. The mechanism of action has not been conclusively
determined, but is believed to be due to thermal effects and/or
singlet oxygen produced by cavitation. Ultrasound is capable of
penetrating tissue to a far greater distance than light, making
more of the body accessible to non-invasive treatment.
Surprisingly, it was discovered that protoporphyrin-IX is also an
effective sonosensitizer (N. Yumita et al., Jpn J Cancer Res (1989)
80(3):219-22), enabling the destruction of cells by ultrasound
under conditions that would otherwise be ineffective. Again, the
mechanism of action is unclear, but has been hypothesized to result
from singlet oxygen formation.
[0004] To date, there are a number of reported in vitro and in vivo
experiments, but no clinical trial results (H. Hirschberg et al.,
Ther Deliv (2017) 8:331-42). For example, N. Yumita et al., supra,
investigated the effect of SDT on mouse sarcoma 180 or rat ascites
hepatoma 130 cells in vitro, using hematoporphyrin (10, 25, or 50
.mu.g/mL) and ultrasound (1.92 MHz) at intensities of 1.27, 2.21 or
3.18 W/cm.sup.2, for a duration of 15, 30 or 60 seconds.
Hematoporphyrin was applied to the cells 15, 30, or 60 seconds
before ultrasound application. Yumita reported that 60 seconds of
ultrasound alone damaged a significant number of cells (16% and 17%
for sarcoma 180 and ascites hepatoma, respectively), as determined
by trypan blue dye exclusion. A larger number of cells were damaged
at the higher intensities (2.21 W/cm.sup.2: 71% and 75%; 3.18
W/cm.sup.2: 79% and 86%). When hematoporphyrin was added (50
.mu.g/mL), substantially more sarcoma cells were damaged after
exposure to 1.27 or 3.18 W/cm.sup.2 (67% and 98%), while more AH
cells were damaged at 2.21 and 3.18 W/cm.sup.2 (95% and 96%).
Statistically significant cell damage was also reported using
hematoporphyrin at 25 .mu.g/mL with ultrasound intensity at 3.18
W/cm2 (98% and 96%), equivalent to the cell destruction using 50
.mu.g/mL.
[0005] N. Yumita et al., Cancer Sci (2004) 95:765-69, reported
treating female Sprague-Dawley rats with mammary tumors (induced by
injection of 7,12-dimethylbenz(.alpha.)anthracene) with porfimer
sodium (0, 0.5, 1.0, 2.5, or 5 mg/kg, i.v. 24 hours before
ultrasound) and ultrasound at 1.92 MHz for 15 minutes at
intensities of 1, 2, 3, or 5 W/cm.sup.2. Yumita reported that SDT
treatment with porfimer sodium (2.5 mg/kg or higher) and ultrasound
(3 W/cm.sup.2 or higher) effectively inhibited tumor growth, and
that the higher treatment levels (5 mg/kg at 3 W/cm.sup.2, or 2.5
mg/kg at 5 W/cm.sup.2) were not significantly different from
treatment with 2.5 mg/kg at 3 W/cm.sup.2.
[0006] W. Song et al., supra, investigated the reaction of SAS
cells in vitro, using 5-ALA (1, 10, or 50 .mu.g/mL) applied 4 hours
before ultrasound application, 1.05 MHz with a duty cycle of 60%, a
pulse repetition frequency of 100 Hz, for a 2 min duration,
intensity approximately 2 W/cm.sup.2. Song reported cell viability
of 89%, 88%, 75%, and 62% (for 0, 1, 10, and 50 .mu.g/mL 5-ALA);
the reduction in viability was statistically significant for 10 and
50 .mu.g/mL. Song also reported that treatment with ultrasound
increased SAS cell apoptosis, intracellular reactive oxygen
species, and lipid peroxidation, and that addition of 10 .mu.g/mL
5-ALA significantly increased these effects.
[0007] S. Suehiro et al., J Neurosurg (2018) 129:1416-28, reported
in vitro studies with U87 and U251 glioma cells, and
U251.sup.Oct-3/4 glioma stem-like cells, using 5-ALA (1 mM) and
ultrasound (3 MHz) at 2 W/cm.sup.2, using a 20% duty cycle for 3
minutes. Suehiro reported that ultrasound alone destroyed U87 and
U251.sup.Oct-3/4 to a significant degree, but not U251 cells.
Ultrasound in combination with 5-ALA (1 mM) was substantially
cytotoxic to all tumor cells tested (but not to normal control
cells), and significantly more effective than ultrasound alone in
all three cases. Suehiro also used immunodeficient BALB/c nude mice
injected with human U87 glioma cells or U251.sup.Oct-3/4 glioma
stem-like cells, treated with 5-ALA (100 mg/kg) and ultrasound (2.2
MHz, 0.5 or 2.0 W/cm.sup.2, 20% duty cycle for 3 minutes), repeated
weekly for 3 weeks. Suehiro reported that SDT treatment
significantly improved the survival of treated mice.
[0008] J. Y. Kou et al., Cell Death Dis (2017) 8:e2558 reported in
vitro studies on human THP-1 monocytes (induced to become
macrophages and foam cells), using berberine as sonosensitizer (30
.mu.g/mL), exposed to ultrasound (1.0 MHz) at intensities 0.4
W/cm.sup.2, for durations of 10 minutes (other concentrations,
intensities, and durations were also tried, but not in
combination). Kou reported that treatment induced autophagy in
macrophages, and increased cholesterol efflux.
[0009] M. Nonaka et al., Anticancer Res (2009) 29:943-50, used C6
rat glioma cells injected into Wistar rats, and treated with Rose
Bengal (50 mg/kg, i.v. 10 minutes before treatment) and ultrasound
(1 MHz at 25 W/cm.sup.2, for 5 minutes, with the transducer applied
directly to the brain surface through a 10 mm craniotomy). Control
groups lacking glioma cells were also tested at 0, 10 or 50 mg/kg
Rose Bengal and ultrasound at 25 and 110 W/cm.sup.2. Nonaka
reported that rats with normal brain tissue showed no lesions at 25
W/cm.sup.2, with or without Rose Bengal. Rats with normal brain
tissue treated with ultrasound alone at 110 W/cm.sup.2 for 3
minutes displayed coagulation necrosis in 2 out of 6 rats, and in 5
out of 6 rats treated for 5 minutes at that intensity. Rats treated
with Rose Bengal (10 or 50 mg/kg) and ultrasound at 110 W/cm.sup.2
for 3 minutes all displayed lesions (5/5 for each group). Rats
treated with Rose Bengal (10 or 50 mg/kg) and ultrasound at 110
W/cm.sup.2 for 5 minutes also displayed lesions (6/7 at 10 mg/kg;
6/6 at 50 mg/kg).
[0010] T. Ohmura et al., Anticancer Res (2011) 31:25274-33, used C6
rat glioma cells injected into Wistar rats, and treated with 5-ALA
(100 mg/kg, administered orally 3 hours before ultrasound
treatment) and ultrasound 1.04 MHz at 10 W/cm.sup.2 for 5 minutes,
with the ultrasound transducer applied directly to the brain
surface through a 10 mm craniotomy. Rats with normal brain tissue
were also treated with ultrasound at 1.04 MHz at 10, 15, 20, or 25
W/cm.sup.2 for five minutes. Ohmura reported that rats with normal
brain tissue that received ultrasound at 15, 20, or 25 W/cm.sup.2
exhibited necrosis at the ultrasound focus region. Rats with glioma
cells treated with SDT exhibited significantly smaller tumors than
rats that received 5-ALA or ultrasound alone.
[0011] E-J Jeong et al., Ultrasound Med Biol (2012) 38:2143-50,
used Sprague Dawley rats inoculated with C6 glioma cells, treated
with 5-ALA (60 mg/kg) or Radachlorin (40 mg/kg); and ultrasound at
1.0 MHz, 2.65 W/cm.sup.2 for 20 minutes (16 minutes of ultrasound,
followed by a 3 minute break, followed by an additional 4 minutes
of ultrasound). Jeong reported that rats receiving SDT exhibited
tumors significantly smaller in size than the control groups.
[0012] Y Li et al., PLoS One (2015) 10:e0132074, used rat
osteosarcoma UMR-106 cells in BALB/c nude mice, treated daily with
5-ALA (250 mg/kg i.v., 8 hours before ultrasound) and ultrasound at
1.0 MHz, 2.5 W/cm.sup.2, 10% duty factor, pulse repetition at 100
Hz, for 8 minutes daily for 10 days. Li reported that mice
receiving ultrasound alone exhibited small tumor volumes than
controls or mice receiving only 5-ALA, and that mice receiving SDT
exhibited smaller tumor volumes significantly smaller than all
other groups.
[0013] Further advances in sonodynamic therapy have often focused
on improving the sensitizer, increasing the selectivity for
malignant tissue, the distribution throughout the body, or the
sensitivity to ultrasound. Woodburn et al., US 20010002251,
disclosed the use of texaphyrins as an SDT sensitizer. Sanderson et
al., disclosed the use of tetrasulphamoylphthalo-cyanine and
naphthalocyanine derivatives (GB 2343186), and
tetrasulphamoylphthalocyanine and naphthalocyanines (GB 2343186) as
dyes for indicating diseased tissue and as sensitizers for SDT or
PDT. See also Alfheim et al., U.S. Pat. No. 6,498,945; Lawandy,
U.S. Pat. No. 5,817,048; Iger, WO 1998/052610; Lewis et al., US
20090275548M; and Wang et al., US 201190070296A1. However, to date
no sonodynamic therapy has been approved by regulatory agencies for
use in humans.
BRIEF SUMMARY
[0014] Provided herein is a safe and effective sonodynamic
therapy.
[0015] One aspect is a method for selectively inducing a directly
cytotoxic effect within malignant tissue in a subject, the method
comprising: providing an effective amount of 5-aminolevulinic acid
to the malignant tissue; and exposing the tissue to ultrasound
energy ("sonicating") using a focused ultrasound device, at a
frequency of about 0.1 MHz to about 3 MHz, at an intensity at the
ultrasound beam focus of about 3 W/cm.sup.2 to about 100
W/cm.sup.2.
[0016] Another aspect is a method for selectively inducing
apoptosis within malignant tissue in a subject, the method
comprising: providing an effective amount of 5-aminolevulinic acid
to the malignant tissue; and sonicating the tissue to ultrasound
energy using a focused ultrasound device, at a frequency of about
0.1 MHz to about 3 MHz, at an intensity at the ultrasound beam
focus of about 3 W/cm.sup.2 to about 100 W/cm.sup.2.
[0017] Another aspect is a dosage form for use with a FUS device in
the treatment of a subject in need of treatment, the dosage form
comprising a container, comprising an effective amount of
5-aminolevulinic acid sufficient to treat the subject; and a
machine-readable identifier readable by the FUS device, wherein the
machine-readable identifier identifies the source of the
5-aminolevulinic acid, the amount of 5-aminolevulinic acid, the
subject for which the 5-aminolevulinic acid has been prescribed,
the FUS treatment parameters prescribed for the subject, an
identification code or serial number, or a combination thereof.
[0018] Another aspect is A system for treating malignant tissue in
a subject, the system comprising: an effective amount of
5-aminolevulinic acid; and a focused ultrasound (FUS) device.
BRIEF DESCRIPTION OF THE DRAWINGS
[0019] FIG. 1 shows the inhibition of implanted C6 glioma tumor
growth in mice resulting from: (a) no treatment (solid circles);
(b) treatment only with 5-ALA (squares); (c) treatment only with
focused ultrasound (triangles); (d) treatment with 5-ALA and
focused ultrasound, maximum brain temperature limited to 32.degree.
C. (inverted triangles); (e) treatment with 5-ALA and focused
ultrasound, maximum brain temperature limited to 37.degree. C.
(diamonds); and (f) treatment with 5-ALA and focused ultrasound in
16 cycles (each 85 seconds on, 60 seconds rest), maximum brain
temperature limited to 37.degree. C. (open circles).
[0020] FIG. 2 shows the survival of mice with implanted C6 glioma
tumor cells following: (a) no treatment; (b) treatment only with
5-ALA; (c) treatment only with focused ultrasound; (d) treatment
with 5-ALA and focused ultrasound, maximum brain temperature
limited to 32.degree. C.; (e) treatment with 5-ALA and focused
ultrasound, maximum brain temperature limited to 37.degree. C.; and
(f) treatment with 5-ALA and focused ultrasound at 16 multiple
points, maximum brain temperature limited to 37.degree. C.
DETAILED DESCRIPTION
[0021] One aspect is a method for selectively inducing a directly
cytotoxic effect within malignant tissue in a subject, by providing
an effective amount of 5-aminolevulinic acid to the malignant
tissue; and exposing the tissue to ultrasound energy ("sonicating")
using a focused ultrasound device, at a frequency of about 0.1 MHz
to about 3 MHz, at an intensity at the ultrasound beam focus of
about 3 W/cm.sup.2 to about 100 W/cm.sup.2. Directly cytotoxic
effects include induction of apoptosis, necrosis, and/or physical
destruction of cells. The effective amount of 5-ALA can be
determined by standard methods. In general, the effective amount
will be an amount sufficient to substantially stain the malignant
tissue to be treated, without substantially staining normal tissue,
or inducing an unacceptable level of toxicity. Without being bound
by any particular theory, it is believed that sonicating tissue
causes cavitation and microbubble generation, the collapse of which
generate photons having wavelengths between about 300 nm and 700 nm
within the tissue, and that these photons activate
protoporphyrin-IX, leading to tissue destruction.
[0022] Where a range of values is provided herein, it is understood
that each intervening value, to the tenth of the unit of the lower
limit unless the context clearly dictates otherwise, between the
upper and lower limit of that range and any other stated or
intervening value in that stated range, is encompassed within the
disclosure. The upper and lower limits of these smaller ranges may
independently be included in the smaller ranges, and are also
encompassed within the disclosure, subject to any specifically
excluded limit in the stated range. Where the stated range includes
one or both of the limits, ranges excluding either or both of those
included limits are also included in the disclosure.
[0023] All ranges disclosed herein also encompass any and all
possible sub-ranges and combinations of sub-ranges thereof. Any
listed range can be recognized as sufficiently describing and
enabling the same range being broken down into at least equal
halves, thirds, quarters, fifths, tenths, etc. As a non-limiting
example, each range discussed herein can be readily broken down
into a lower third, middle third and upper third, and so forth. As
will also be understood by one skilled in the art all language such
as "up to", "at least", "greater than", "less than", and the like
include the number recited and refer to ranges which can be
subsequently broken down into sub-ranges as discussed above.
Finally, as will be understood by one skilled in the art, a range
includes each individual member. Thus, for example, a group having
1-3 articles refers to groups having 1, 2, or 3 articles.
Similarly, a group having 1-5 articles refers to groups having 1,
2, 3, 4, or 5 articles, and so forth.
[0024] It is appreciated that certain features of the disclosure,
which are, for clarity, described in the context of separate
embodiments, may also be provided in combination in a single
embodiment. Conversely, various features of the disclosure, which
are, for brevity, described in the context of a single embodiment,
may also be provided separately or in any suitable sub-combination.
All combinations of the embodiments pertaining to the disclosure
are specifically embraced by the present disclosure and are
disclosed herein just as if each and every combination was
individually and explicitly disclosed. In addition, all
sub-combinations of the various embodiments and elements thereof
are also specifically embraced by the present disclosure and are
disclosed herein just as if each and every such sub-combination was
individually and explicitly disclosed herein.
[0025] Malignant Tissue
[0026] Malignant tissue is typically tumorous or cancerous, but in
general may be any type of tissue that is capable of taking up
5-ALA and accumulating protoporphyrin-IX, for example a benign
tumor or other unwanted growth. Focused ultrasound is capable of
passing through intervening tissue, which enables treatment of
malignant tissue situated at otherwise inaccessible positions. For
this reason, the methods of the disclosure are particularly useful
for treating types of intracranial tumors, such as glioblastoma
multiforme (including low grade and high grade glioblastomas),
optical pathway gliomas, diffuse intrinsic pontine gliomas,
astrocytoma, ependymoma, medulloblasoma, oligodendroglioma,
hemangioblastoma, rhabdoid tumors, brain metastases from other
cancers (including, for example without limitation, breast
adenocarcinoma, small cell lung carcinoma, non-small cell lung
carcinoma, squamous cell lung carcinoma, metastatic malignant
melanoma, and prostate carcinoma), meningioma, primary pituitary
gland malignancies, malignant nerve sheath tumors, and
neurofibromas. Other malignant tissues include, without limitation,
neoplasms, carcinomas, sarcomas, leukemias, lymphomas, and the
like. Leukemias and lymphomas include, for example, cutaneous
T-cell lymphoma (CTCL), noncutaneous peripheral T-cell lymphoma,
lymphomas associated with human T-cell lymphotropic virus (HTLV),
for example, adult T-cell leukemia/lymphoma (ATLL), acute
lymphocytic leukemia, acute nonlymphocytic leukemias, chronic
lymphocytic leukemia, chronic myelogenous leukemia, Hodgkin's
Disease, non-Hodgkin's lymphomas, and multiple myeloma. Other
tumors include, without limitation, childhood solid tumors such as
brain tumors, neuroblastoma, retinoblastoma, Wilms' Tumor, bone
tumors, and soft-tissue sarcomas; common solid tumors of adults
such as head and neck cancers (e.g., infiltrating or metastatic
squamous cell carcinoma, salivary gland tumors, nasopharyngeal
carcinomas, oral, laryngeal, and esophageal tumors); genitourinary
cancers (e.g., urethral, ureteral, renal cell, bladder carcinoma
and bladder carcinoma in situ, locally advanced or metastatic
carcinoma of the prostate, bladder, renal, uterine, ovarian,
testicular, cancers, uterine, cervical, and uterine carcinoma),
rectal, and colon cancer; lung cancer (including mesothelioma,
small cell lung carcinoma, non-small cell lung carcinoma, squamous
cell lung carcinoma); breast cancer; gastric, esophageal, and colon
carcinoma, cholangiocarcinoma, hepatic carcinoma, and pancreatic
adenocarcinoma; melanoma, infiltrating basal cell carcinomas, and
other skin cancers; stomach cancer, brain cancer, liver cancer and
thyroid cancer.
[0027] In some embodiments, the malignant tissue is glioblastoma
multiforme, optical pathway glioma, diffuse intrinsic pontine
glioma, astrocytoma, ependymoma, medulloblasoma, oligodendroglioma,
hemangioblastoma, rhabdoid tumor, brain metastases from another
cancers (such as breast adenocarcinoma, small cell lung carcinoma,
non-small cell lung carcinoma, squamous cell lung carcinoma,
metastatic malignant melanoma, or prostate carcinoma), meningioma,
primary pituitary gland malignancy, malignant nerve sheath tumor,
neurofibroma, cutaneous T-cell lymphoma (CTCL), noncutaneous
peripheral T-cell lymphoma, lymphomas associated with human T-cell
lymphotropic virus (HTLV), adult T-cell leukemia/lymphoma (ATLL),
acute lymphocytic leukemia, acute nonlymphocytic leukemias, chronic
lymphocytic leukemia, chronic myelogenous leukemia, Hodgkin's
Disease, non-Hodgkin's lymphomas, multiple myeloma, neuroblastoma,
retinoblastoma, Wilms' Tumor, bone tumors, soft-tissue sarcomas,
infiltrating or metastatic squamous cell carcinoma, salivary gland
tumors, nasopharyngeal carcinomas, oral, laryngeal, esophageal
tumors, urethral cancer, ureteral cancer, renal cell cancer,
bladder carcinoma, bladder carcinoma in situ, metastatic carcinoma
of the prostate, bladder, renal, uterine, ovarian, testicular,
cancers, uterine, cervical, and uterine carcinoma, rectal or colon
cancer, lung cancer, mesothelioma, small cell lung carcinoma,
non-small cell lung carcinoma, squamous cell lung carcinoma, breast
cancer; gastric cancer, esophageal cancer, and colon carcinoma,
cholangiocarcinoma, hepatic carcinoma, pancreatic adenocarcinoma,
melanoma, infiltrating basal cell carcinomas, other skin cancers,
liver cancer or thyroid cancer. In some embodiments, the malignant
tissue is a glioblastoma multiforme, astrocytoma, ependymoma,
medulloblasoma, oligodendroglioma, hemangioblastoma, or a rhabdoid
tumor. In some embodiments, the malignant tissue is glioblastoma
multiforme.
[0028] 5-Aminolevulinic Acid
[0029] 5-ALA can be provided in any pharmaceutically acceptable
formulation, and may be provided as the free acid, a
pharmaceutically acceptable salt, or a pharmaceutically acceptable
ester. A formulation, Gliolan.RTM., is commercially available.
[0030] Salts, esters, amides, prodrugs and other derivatives of the
active agents can be prepared using standard procedures known to
those skilled in the art of synthetic organic chemistry and
described, for example, by March (1992) Advanced Organic Chemistry;
Reactions, Mechanisms and Structure, 4th Ed. N.Y.
Wiley-Interscience. Pharmaceutically acceptable salts are salts
that retain the biological effectiveness and properties of the
parent compound and which are not biologically or otherwise
undesirable. 5-ALA is capable of forming acid and/or base salts by
virtue of the presence of amino and/or carboxyl groups. Many such
salts are known in the art, for example, as described in WO
87/05297. Pharmaceutically acceptable acid addition salts can be
formed with inorganic acids and organic acids. Inorganic acids from
which salts can be derived include, for example, hydrochloric acid,
hydrobromic acid, sulfuric acid, nitric acid, phosphoric acid, and
the like. Organic acids from which salts can be derived include,
for example, acetic acid, propionic acid, glycolic acid, pyruvic
acid, oxalic acid, maleic acid, malonic acid, succinic acid,
fumaric acid, tartaric acid, citric acid, benzoic acid, cinnamic
acid, mandelic acid, methanesulfonic acid, ethanesulfonic acid,
p-toluenesulfonic acid, salicylic acid, and the like.
Pharmaceutically acceptable base addition salts can be formed with
inorganic and organic bases. Inorganic bases from which salts can
be derived include, for example, sodium, potassium, lithium,
ammonium, calcium, magnesium, iron, zinc, copper, manganese,
aluminum, and the like. Organic bases from which salts can be
derived include, for example, primary, secondary, and tertiary
amines, substituted amines including naturally occurring
substituted amines, cyclic amines, basic ion exchange resins, and
the like, such as isopropylamine, trimethylamine, diethylamine,
triethylamine, tripropylamine, and ethanolamine. Pharmaceutically
acceptable esters include those obtained by replacing a hydrogen on
an acidic group with an alkyl group, for example by reacting the
acid group with an alcohol or a haloalkyl group. Examples of esters
include, without limitation, those in which the hydrogen on an
--C(O)OH group is replaced with an alkyl to form an
--C(O)O-alkyl.
[0031] In some embodiments, the 5-ALA is sterilized by gamma
irradiation (see U.S. Pat. No. 6,335,465, incorporated herein by
reference in full). The 5-ALA formulation can be administered
orally, intravenously, intrathecally, or intratumorally. In some
embodiments, the 5-ALA is administered by intravenous
administration. In some embodiments, gamma-irradiated 5-ALA is
administered by intravenous administration. In some embodiments,
the 5-ALA is administered at a dosage of at least about 1, 2, 3, 4,
5, 6, 7, 8, 9, 10, 12, 15, 20, 25, 30, 35, 40, 45, 50, 55, 60, 65,
70, 75, 80, 85, 90, 95, 96, 97, 98, 99, 100, 120, 125, 150, 175,
200, 300, 400, 500, 600, 750, or at least about 1000 mg/kg. In some
embodiments, the 5-ALA is administered at a dosage of no more than
about 1000, 900, 800, 700, 600, 500, 400, 300, 250, 200, 180, 175,
160, 150, 140, 130, 120, 110, 100, 90, 80, 70, 60, 50, 45, 40, 35,
30, 25, or 20 mg/kg. In some embodiments, 5-ALA is administered at
a dosage of about 0.5 to about 250 mg/kg. In some embodiments,
5-ALA is administered at a dosage of 1 to 150 mg/kg. In some
embodiments, 5-ALA is administered at a dosage of 5 to 90 mg/kg. In
some embodiments, 5-ALA is administered at a dosage of 10 to 40
mg/kg.
[0032] The effective amount of 5-ALA required can be determined by
standard methods known to those of skill in the art. For example,
as described in Example 1 herein, one can implant tumor tissue into
a mouse or other laboratory model subject, and treat the subject
with different amounts of 5-ALA and FUS. As shown in FIG. 1, rats
can be treated with 20 mg/kg of 5-ALA, then sonicated with 6.9
W/cm.sup.2, 13.8 W/cm.sup.2, 27.6 W/cm.sup.2, or 55.2 W/cm.sup.2
for 20 minutes. The results show that sonication at 13.8 W/cm.sup.2
raised tumor temperature by about 2.degree. C., to 32.degree. C.
Sonication at 27.6 W/cm.sup.2 raised tumor temperature to about
37.degree. C. Rats sonicated at 55.2 W/cm.sup.2 suffered tissue
damage. Untreated controls exhibited a normalized tumor volume of
32.+-.10 mm.sup.3, while 5-ALA only and FUS only groups exhibited a
normalized tumor volume of 24.+-.6 mm.sup.3. All experimental
groups exhibited inhibited tumor growth compared to control animals
(see FIG. 1), and improved survival (see FIG. 2). The group that
was sonicated at multiple points within the tumor (MP group)
exhibited the greatest increase in survival, with 50% of the
subjects surviving past 60 days. In some embodiments, the effective
amount of 5-ALA is between 1 mg/kg and 1,000 mg/kg. In some
embodiments, the effective amount of 5-ALA is between 5 mg/kg and
750 mg/kg. In some embodiments, the effective amount of 5-ALA is
between 10 mg/kg and 750 mg/kg. In some embodiments, the effective
amount of 5-ALA is between 20 mg/kg and 500 mg/kg. In some
embodiments, the effective amount of 5-ALA is between 40 mg/kg and
500 mg/kg. In some embodiments, the effective amount of 5-ALA is
between 10 mg/kg and 40 mg/kg. In some embodiments, the effective
amount of 5-ALA is between 10 mg/kg and 20 mg/kg.
[0033] In some embodiments, an incubation period is included
between administering 5-ALA and sonicating the malignant tissue, in
order to allow sufficient time for 5-ALA to be taken up by the
malignant tissue and converted to protoporphyrin-IX. In some
embodiments, the incubation period is at least about 30 minutes, at
least about one hour, at least about 2 hours, at least about 3
hours, at least about 4 hours, at least about 5 hours, at least
about 6 hours, at least about 7 hours, at least about 8 hours, at
least about 9 hours, at least about 10 hours, at least about 11
hours, at least about 12 hours, at least about 13 hours, at least
about 14 hours, at least about 15 hours, at least about 16 hours,
at least about 18 hours, at least about 20 hours, or at least about
24 hours. In some embodiments, the incubation period is 72 hours,
less than about 72 hours, less than about 60 hours, less than about
48 hours, less than about 36 hours, less than about 24 hours, less
than about 22 hours, less than about 20 hours, less than about 18
hours, less than about 16 hours, less than about 15 hours, less
than about 14 hours, less than about 13 hours, less than about 12
hours, less than about 11 hours, less than about 10 hours, less
than about 9 hours, less than about 8 hours, less than about 7
hours, less than about 6 hours, less than about 5 hours, less than
about 4 hours, or less than about 3 hours. In some embodiments, the
incubation period is between 1 and 72 hours. In some embodiments,
the incubation period is between 2 and 48 hours. In some
embodiments, the incubation period is between 3 and 36 hours. In
some embodiments, the incubation period is between 4 and 24 hours.
In some embodiments, the incubation period is between 4 and 18
hours. In some embodiments, the incubation period is between 4 and
24 hours. In some embodiments, the incubation period is between 4
and 18 hours. In some embodiments, the incubation period is about 6
hours.
[0034] Potentiating Agents
[0035] In some embodiments, the method further comprises
administering a potentiating agent that enhances the therapeutic
effect of 5-ALA, for example by promoting or increasing the uptake
or accumulation of protoporphyrin-IX and/or 5-ALA, decreasing the
rate at which protoporphyrin-IX and/or 5-ALA is metabolized, and
the like. The potentiating agent can thus reduce the amount of
5-ALA required in order to obtain a given effect, or can increase
the effect obtained from a given amount of 5-ALA, or any
combination of desired effect and amount in between. Suitable
potentiating agents include, for example without limitation,
methotrexate, doxycycline, minocycline, Vitamin D.sub.3 and
derivatives thereof. See, e.g., D.-F. Yang et al., J Formos Med
Assoc (2014) 113(2):88-93; M.-J. Lee et al., PLoS ONE (2017)
12(5):e0178493; and E. V. Maytin et al., Isr J Chem (2012)
52(8-9):767-75. In some embodiments, the potentiating agent is
selected from the group consisting of methotrexate, doxycycline,
minocycline, Vitamin D.sub.3 and derivatives thereof. In some
embodiments, the potentiating agent is methotrexate. In some
embodiments, the potentiating agent is doxycycline. In some
embodiments, the potentiating agent is minocycline. In some
embodiments, the potentiating agent is Vitamin D.sub.3. In some
embodiments, a combination of two or more potentiating agents is
used. In some embodiments, a combination of two or more of
methotrexate, doxycycline, minocycline, and Vitamin D.sub.3 is
used.
[0036] The potentiating agent can be administered at the same time
as 5-ALA, or at any other time prior to sonication. The optimal
time for administering a potentiating agent can vary with the
selection of potentiating agent or combination of agents. In some
embodiments, the potentiating agent is administered at the same
time as the 5-ALA. In some embodiments, the potentiating agent is
administered in the same formulation as the 5-ALA. In some
embodiments, the potentiating agent is administered at a different
time. In some embodiments, the potentiating agent is administered
prior to 5-ALA administration. In some embodiments, the
potentiating agent is administered at least about 30 minutes, at
least about one hour, at least about 2 hours, at least about 3
hours, at least about 4 hours, at least about 5 hours, at least
about 6 hours, at least about 7 hours, at least about 8 hours, at
least about 9 hours, at least about 10 hours, at least about 11
hours, at least about 12 hours, at least about 13 hours, at least
about 14 hours, at least about 15 hours, at least about 16 hours,
at least about 18 hours, at least about 20 hours, at least about 24
hours, at least about 36 hours, at least about 48 hours, at least
about 3 days, at least about 4 days, at least about 5 days, or at
least about 6 days prior to the first sonication. In some
embodiments, the potentiating agent is administered at 8 days, 7
days, 6 days, 5 days, 4 days, 84 hours, 72 hours, less than about
72 hours, less than about 60 hours, less than about 48 hours, less
than about 36 hours, less than about 24 hours, less than about 22
hours, less than about 20 hours, less than about 18 hours, less
than about 16 hours, less than about 15 hours, less than about 14
hours, less than about 13 hours, less than about 12 hours, less
than about 11 hours, less than about 10 hours, less than about 9
hours, less than about 8 hours, less than about 7 hours, less than
about 6 hours, less than about 5 hours, less than about 4 hours, or
less than about 3 hours prior to the first sonication. In some
embodiments, the potentiating agent administration period is
between 1 and 72 hours prior to sonication. In some embodiments,
the potentiating agent administration period is between 2 hours and
5 days prior to sonication. In some embodiments, the potentiating
agent administration period is between 18 hours and 4 days prior to
sonication. In some embodiments, the potentiating agent
administration period is between 24 hours and 4 days prior to
sonication. In some embodiments, the potentiating agent
administration period is between 24 and 48 hours prior to
sonication. In some embodiments, the potentiating agent
administration period is between 48 and 96 hours prior to
sonication. In some embodiments, the potentiating agent
administration period is between 4 and 18 hours prior to
sonication.
[0037] The amount of potentiating agent administered can be
determined by those of skill in the art, and will in general depend
on the potentiating agent or agents selected and the degree of
potentiating effect to be obtained. Suitable methods include, for
example without limitation, cell culture assays and/or in vivo
experiments with model animals or explanted tissues to determine
the degree of cell killing using varying amounts of 5-ALA and/or
potentiating agents, with either sonication or photodynamic
treatment. See, e.g., D.-F. Yang et al., J Formos Med Assoc (2014)
113(2):88-93; M.-J. Lee et al., PLoS ONE (2017) 12(5):e0178493; and
E. V. Maytin et al., Isr J Chem (2012) 52(8-9):767-75.
[0038] The amount of potentiating agent used will be less than the
amount at which unacceptable toxicity is experienced, and will be
large enough to decrease the amount of 5-ALA required to obtain a
potentiated effect. For example, one can determine the amount or
number of malignant tissue or cells killed using a set amount of
5-ALA as a baseline for comparison, and then determine the amount
or number of malignant tissue or cells killed using the same amount
of 5-ALA in combination with different concentrations or amounts of
the potentiating agent. Alternatively, one can determine the amount
of 5-ALA needed to produce the same level of killing in the
presence of different concentrations or amounts of the potentiating
agent. The amount or number of malignant tissue or cells killed can
be determined by cell counting, measurement of tumor volume, vital
dye exclusion, and other techniques commonly used in medical
research. The effect obtained with the potentiating agent will be
an increase in effect or a decrease in 5-ALA dose of at least 1, 2,
3, 4, 5, 6, 7, 8, 9, 10, 15, 20, 25, 30, 35, 40, 45, 50, 55, 60,
65, 70, 75, 80, 85, 90, 95, 96, 97, 98, or 99% from the baseline
measure. In some embodiments, the effect obtained with the
potentiating agent is an increase in effect of at least 1, 2, 3, 4,
5, 6, 7, 8, 9, 10, 15, 20, 25, 30, 35, 40, 45, 50, 55, 60, 65, 70,
75, 80, 85, 90, 95, 96, 97, 98, 99, 100, 120, 125, 150, 175, 200,
300, 400, or 500% from the baseline measure of degree of killing.
In some embodiments, the effect obtained with the potentiating
agent is a decrease in the amount of 5-ALA required to obtain the
baseline killing rate of at least 1, 2, 3, 4, 5, 6, 7, 8, 9, 10,
15, 20, 25, 30, 35, 40, 45, 50, 55, 60, 65, 70, 75, 80, 85, 90, 95,
96, 97, 98, or 99%.
[0039] The amount of potentiating agent can be greater, equal, or
less than the amount that is normally or typically prescribed for
use of the potentiating agent alone. The upper limit is that amount
at which unacceptable toxicity is experienced, either alone or in
combination with 5-ALA. The lower limit is the amount needed to
obtain a measurable potentiation effect, and can be 1, 2, 3, 4, 5,
6, 7, 8, 9, 10, 15, 20, 25, 30, 35, 40, 45, 50, 55, 60, 65, 70, 75,
80, 85, 90, 95, 96, 97, 98, 99, 100, 120, 125, 150, 175, or 200% of
the typical dose. For example without limitation, methotrexate can
be administered as a single oral dose of about 7.5 mg to 10 mg
between 24 hours and 72 hours prior to sonication; doxycycline can
be administered BID at a dose of 100 mg, beginning with a 200 mg
initial loading dose, starting two to four days prior to
sonication; minocycline can be administered BID at a dose of 50 to
100 mg, starting two to four days prior to sonication; and Vitamin
D.sub.3 can be administered as cholecalciferol at a dose of 10,000
to 100,000 IU/day for two to four days prior to sonication.
[0040] Microbubbles
[0041] Microbubbles (also known as microspheres) are gas-filled
spheres having a diameter on the order of about 1 to 5 .mu.m. They
are sometimes used as contrast agents in medical sonography, as
their echogenic properties help distinguish liquid-filled vessels
from surrounding tissues. See, e.g., P. A. Dijkmans et al., Eur J
Cardiology (2004) 5:245-56. The gas is often air, nitrogen, sulfur
hexafluoride, or a perfluorocarbon such as, for example,
octafluoropropane. The shell of the microbubble is often albumin,
galactose, lipid, or a polymer. In an ultrasound acoustic field,
microbubbles undergo linear oscillation at low power, and
non-linear oscillation at higher power, leading to rupture at high
power. The frequencies at which microbubbles resonate are
determined primarily by the choice of gas in the core, and the
mechanical properties of the shell. Mixtures of two or more
different types of microbubbles can be used. In the practice of
methods of the disclosure, microbubbles can be used to cause
cavitation (and thus target cell death) at lower acoustic power
than would otherwise obtain. In some embodiments, an effective
amount of microbubbles is provided to the malignant tissue.
[0042] An effective amount of microbubbles is a quantity sufficient
to increase the direct cytotoxic effect of 5-ALA and FUS on
malignant tissue by at least 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 15, 20,
25, 30, 35, 40, 45, 50, 55, 60, 65, 70, 75, 80, 85, 90, 95, 96, 97,
98, 99, 100, 120, 125, 150, 175, 200, 300, 400, or 500% from the
baseline measure of degree of killing. Alternatively, the effective
amount of microbubbles can be expressed as the quantity sufficient
to decrease the 5-ALA dose and/or FUS dose by at least 1, 2, 3, 4,
5, 6, 7, 8, 9, 10, 15, 20, 25, 30, 35, 40, 45, 50, 55, 60, 65, 70,
75, 80, 85, 90, 95, 96, 97, 98, or 99% from the baseline
measure.
[0043] Microbubbles can be prepared by methods known in the art, or
can be obtained from commercial sources. Suitable microbubbles
include, without limitation, enhanced contrast ultrasound
microbubbles such as Definity.RTM. perflutren lipid microbubbles
(Lantheus Medical Imaging, N. Billerica, Mass.), Levovist.RTM.
lipid/galactose microspheres (Schering), Optison.RTM. microbubbles
(GE Healthcare), and Lumason.RTM. microbubbles (Bracco Imaging
(Monroe Township, N.J.). In some embodiments, the microbubbles are
enhanced contrast ultrasound microbubbles. In some embodiments, the
microbubbles comprise sulfur hexafluoride or a perfluorocarbon. In
some embodiments, the perfluorocarbon is octafluoropropane or
perfluorohexane. In some embodiments, the microbubbles comprise air
or nitrogen. In some embodiments, the microbubble shell comprises
albumin. In some embodiments, the microbubbles are Definity.RTM.
perflutren lipid microbubbles, Levovist.RTM. lipid/galactose
microspheres, Optison.RTM. microbubbles, or Lumason.RTM.
microbubbles.
[0044] Microbubbles can be administered together with 5-ALA and/or
a potentiating agent, depending on the half-life of the
microbubbles in the subject's system. In general, many microbubble
agents have a very short half-life in human circulation, and
accordingly are typically administered shortly before sonication.
The quantity administered and the mode of administration is similar
to the quantity and mode used by those of skill in the art when
administering microbubbles for purposes of contrast-enhanced
ultrasound sonography. The quantity administered will be at least
5, 10, 15, 20, 25, 30, 35, 40, 45, 50, 55, 60, 65, 70, 75, 80, 85,
90, 95, 100, 105, 110, 120, 140, 150, 160, 180, 200, 250, 300, 350,
or 400% of the quantity used or recommended for use as a
contrast-enhanced ultrasound sonography agent. The quantity
administered will be no more than 500, 450, 400, 350, 300, 250,
200, 150, 100, 90, 80, 75, 70, 60, 50, 45, 40, 35, 30, 25, or 20%
of the quantity used or recommended for use as a contrast-enhanced
ultrasound sonography agent.
[0045] Focused Ultrasound
[0046] The malignant tissue is exposed to focused ultrasound energy
("sonicated") using a focused ultrasound (FUS) device. Suitable
devices include the Exablate.RTM. Model 4000 Type-2 system
(Insightec, Dallas, Tex.), and the like. The Type-2 has a dedicated
1000-element transducer which can operate in a sonication mode
(i.e., a focused ultrasound pressure wave delivery mode) that uses
low duration duty cycles to generate "burst sonication" at low
power. This burst sonication mode enables the device to induce
stable cavitation when used in conjunction with microbubbles at
much lower energy levels than ultrasound-induced cavitation. The
oscillation of the microbubbles induces a well targeted, temporary
and reversible, but stable blood brain barrier disruption. The
hallmark feature of the Exablate.RTM. device is its ability to
monitor acoustic feedback in real-time to ensure a safe and
effective BBB disruption. The Exablate.RTM. device is a magnetic
resonance-guided focused ultrasound (MRgFUS) device, hence, it
utilizes real time MR imaging to assess and monitor the safety of
the procedure.
[0047] The ultrasound frequency is at least about 0.1 MHz, at least
about 0.2 MHz, at least about 0.25 MHz, at least about 0.3 MHz, at
least about 0.4 MHz, at least about 0.45 MHz, at least about 0.5
MHz, at least about 0.55 MHz, at least about 0.6 MHz, at least
about 0.65 MHz, at least about 0.7 MHz, at least about 0.75 MHz, at
least about 0.8 MHz, at least about 0.85 MHz, at least about 0.9
MHz, at least about 0.95 MHz, at least about 1 MHz, at least about
1.1 MHz, at least about 1.5 MHz, at least about 2.0 MHz, at least
about 2.1 MHz, at least about 2.2 MHz, at least about 2.3 MHz, at
least about 2.4 MHz, at least about 2.5 MHz, at least about 2.75
MHz, at least about 3.0 MHz, at least about 3.5 MHz, at least about
4.0 MHz, at least about 4.5 MHz, at least about 5.0 MHz, at least
about 6.0 MHz, at least about 7.0 MHz, at least about 8.0 MHz, at
least about 9.0 MHz, or at least about 10.0 MHz. The ultrasound
frequency is no more than about 20 MHz, no more than about 15 MHz,
no more than about 10 MHz, no more than about 9.0 MHz, no more than
about 8.0 MHz, no more than about 7.0 MHz, no more than about 6.0
MHz, no more than about 5.0 MHz, no more than about 4.0 MHz, no
more than about 3.0 MHz, no more than about 2.8 MHz, no more than
about 2.6 MHz, no more than about 2.5 MHz, no more than about 2.4
MHz, no more than about 2.3 MHz, no more than about 2.2 MHz, no
more than about 2.1 MHz, or no more than about 2.0 MHz.
[0048] The focused ultrasound intensity, at the ultrasound beam
focus, is at least about 1 W/cm.sup.2, at least about 1.5
W/cm.sup.2, at least about 2.0 W/cm.sup.2, at least about 2.5
W/cm.sup.2, at least about 3.0 W/cm.sup.2, at least about 3.5
W/cm.sup.2, at least about 4.0 W/cm.sup.2, at least about 4.5
W/cm.sup.2, at least about 5.0 W/cm.sup.2, at least about 6.0
W/cm.sup.2, at least about 7.0 W/cm.sup.2, at least about 8.0
W/cm.sup.2, at least about 9.0 W/cm.sup.2, at least about 10.0
W/cm.sup.2, at least about 15 W/cm.sup.2, at least about 20
W/cm.sup.2, at least about 25 W/cm.sup.2, at least about 30
W/cm.sup.2, at least about 35 W/cm.sup.2, at least about 40
W/cm.sup.2, at least about 45 W/cm.sup.2, at least about 50
W/cm.sup.2, at least about 60 W/cm.sup.2, at least about 70
W/cm.sup.2, at least about 75 W/cm.sup.2, at least about 80
W/cm.sup.2, at least about 90 W/cm.sup.2, at least about 100
W/cm.sup.2, at least about 120 W/cm.sup.2, at least about 125
W/cm.sup.2, at least about 130 W/cm.sup.2, at least about 140
W/cm.sup.2, at least about 145 W/cm.sup.2, at least about 150
W/cm.sup.2, or at least about 200 W/cm.sup.2. The focused
ultrasound intensity, at the ultrasound beam focus, is less than
about 200 W/cm.sup.2, less than about 150 W/cm.sup.2, less than
about 125 W/cm.sup.2, less than about 100 W/cm.sup.2, less than
about 98 W/cm.sup.2, less than about 95 W/cm.sup.2, less than about
92 W/cm.sup.2, less than about 90 W/cm.sup.2, less than about 89
W/cm.sup.2, less than about 88 W/cm.sup.2, less than about 87
W/cm.sup.2, less than about 86 W/cm.sup.2, less than about 85
W/cm.sup.2, less than about 84 W/cm.sup.2, less than about 83
W/cm.sup.2, less than about 82 W/cm.sup.2, less than about 81
W/cm.sup.2, less than about 80 W/cm.sup.2, less than about 75
W/cm.sup.2, less than about 70 W/cm.sup.2, less than about 68
W/cm.sup.2, less than about 67 W/cm.sup.2, less than about 65
W/cm.sup.2, less than about 66 W/cm.sup.2, less than about 64
W/cm.sup.2, less than about 63 W/cm.sup.2, less than about 62
W/cm.sup.2, less than about 61 W/cm.sup.2, less than about 60
W/cm.sup.2, less than about 58 W/cm.sup.2, less than about 55
W/cm.sup.2, less than about 54 W/cm.sup.2, less than about 53
W/cm.sup.2, less than about 52 W/cm.sup.2, less than about 51
W/cm.sup.2, less than about 50 W/cm.sup.2, less than about 45
W/cm.sup.2, less than about 40 W/cm.sup.2, less than about 35
W/cm.sup.2, or less than about 30 W/cm.sup.2. In some embodiments,
the focused ultrasound intensity is the spatial peak temporal
average intensity (I.sub.SPTA).
[0049] The FUS energy applied during sonodynamic treatment is in
general less than the amount of energy when using FUS to ablate
tissue, and may be further reduced when microbubbles are
administered prior to sonication. In some embodiments, the FUS
energy applied is at least 10, 20, 30, 40, 50, 60, 70, 75, 80, 90,
100, 125, 150, 175, 200, 225, 250, 275, 300, 350, 400, 450, 500,
550, 600, 650, 700, 750, 800, 900, 1000, 1200, 1400, 1600, 1800, or
2000 Joules. In some embodiments, the FUS energy applied is no more
than 5000, 4000, 3000, 2500, 2250, 2000, 1900, 1800, 1700, 1600,
1500, 1400, 1300, 1250, 1200, 1150, 1100, 1050, 1000, 950, 900,
850, 800, 750, 700, 650, 600, 550, 500, 450, 400, 350, 300, or 250
J. In some embodiments, the FUS energy applied is between 10 J and
2000 J. In some embodiments, the FUS energy applied is between 20 J
and 1500 J. In some embodiments, the FUS energy applied is between
50 J and 1250 J. In some embodiments, the FUS energy applied is
between 100 J and 1250 J. In some embodiments, the FUS energy
applied is between 250 J and 1250 J. In some embodiments, the FUS
energy applied is between 500 J and 1250 J.
[0050] The duration of sonication can vary depending on the
subject, the particular type and stage of the malignant tissue, the
location and amount of the malignant tissue, and the degree to
which the malignant tissue takes up 5-ALA and accumulates
protoporphyrin-IX. In some embodiments, the malignant tissue is
sonicated at multiple points, for example, at multiple points
within a tumor. As used herein, a "point" refers to an FUS focal
point and the tissue surrounding the point that is affected by the
FUS. By sonicating points distributed throughout the malignant
tissue, one can achieve a more even and constant effect throughout
the tumor volume. This also permits one to use a lower power, which
reduces the possible rise in temperature (and with it, the possible
risk to surrounding normal tissue). In some embodiments, malignant
tissue is sonicated at individual points that together expose all
of the malignant tissue to FUS. In some embodiments, the points
overlap. The points can be sonicated simultaneously, individually,
or in groups. For example, in a treatment that includes targeting
16 points, all 16 points can be sonicated simultaneously, or the
points can be sonicated sequentially, or in a random order, or in
groups such as, for example, in pairs or triplets, or groups of
other sizes. Where groups are sonicated, the groups can be
physically grouped, or distributed to non-adjacent regions. In some
embodiments, the malignant tissue is sonicated at 1, 2, 3, 4, 5, 6,
7, 8, 9, 10, 11, 12, 15, 20, 25, or 30 individual points, or at any
value from 1 to 30. In some embodiments, the malignant tissue is
sonicated at no more than 30, 25, 20, 19, 18, 17, 16, 15, 14, 13,
12, 11, or 10 individual points.
[0051] In some embodiments, the sonication duration is at least
about 20 seconds, at least about 30 seconds, at least about 45
seconds, at least about 1 minute, at least about 2 minutes, at
least about 3 minutes, at least about 4 minutes, at least about 5
minutes, at least about 6 minutes, at least about 7 minutes, at
least about 8 minutes, at least about 9 minutes, at least about 10
minutes, at least about 15 minutes, at least about 20 minutes, at
least about 30 minutes, at least about 45 minutes, at least about
60 minutes, at least about 75 minutes, at least about 90 minutes,
at least about 105 minutes, at least about 120 minutes, at least
about 135 minutes, at least about 150 minutes, at least about 165
minutes, at least about 180 minutes, at least about 195 minutes, at
least about 210 minutes, at least about 230 minutes, at least about
245 minutes, at least about 260 minutes, at least about 275
minutes, at least about 300 minutes, at least about 330 minutes, or
at least about 360 minutes. In some embodiments, the sonication
duration is less than about 360 minutes, less than about 330
minutes, less than about 300 minutes, less than about 290 minutes,
less than about 280 minutes, less than about 270 minutes, less than
about 260 minutes, less than about 250 minutes, less than about 240
minutes, less than about 230 minutes, less than about 220 minutes,
less than about 210 minutes, less than about 200 minutes, less than
about 195 minutes, less than about 190 minutes, less than about 185
minutes, less than about 180 minutes, less than about 170 minutes,
less than about 160 minutes, less than about 150 minutes, less than
about 140 minutes, less than about 130 minutes, less than about 120
minutes, less than about 110 minutes, less than about 100 minutes,
less than about 90 minutes, less than about 80 minutes, less than
about 70 minutes, less than about 60 minutes, less than about 50
minutes, less than about 40 minutes, less than about 30 minutes,
less than about 20 minutes, or less than about 10 minutes.
[0052] The sonication can be continuous, or cyclic. In cyclic
sonication, periods of exposure to focused ultrasound ("sonication
periods") are interspersed with rest periods, with no sonication.
In some embodiments, the sonication includes at least one rest
period. In an embodiment, the sonication periods and rest periods
are each independently at least about 5 seconds, at least about 10
seconds, at least about 15 seconds, at least about 20 seconds, at
least about 25 seconds, at least about 30 seconds, at least about
35 seconds, at least about 40 seconds, at least about 45 seconds,
at least about 50 seconds, at least about 55 seconds, at least
about 60 seconds, at least about 65 seconds, at least about 70
seconds, at least about 75 seconds, at least about 80 seconds, at
least about 85 seconds, at least about 90 seconds, at least about
95 seconds, at least about 100 seconds, at least about 105 seconds,
at least about 110 seconds, at least about 115 seconds, at least
about 120 seconds, at least about 125 seconds, at least about 130
seconds, at least about 140 seconds, at least about 150 seconds, at
least about 160 seconds, at least about 165 seconds, at least about
170 seconds, at least about 175 seconds, or at least about 180
seconds. In an embodiment, the sonication periods and rest periods
are each independently less than about 600 seconds, less than about
500 seconds, less than about 400 seconds, less than about 300
seconds, less than about 250 seconds, less than about 240 seconds,
less than about 220 seconds, less than about 200 seconds, less than
about 180 seconds, less than about 170 seconds, less than about 160
seconds, less than about 150 seconds, less than about 140 seconds,
less than about 130 seconds, less than about 120 seconds, less than
about 110 seconds, less than about 100 seconds, less than about 95
seconds, less than about 90 seconds, less than about 85 seconds,
less than about 80 seconds, less than about 75 seconds, less than
about 70 seconds, less than about 65 seconds, less than about 60
seconds, less than about 55 seconds, or less than about 50
seconds.
[0053] In the method of the disclosure, malignant tissue is
selectively destroyed without affecting non-malignant tissue
present at the ultrasound focus. In some embodiments, less than
about 25%, less than about 20%, less than about 15%, less than
about 10%, less than about 5%, less than about 4%, less than about
3%, less than about 2%, less than about 1% of the non-malignant
tissue present at the ultrasound focus is damaged. In some
embodiments, about 1%, about 2%, about 3%, about 4%, about 5%,
about 10%, about 15%, about 20%, or about 25% of the non-malignant
tissue present at the ultrasound focus is damaged. The amount of
tissue damage can be determined using methods known to those of
ordinary skill in the art, for example using MRI. In some
embodiments, the temperature of the malignant tissue is raised by
no more than 15.degree. C., no more than 14.degree. C., no more
than 13.degree. C., no more than 12.degree. C., no more than
11.degree. C., no more than 10.degree. C., no more than 9.degree.
C., no more than 8.degree. C., no more than 7.degree. C., no more
than 6.degree. C., no more than 5.degree. C., no more than
4.degree. C., no more than 3.degree. C., no more than 2.degree. C.,
or no more than 1.degree. C.
[0054] The ultrasound can be focused on the malignant tissue, or
can be focused on a broader volume that includes the malignant
tissue. Treatment with 5-ALA renders the malignant tissue more
susceptible to FUS, making it possible to destroy malignant tissue
without undue damage to non-malignant tissue included in the focus
volume. For example, the tumor and a volume around it can be
sonicated. Additionally, one can sonicate a complete anatomic
region of the brain, such as, for example without limitation, a
temporal lobe, a parietal lobe, a frontal lobe, an occipital lobe,
the thalamus, the pituitary gland, the pons, the corpus callosum,
the basal ganglia, the brainstem, an entire hemisphere, the
supratentorial region, the infratentorial region, and the like.
Additionally, one can sonicate a part or the whole of the brain
FLAIR region (fluid-attenuated inversion recovery--an MRI technique
designed to remove the signal from liquids in the brain). The
methods of the disclosure can also in conjunction with surgical
resection of a tumor, for example to treat the resulting tumor
cavity to eliminate any malignant cells not removed by the
resection.
[0055] In some embodiments, the position of the tumor is located
using magnetic resonance imaging (MRI). In some embodiments, the
tumor is located using X-ray imaging. In some embodiments, the
tumor is sonicated. In some embodiments, the tumor and a volume
around the tumor is sonicated. In some embodiments, the tumor and a
margin extending from the tumor surface by 0.2, 0.5, 1, 2, 3, 4, 5,
6, 7, or 8 cm is sonicated. In some embodiments, a complete
anatomic region of the brain undergoes sonication. In some
embodiments, a temporal lobe, a parietal lobe, a frontal lobe, an
occipital lobe, the thalamus, the pituitary gland, the pons, the
corpus callosum, the basal ganglia, the brainstem, an entire
hemisphere, the supratentorial region, or the infratentorial region
is sonicated. In some embodiments, the brain FLAIR region is
sonicated. In some embodiments, two or more anatomical regions are
sonicated. In some embodiments, the tumor is resected, and the
tumor cavity is sonicated to eliminate residual malignant tissue or
cells. In some embodiments, the tumor cavity is sonicated to a
depth of 0.2, 0.5, 1, 2, 3, 4, 5, 6, 7, or 8 cm.
[0056] In some embodiments, the method of the disclosure, including
the administration of 5-ALA and sonication of malignant tissue, is
repeated at a treatment interval or at least about 1 day, at least
about 2 days, at least about 3 days, at least about 4 days, at
least about 5 days, at least about 6 days, at least about 7 days,
at least about 8 days, at least about 9 days, at least about 10
days, at least about 12 days, at least about 14 days, at least
about 15 days, at least about 16 days, at least about 18 days, at
least about 20 days, at least about 21 days, at least about 24
days, at least about 25 days, at least about 26 days, at least
about 28 days, at least about 30 days, at least about 35 days, at
least about 40 days, at least about 45 days, at least about 50
days, at least about 55 days, at least about 60 days, at least
about 65 days, at least about 70 days, at least about 75 days, at
least about 80 days, at least about 85 days, or at least about 90
days. In some embodiments, the treatment repetition interval is
less than about 120 days, less than about 110 days, less than about
100 days, less than about 90 days, less than about 80 days, less
than about 70 days, less than about 60 days, less than about 50
days, less than about 40 days, less than about 30 days, less than
about 20 days, less than about 14 days, less than about 10 days,
less than about 7 days, less than about 6 days, less than about 5
days, less than about 4 days, less than about 3 days, or less than
about 2 days.
[0057] The subject of the disclosure is a mammal, which can be a
human or a non-human mammal, for example a companion animal, such
as a dog, cat, rat, or the like, or a farm animal, such as a horse,
donkey, mule, goat, sheep, pig, or cow, and the like. In some
embodiments, the subject is human.
[0058] Another aspect is the method for selectively inducing
apoptosis within malignant tissue in a subject, by providing an
effective amount of 5-aminolevulinic acid to the malignant tissue,
and sonicating the tissue using a focused ultrasound device, at a
frequency of about 0.1 MHz to about 3 MHz, at an intensity at the
ultrasound beam focus of about 3 W/cm.sup.2 to about 100
W/cm.sup.2, using the methods and parameters set forth above.
[0059] Dosage Forms and Systems
[0060] It can occur that sonication is performed by a person other
than a treating physician. In order to minimize risks, and insure
that treatment is performed appropriately, one aspect is a dosage
form for keying the focused ultrasound device operation to the
subject to be treated. In some embodiments, the 5-ALA formulation
is provided in a container that comprises a machine-readable
identifier, wherein the identifier identifies the contents of the
container, the source of the formulation, the amount of the
formulation, the subject to which the formulation is to be
administered, the focused ultrasound treatment prescribed for the
subject (for example, specifying the ultrasound frequency, power,
energy, duration, or a combination thereof), an identification code
or serial number, or a combination thereof. The machine-readable
identifier can be encrypted, in order to preserve confidential
patient information. In some embodiments, the container is
sufficient to contain an effective amount of 5-aminolevulinic acid,
an effective amount of a potentiating agent, and/or an effective
amount of microbubbles. In some embodiments, the machine-readable
identifier is a bar code, QR code, or RFID device. In some
embodiments, the focused ultrasound device includes a device for
reading the machine-readable identifier. In some embodiments, the
machine-readable identifier is encrypted. In some embodiments, the
FUS device is locked in the absence of an appropriate
machine-readable identifier. In some embodiments, the FUS device
treatment parameters are programed via the machine-readable
identifier.
SPECIFIC EMBODIMENTS
[0061] In some embodiments, provided is a method for selectively
inducing a directly cytotoxic effect within malignant tissue in a
subject, the method comprising providing an effective amount of
5-aminolevulinic acid, or a pharmaceutically acceptable salt or
ester thereof, to the malignant tissue; and exposing the tissue to
ultrasound energy ("sonicating") using a focused ultrasound device,
at a frequency of about 0.1 MHz to about 3 MHz, at an intensity at
the ultrasound beam focus of about 3 W/cm.sup.2 to about 100
W/cm.sup.2.
[0062] In some embodiments, provided is a method for selectively
inducing apoptosis within malignant tissue in a subject, the method
comprising providing an effective amount of 5-aminolevulinic acid,
or a pharmaceutically acceptable salt or ester thereof, to the
malignant tissue; and exposing the tissue to ultrasound energy
("sonicating") using a focused ultrasound device, at a frequency of
about 0.1 MHz to about 3 MHz, at an intensity at the ultrasound
beam focus of about 3 W/cm.sup.2 to about 100 W/cm.sup.2.
[0063] In some embodiments, the 5-aminolevulinic acid is
gamma-irradiated 5-amino-levulinic acid. In an embodiment, the
malignant tissue is exposed to ultrasound for a duration of about 1
min to about 6 hours. In an embodiment, the malignant tissue is
exposed to ultrasound for a duration of about 1 min to about 180
min.
[0064] In some embodiments, the intensity is from about 5
W/cm.sup.2 to about 80 W/cm.sup.2. In some embodiments, the
intensity is from about 5 W/cm.sup.2 to about 60 W/cm.sup.2. In an
embodiment, the intensity is from about 5 W/cm.sup.2 to about 50
W/cm.sup.2. In some embodiments, the energy applied at the focus is
between 10 J and 2000 J. In some embodiments, the energy applied at
the focus is between 10 J and 2000 J.
[0065] In an embodiment, there is an incubation period between
providing 5-aminolevulinic acid and soniciating the malignant
tissue. In some embodiments, the incubation period is from about 1
hour to about 72 hours. In some embodiments, the incubation period
is about 3 hours.
[0066] In some embodiments, the malignant tissue comprises tumor
tissue. In some embodiments, the tumor tissue comprises
glioblastoma multiforme, optical pathway glioma, diffuse intrinsic
pontine glioma, astrocytoma, ependymoma, medulloblasoma,
oligodendroglioma, hemangioblastoma, rhabdoid tumor, brain
metastases from another cancer (selected from breast
adenocarcinoma, small cell lung carcinoma, non-small cell lung
carcinoma, squamous cell lung carcinoma, metastatic malignant
melanoma, and prostate carcinoma), meningioma, primary pituitary
gland malignancy, malignant nerve sheath tumor, neurofibroma,
cutaneous T-cell lymphoma (CTCL), noncutaneous peripheral T-cell
lymphoma, lymphomas associated with human T-cell lymphotropic virus
(HTLV), adult T-cell leukemia/lymphoma (ATLL), acute lymphocytic
leukemia, acute nonlymphocytic leukemias, chronic lymphocytic
leukemia, chronic myelogenous leukemia, Hodgkin's Disease,
non-Hodgkin's lymphomas, multiple myeloma, neuroblastoma,
retinoblastoma, Wilms' Tumor, bone tumors, soft-tissue sarcomas,
infiltrating or metastatic squamous cell carcinoma, salivary gland
tumors, nasopharyngeal carcinomas, oral, laryngeal, esophageal
tumors, urethral cancer, ureteral cancer, renal cell cancer,
bladder carcinoma, bladder carcinoma in situ, metastatic carcinoma
of the prostate, bladder, renal, uterine, ovarian, testicular,
cancers, uterine, cervical, and uterine carcinoma, rectal or colon
cancer, lung cancer, mesothelioma, small cell lung carcinoma,
non-small cell lung carcinoma, squamous cell lung carcinoma, breast
cancer, gastric cancer, esophageal cancer, and colon carcinoma,
cholangiocarcinoma, hepatic carcinoma, pancreatic adenocarcinoma,
melanoma, infiltrating basal cell carcinomas, other skin cancers,
liver cancer or thyroid cancer.
[0067] In an embodiment, the tumor tissue comprises glioblastoma.
In an embodiment, the malignant tissue is sonicated at multiple
individual points. In some embodiments, the malignant tissue is
located by magnetic resonance imaging prior to sonicating.
[0068] In some embodiments, the tissue sonicated comprises
malignant tissue and non-malignant tissue. In some embodiments, the
tissue sonicated comprises malignant tissue and a margin around the
malignant tissue. In some embodiments, the outer edge of the margin
is 0.2 cm to 5 cm from the malignant tissue. In some embodiments,
the outer edge of the margin is 1 cm to 3 cm from the malignant
tissue. In some embodiments, the tissue sonicated comprises a
margin around a resection location after resection of malignant
tissue. In some embodiments, the outer edge of the margin is 0.2 cm
to 5 cm from the malignant tissue resection site.
[0069] In some embodiments, the tissue sonicated comprises a
complete anatomic region of the brain. In some embodiments, the
complete anatomic region of the brain is a temporal lobe, a
parietal lobe, a frontal lobe, an occipital lobe, the thalamus, the
pituitary gland, the pons, the corpus callosum, the basal ganglia,
the brainstem, a hemisphere, the supratentorial region, or the
infratentorial region. In some embodiments, the complete anatomic
region of the brain is the brain FLAIR region.
[0070] In an embodiment, less than about 25% of the non-malignant
tissue in the ultrasound beam focus is damaged. In an embodiment,
less than about 10% of the non-malignant tissue in the ultrasound
beam focus is damaged. In an embodiment, less than about 5% of the
non-malignant tissue in the ultrasound beam focus is damaged. In
some embodiments, the temperature of the malignant tissue is raised
by sonication by no more than about 10.degree. C. In some
embodiments, the temperature of the malignant tissue is raised by
sonication by no more than about 5.degree. C. In some embodiments,
the temperature of the malignant tissue is raised by sonication by
no more than about 2.degree. C.
[0071] In some embodiments, the subject is human. In some
embodiments, the 5-aminolevulinic acid is provided to the malignant
tissue by oral administration of an oral formulation or intravenous
administration of an i.v. formulation to the subject. In some
embodiments, the 5-aminolevulinic acid is provided to the malignant
tissue by intravenous administration to the subject.
[0072] In some embodiments, the method further comprises providing
an effective amount of a 5-ALA potentiating agent to the malignant
tissue. In some embodiments, the potentiating agent is selected
from the group consisting of doxycycline, methotrexate,
minocycline, and Vitamin D.sub.3 or a derivative thereof. In some
embodiments, the method further comprises providing an effective
amount of microbubbles to the malignant tissue. In some
embodiments, the microbubbles are enhanced contrast ultrasound
microbubbles. In some embodiments, the microbubbles comprise sulfur
hexafluoride or a perfluorocarbon.
[0073] In some embodiments, the 5-aminolevulinic acid is provided
in a container, the container further comprising a machine-readable
identifier, wherein the machine-readable identifier identifies the
source of the 5-aminolevulinic acid, the amount of 5-aminolevulinic
acid, the subject to which the 5-aminolevulinic acid is to be
administered, the focused ultrasound treatment parameters
prescribed for the subject, an identification code or serial
number, or a combination thereof. In some embodiments, the focused
ultrasound treatment parameters comprise the ultrasound frequency,
power, energy, duration, or a combination thereof. In some
embodiments, the focused ultrasound device comprises a scanning
element capable of scanning the machine-readable identifier,
wherein the treatment parameters of the focused ultrasound device
are set in response to the machine-readable identifier. In some
embodiments, the focused ultrasound device is locked in the absence
of a machine-readable identifier.
[0074] In some embodiments, the effective amount of 5-ALA is
between about 1 mg/kg body weight and 1000 mg/kg body weight. In
some embodiments, the effective amount of 5-ALA is between about 10
mg/kg body weight and 750 mg/kg body weight. In some embodiments,
the effective amount of 5-ALA is between about 20 mg/kg body weight
and 500 mg/kg body weight.
[0075] In some embodiments, steps a) through b) are repeated at a
treatment interval of about 1 day to about 60 days. In some
embodiments, the ultrasound exposure duration comprises at least
one rest period. In some embodiments, the ultrasound exposure
duration comprises rest periods of about 10 seconds to about 120
seconds, separated by sonication periods of about 10 seconds to
about 180 seconds. In some embodiments, the sonication periods are
about 60 to about 90 seconds, and the rest periods are about 45 to
about 75 seconds.
[0076] In some embodiments, provided is a dosage form for use with
a FUS device in the treatment of a subject in need of treatment,
the dosage form comprising a container, comprising an effective
amount of 5-aminolevulinic acid sufficient to treat the subject;
and a machine-readable identifier readable by the FUS device,
wherein the machine-readable identifier identifies the source of
the 5-aminolevulinic acid, the amount of 5-aminolevulinic acid, the
subject for which the 5-aminolevulinic acid has been prescribed,
the FUS treatment parameters prescribed for the subject, an
identification code or serial number, or a combination thereof. In
some embodiments, the machine-readable identifier is encrypted, and
comprises information for automatically programming the FUS.
[0077] In some embodiments, provided is a system for treating
malignant tissue in a subject, the system comprising an effective
amount of 5-aminolevulinic acid; and a focused ultrasound (FUS)
device. In some embodiments, the system further comprises an
effective amount of a potentiating agent and/or an effective amount
of microbubbles. In some embodiments, the system further comprises
a container sufficient to contain the effective amount of
5-aminolevulinic acid, an effective amount of a potentiating agent,
and/or an effective amount of microbubbles; wherein the container
comprises a machine-readable identifier readable by the FUS device,
wherein the machine-readable identifier identifies the source of
the 5-aminolevulinic acid, the amount of 5-aminolevulinic acid, the
subject for which the 5-aminolevulinic acid has been prescribed,
the FUS treatment parameters prescribed for the subject, an
identification code or serial number, or a combination thereof. In
some embodiments, the machine-readable identifier is encrypted, and
comprises information for automatically programming the FUS. In
some embodiments, the FUS is locked in the absence of the
machine-readable identifier. In some embodiments, the FUS device is
a magnetic resonance-guided FUS device (MRgFUS).
EXAMPLES
[0078] The following preparations and examples are given to enable
those skilled in the art to more clearly understand and to practice
the present invention. They should not be considered as limiting
the scope of the invention, but merely as being illustrative and
representative thereof.
Example 1
[0079] Treatment Procedure
[0080] Male Wistar rats received injections of 4.times.10.sup.5 C6
glioma tumor cells by injection into the right cortex of the brain.
On day 7 after injection, rats were administered 5-aminolevulinic
acid (20 mg/kg or 0 mg/kg, Levulan.RTM., DUSA Pharmaceuticals,
Wilmington, Mass.) orally, three hours prior to treatment.
[0081] Rats were anesthetized and set inside an MRI-guided focused
ultrasound system ("FUS", RK300, FUS Instruments, Toronto, Canada),
having a 25 mm diameter spherically curved transducer (resonant
frequency f.sub.0=1.06 MHz, focal number=0.8). The FUS, with rat,
was then inserted into a 7 Telsa MRI system (Brucker BioSpec 70/30
USR, Bruker Ltd., Milton, Ontario, Canada). The MRI was used to
precisely aim the FUS device at the brain tumor. Rats were then
sonicated at one of four spatial peak temporal average intensities
(I.sub.SPTA) (6.9 W/cm.sup.2, 13.8 W/cm.sup.2, 27.6 W/cm.sup.2, or
55.2 W/cm.sup.2) for 20 minutes. One group (N=6) was cyclicly
sonicated at 27.6 W/cm.sup.2 for 20 minutes, divided into 16
sonication periods of 85 seconds, separated by rest periods of 60
seconds (the multiple point, or "MP" group). In the MP group, 16
individual points within the tumor were sonicated. Control groups
(N=5 each) received 5-ALA without FUS treatment, FUS treatment
without 5-ALA, or neither 5-ALA nor FUS. Tumor temperature was
monitored during sonication using magnetic resonance thermometry.
Normalized tumor volume was measured by MRI on days 7, 14, 21, 28,
and 35 following injection.
[0082] Results
[0083] Sonication at 13.8 W/cm.sup.2 raised tumor temperature by
about 2.degree. C., to 32.degree. C. Sonication at 27.6 W/cm.sup.2
raised tumor temperature to about 37.degree. C. Rats sonicated at
55.2 W/cm.sup.2 suffered tissue damage and were euthanized.
Untreated controls exhibited a normalized tumor volume of 32.+-.10
mm.sup.3, while 5-ALA only and FUS only groups exhibited a
normalized tumor volume of 24.+-.6 mm.sup.3. All experimental
groups exhibited inhibited tumor growth (see FIG. 1), and improved
survival (see FIG. 2). The MP group exhibited the greatest increase
in survival.
Example 2
[0084] This experiment is performed to demonstrate safety and
tolerability of treatment with 5-ALA and MRgFUS.
[0085] Treatment Procedure
[0086] Human subjects are selected meeting the following criteria:
(a) presence of recurrent glioma (WHO grade 3 or 4); (b) prior
treatment using the Stupp protocol; and (c) planned resection of
the tumor. The Stupp protocol is radiotherapy of 2 Gy Monday
through Friday for six weeks, totaling 60 Gy, with temozolomide (75
mg/m.sup.2 body surface area) daily for the six weeks of
radiotherapy, followed by six cycles of temozolomide (150-200
mg/m.sup.2) for 5 days each 28 day cycle after completion of
radiotherapy (R. Stupp et al., New Engl J Med (2005)
352:987-96).
[0087] Each subject is treated with intravenous 5-ALA and MRgFUS at
the amounts set forth in Table 1 below, at 2 to 4 weeks prior to
the subject's planned craniotomy. In each subject, the FUS is
focused on one half of the tumor, including enhancing and
non-enhancing regions. The treatment is performed first with dose
level 1, and the subjects are examined for dose limiting toxicities
(DLT). If no DLTs are observed, the next cohort of subjects is
treated at dose level 2. This escalation is repeated for each
cohort unless a DLT is observed. If one DLT is observed, the dose
level is repeated with the next cohort, with an expansion of
additional three subjects. If two or more DLTs are observed, the
prior dose level is designated as the maximum tolerated dose.
TABLE-US-00001 TABLE 1 Dose Levels Dose Level 5-ALA (mg/kg) FUS
(Joules) 1 10 250 2 10 500 3 10 1000 4 20 250 5 20 500 6 20 1000 7
40 250 8 40 500 9 40 1000
[0088] Results
[0089] The tumor is monitored by MRI or X-ray imaging periodically
prior to resection. Following resection of the tumor, the resected
tumor is examined for differences between the sonicated and
non-sonicated halves, including any reduction in size or grade of
the tissue.
[0090] The discussion of the general methods given herein is
intended for illustrative purposes only. Other alternative methods
and alternatives will be apparent to those of skill in the art upon
review of this disclosure, and are to be included within the spirit
and purview of this application.
[0091] Throughout this specification, various patents, patent
applications and other types of publications (e.g., journal
articles, electronic database entries, etc.) are referenced. The
disclosure of all patents, patent applications, and other
publications cited herein are hereby incorporated by reference in
their entirety to the same extent as if each individual publication
or patent application was specifically and individually indicated
to be incorporated by reference.
[0092] No admission is made that any reference cited herein
constitutes prior art. The discussion of the references states what
their authors assert, and the inventors reserve the right to
challenge the accuracy and pertinence of the cited documents. It
will be clearly understood that, although a number of information
sources, including scientific journal articles, patent documents,
and textbooks, are referred to herein; this reference does not
constitute an admission that any of these documents forms part of
the common general knowledge in the art.
* * * * *