The introduction of lipophilic derivatives of the naturally occurring heme precursor 5-aminolevulinic acid (5-ALA) into photomedicine has led to a true revival of this research area. 5-ALA-mediated photodynamic therapy (PDT) and fluorescence photodetection (FD) of neoplastic disease is probably one of the most selective cancer treatments currently known in oncology. To date, this method has been assessed experimentally for the treatment of various medical indications. However, the limited local bioavailability of 5-ALA has widely prevented its use in daily clinical practice. Although researchers were already aware of this drawback early during the development of 5-ALA-mediated PDT, only recently have well-established concepts in pharmaceutical science been adapted to investigate ways to overcome this drawback. Recently, two derivatives of 5-ALA, methylaminolevulinate (MAL) and hexylaminolevulinate (HAL), gained marketing authorization from the regulatory offices in Europe and Australia. MAL is marketed under the trade name Metvix for the treatment of actinic keratosis and difficult-to-treat basal cell carcinoma. HAL has recently been launched under the trade name Hexvix to improve the detection of superficial bladder cancer in Europe. This review will first present the fundamental concepts underlying the use of 5-ALA derivatives in PDT and FD from a chemical, biochemical and pharmaceutical point of view. Experimental evidences from preclinical data on the improvements and limits observed with 5-ALA derivatives will then be introduced. The state-of-the-art from clinical studies with 5-ALA esters will be discussed, with special emphasis placed on the process that led to the development of MAL in dermatology and to HAL in urology. Finally, we will discuss promising medical fields in which use of 5-ALA derivatives might potentially lead to further use of this methodology in photomedicine.

Due mainly to the extensive use of antibiotics, the spread of multiresistant bacterial strains is one of the most worrying threats to public health. One strategy that can be used to overcome potential shortcomings might be the inactivation of these microorganisms by 5-aminolevulinic acid (5-ALA) or 5-ALA derivative-mediated photodynamic therapy (PDT). 5-ALA has no photoactive properties, but when it is given exogenously, it acts as a precursor of photosensitive porphyrins predominantly in tissues or organisms that are characterized by a high metabolic turnover, such as tumors, macrophages, and bacteria. However, the weak ability of 5-ALA to cross biological barriers has led to the introduction of more lipophilic derivatives, such as methyl aminolevulinate or hexyl aminolevulinate, which display improved capacities to reach the cytoplasm. Starting from the hypothesis that more lipophilic compounds carrying only a permanent positive charge under physiological conditions may more easily cross the bacterial multilayer barrier, we have tested the efficacies of some 5-ALA n-alkyl esters for the inactivation of bacteria. For this purpose, different bacterial strains were incubated with 5-ALA or its corresponding esters of different lipophilicities. Then, the bacteria were irradiated with light and the numbers of CFU post-PDT were counted and compared to those for the controls, which were kept in the dark. Furthermore, the total amount of accumulated porphyrins was quantified by high-pressure liquid chromatography analysis. In our studies, analysis of the bacterial extracts revealed the presence of all the porphyrins involved in heme biosynthesis, from uroporphyrin to protoporphyin IX. The efficacy of bacterial inactivation was a function of the total amount of porphyrins produced, independently of their nature. The 5-ALA methyl and butyl esters were the most effective compounds with respect to the photodynamic inactivation of bacteria. We observed significant differences in terms of the optimal drug concentration, bactericidal activities, and porphyrin production.

The hexylester of 5-aminolevulinic acid (HAL) is a very efficient precursor of the photosensitizer protoporphyrin IX (PpIX) for photodynamic therapy (PDT). Our previous study, performed in rat orthotopic bladder tumors, indicated an opposite effect of HAL/PpIX-PDT according to HAL concentration. The present study investigated possible reasons for this differential effect considering the impact of extracted amounts of PpIX in normal and tumor bearing bladders along with PpIX distribution in distinctive histopathological layers. High performance liquid chromatography (HPLC) analysis of tumor and normal bladder tissues after 8 mM and 16 mM HAL instillation showed that PpIX was the main porphyrin species. The PpIX production in tumor bladders instilled with 8 mM HAL was significantly higher than after 16 mM HAL. Fluorescence confocal microscopy demonstrated a punctuate bright fluorescence pattern in tumor zones of bladders instilled with 8 mM HAL, whereas a more diffuse cytoplasmatic fluorescence distribution was observed after 16 mM HAL instillation. Immunofluorescence staining together with transmission electron microscopy showed severe mitochondrial damage in tumor zones of bladders treated with 8 mM HAL/PpIX PDT, with intact mitochondria in tumor zones of bladders treated with 16 mM HAL/PpIX PDT. We conclude that the differential response to HAL/PpIX PDT in function of HAL concentrations could be attributed to diminished PpIX synthesis and differential intracellular localisation of PpIX. Mitochondria were shown to be the critical photodamaged sites of HAL/PpIX PDT and as such tissue sensitivity to treatment can be estimated through investigation of intracellular PpIX distribution.

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