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Non-healing wounds pose a major burden to patients and health care systems alike. These wounds are chronically stuck in the inflammatory phase of the healing process without transitioning to the proliferative phase. They are also characterized by the excessive presence of leukocytes which are assumed to provoke the persistent inflammation observed in pathological wound healing. Recent studies suggested a beneficial role of cold physical plasma in the treatment of chronic wounds. Hence, it was the central question, whether exposure to cold physical plasma would affect the viability and/or function of human leukocytes. Cold plasma displays various properties of which the generation of reactive molecules, such as reactive oxygen and nitrogen species (ROS/RNS), where found to be central in mediating redox changes in leukocytes. Oxidative stress was present especially in lymphocytes that readily underwent apoptosis after exposure to plasma. This was largely a direct consequence of plasma-generated hydrogen peroxide but not superoxide or RNS. Amount of apoptosis was comparable among several lymphocyte subpopulations, with the wound healing-relevant γδ T cells being least affected. Lymphocyte apoptosis was accompanied by mitochondrial membrane depolarization, caspase 3 activation, DNA fragmentation, and phosphatidylserine exposure. These results are in line with previous characterizations of the intrinsic apoptotic pathway in redox biology, and suggest that plasma-induced apoptosis was not mediated by alternative molecular mechanisms. An important immune response mechanism, the proliferation of lymphocytes, was not interrupted in plasma-treated but non-apoptotic cells. In wounds, a central role of leukocytes is to orchestrate the healing response via the release of small communication molecules called cytokines. Non-healing wounds are associated with elevated amounts of pro-inflammatory IL-1β, IL-6, and TNFα, and plasma-treatment of leukocytes strongly decreased their concentrations. At the same time, the expression of anti inflammatory cytokines (IL-10, TGFβ) was markedly increased. The pro inflammatory chemokine IL-8 was the only molecule to be significantly increased in supernatants of plasma-treated cells. IL-8 is the major chemo-attractant for neutrophil granulocytes. Neutrophils are frequently associated with non-healing wounds. These professional phagocytes are the first to migrate to the site of injury where they inactivate invading pathogens by various mechanisms. Importantly, highly relevant effector functions remained mostly unaffected by plasma treatment: the phagocytosis of bacteria, the oxidative burst, and the intracellular killing of microbes. Of note, plasma induced a strong induction of neutrophil extracellular traps (NETs). Decorated with antimicrobial proteins, NETs are web-like chromatin extrusions that entrap pathogens. These results have several implications for wound healing. Plasma-treated neutrophils were still capable of eradicating bacteria, which are frequently associated with non-healing wounds. In addition, plasma-induced NETs could aid in wound healing by providing an antibacterial scaffold to safeguard against further dissemination of microorganisms. Chronic wounds display a state of sustained inflammation and plasma induced apoptosis but not necrosis in lymphocytes. This was an important finding as necrosis, the involuntary cell death, is associated with the release of intracellular content, enhancing inflammation. By contrast, apoptosis dampens it as dead cells are cleared by macrophages inducing anti inflammatory responses. Further, the cytokine signature of plasma-treated leukocytes was largely non inflammatory, which could further decrease inflammation in wounds. Altogether, this work provided first insight with regard to effects and mechanisms of cold physical plasma treatment of wound-relevant leukocytes. Generally, these cells were affected by a plasma mediated modulation of their redox state. Future studies should include the possibility of redox modulation into their experimental approach to further elucidate the role of ROS/RNS in inflammation and possibly to improve existing wound healing therapies.
Non-thermal atmospheric pressure plasma has drawn more and more attention to the field of wound healing research during the last two decades. It is characterized by a unique composition, which includes amongst others free radicals, ions and electrons. Furthermore, non-thermal plasma exhibits temperatures that are below those inducing thermal cell damage. Next to its well-established anti-bacterial properties, plasma can have lethal as well as stimulating effects on mammalian cells. Therefore, the medical application of non-thermal plasma on chronic wounds seems to be a promising tool to enable healing processes. However, less is known about the plasma-mediated induction of intracellular signaling pathways in human immune cells, which play a leading part in the process of wound recovery and removal of pathogens. Therefore, this thesis examined the cellular effects of a non-thermal atmospheric pressure plasma treatment on human immune cells using the argon plasma jet kinpen 09. Here, the CD4+ T helper cell line Jurkat, the monocyte cell line THP-1 as well as the corresponding primary cells were investigated. First, cell survival and apoptosis induction was assessed in response to non-thermal plasma treatment by growth curves and flow cytometric assays. On the one hand it could be shown that primary cells are more susceptible to plasma treatment than the respective cell lines. On the other hand, monocytes responded less sensitive to plasma exposure than lymphocytes. Furthermore, this thesis outlined the impact of non-thermal plasma treatment on the gene expression level of immune cells. Therefore, DNA microarray analysis was performed with the cell lines Jurkat and THP-1. It became obvious that plasma exposure modulated the expression of several genes in both cell types. Differential expression of distinct target genes was further validated by quantitative PCR in the immune cell lines. Here, elevated gene expression levels of JUN and FOS in Jurkat cells and increased transcription of JUND in THP-1 cells in response to plasma treatment were made visible. JUN, FOS and JUND are components of the transcription factor AP-1, which is involved amongst others in gene expression of IL-8 and HMOX-1. Consequently, transcriptional induction of the inflammatory cytokine IL-8 as well as the enzymes HMOX-1 and GSR was detected in plasma-treated THP-1 cells. In addition, alterations in the protein activation levels were analyzed in plasma-treated Jurkat, THP-1 cells and primary monocytes. Since some of the identified target genes are known to be associated with the MAPK pathways, the regulation of these cascades was further investigated by western blot analysis. In all investigated cell types the pro-proliferative signaling molecules ERK 1/2 and MEK 1/2 as well as the pro-apoptotic signaling proteins p38 MAPK and JNK 1/2 were activated in a plasma treatment time dependent manner. In contrast to Jurkat and primary monocytes, the anti-apoptotic HSP27 was only induced in THP-1 cells in response to plasma exposure. Moreover, modulation of cytokine production and secretion was examined in the different immune cell types and co-cultured THP-1 and HaCaT keratinocytes by ELISA or flow cytometry. While Jurkat cells showed no plasma-mediated regulation of cytokine expression, THP-1 cells revealed an increased IL-8 secretion after long plasma time duration (360 s). Additionally, the intracellular expression levels of IL-6 and IL-8 were modulated in primary monocytes by plasma exposure. While short plasma treatment caused no alteration of the number of cells expressing IL-8 an up-regulation of the intracellular IL-6 level occurred after 30 s of plasma treatment. Long plasma treatment times resulted in a significant decrease of the intracellular IL-8 and IL-6 production levels. Furthermore, co-cultured THP-1 and HaCaT cells as well as mono-cultured THP-1 and HaCaT cells were examined regarding their cytokine secretion profile. Here, cells treated with plasma (180 s) as well as LPS and plasma (180 s and LPS) were compared with untreated cells. IL-6, IL-8 and GM-CSF secretion was induced by both plasma and plasma combined with LPS treatment in mono-cultivated HaCaT cells and co-cultured cells. Though, the highest cytokine secretion levels were reached in the plasma and LPS exposed co-culture. In contrast, mono-cultivated THP-1 cells only showed an increased secretion of IL-6, IL-8 and TNFa after incubation with plasma together with LPS exposed medium. In conclusion, this study revealed for the first time the non-thermal plasma-modulated expression of numerous genes and cytokines and the activation state of various signaling cascades in human immune cells. Thus, it contributes to gain a better understanding of the immune-modulatory impacts of plasma that might promote the wound healing process.
The aim of this thesis is to concentrate on the investigation of these ROS&RNS composition distribution and their production pathways in the gas phase produced by a plasma jet. By understanding the physical mechanisms behind the generation of the ROS&RNS a precise tuning and design of the composition distribution in the gas phase can be achieved. One crucial physical parameter is the dissipated power inside the plasma. Only if this parameter is known a meaningful comparison of different feed gas settings is possible. Therefore, a concept for measuring the dissipated power inside the plasma for the modified micro-scaled atmospheric pressure plasma jet( µAPPJ) is designed. Additionally, due to achievements within this thesis it is now possible to ignite a homogeneous discharge in argon and helium within the geometry of the µAPPJ. The used feed gas is a determining factor concerning the electron energy distribution function and consequently influencing the production mechanism of the ROS&RNS. First of all, the electrical characterisation of the modified µAPPJ was performed including the alpha-to-gamma transition. It is shown that the alpha-to-gamma transition power is increasing with increasing frequency. For the first time it is now feasible to investigate the influence of the dissipated power on the neutral gas temperature, the metastable atom densities and the ROS&RNS production for the modified µAPPJ with argon and helium as feed gas. Due to the possibility of changing the feed gas and controlling the dissipated power a fundamental insight into the production mechanism of the ROS&RNS generated by the plasma jet is achieved. With rising dissipated power the temperature and the metastable densities as well as the ozone and nitrogen dioxide concentrations are increasing. By adding molecular oxygen and nitrogen to the feed gas of a plasma jet the ROS&RNS composition can be tuned. However, also the dissipated power is changed by the small amount of admixtures. Due to the developed dissipated power measurements within this thesis it was possible to disentangle the influence of the admixture on the power and on the ROS&RNS production. If the dissipated power is fixed for the µAPPJ with argon and helium feed gas, respectively, the highest amount of ozone was measured with oxygen admixture in an argon discharge, the highest amount of dinitrogen pentoxide with nitrogen admixture in an argon discharge and the highest amount of nitrogen dioxide with nitrogen admixture in a helium discharge. Beyond the influence of the dissipated power and the molecular admixture on the ROS&RNS production the feed gas temperature is a crucial parameter for the corresponding chemical reactions. By changing this parameter the distribution of ozone and nitrogen dioxide can be tuned precisely in such a way that with increasing temperature the ozone density goes down and the nitrogen dioxide density rises. Another determinant for the ROS&RNS composition produced by an atmospheric pressure plasma jet is the influence of ambient air. If the ambient air is changing from pure nitrogen to pure oxygen atmosphere the ozone density produced by the plasma jet is increasing. For the same conditions the nitrogen dioxide has a maximum at an oxygen-to-nitrogen ratio of 1:1. To avoid the influence of the ambient air on the reactive species production the afterglow of the µAPPJ was prolonged with a glass tube. By increasing the amount of molecular admixtures to the feed gas with each in equal quantities a totally different ROS&RNS composition can be obtained compared without the glass tube. It figures out that for small molecular admixtures the reactive species composition is nitrogen dominated and for higher admixtures it is oxygen dominated. Consequently, by shielding the ambient air from the active effluent and by admixing molecular oxygen and nitrogen the ROS&RNS composition can be designed.
Because of the vital role of the liquid as interface in plasma medicine, this work is focused on the elucidation of the interaction of plasmas with biologically relevant liquids. The results of this thesis are an important step in the direction of the applications to real biological liquids such as blood and wound secretion ex vivo as well as in vivo. In this thesis the following questions are investigated and answered with the special focus on the free radicals as highly reactive and, therefore, hard to detect relevant group of chemical species: What is the impact of the atmospheric-pressure argon plasma jet on biologically relevant solutions? Which species are generated due to the plasma treatment of liquids? What is an appropriate detection procedure for the qualification and quantification of the short-lived species? Does the surrounding conditions influence the formation of liquid-phase reactive species and can this influence be used to tailor a desired liquid composition? What is the influence of the plasma surroundings? What is the influence of feed gas manipulation regarding the reactive species generation? Can these impacts be used for a selected reactive species composition generation? Does the treated liquid medium affect the plasma-generated reactive species output and in what way? Which are the underlying mechanisms and origins of the plasma-caused chemical changes in the solutions? Do reactive species exist, which origin is located in the gaseous phase? What is the impact of the plasma jet radiation?
In this work the mechanisms leading to the generation of the various reactive oxygen and nitrogen species (RONS) in a cold atmospheric plasma (CAP) jet and means to control their composition were studied. The investigated CAP jet kinpen is typically operated with Ar feed gas (pure or with molecular admixtures), driven at a frequency of approximately 1 MHz and features fast ionization waves or guided streamers, traveling at velocities of several km/s. The complex reaction networks were investigated by numerical and experimental techniques. Detailed experimental, analytical and computational investigations on the mass and heat transport in the plasma plume were performed: A novel analytical approach to diffusion in jet flows, the non-dispersive path mapping approximation (NDPM) was developed. The method for the first time allows for an estimation of the ambient species density in the near-field of jets that feature a non-homogeneous flow-field. The NDPM approximation was employed for the evaluation of laser induced fluorescence measurements on OH. Through combining measurements and NDPM approximation, this approach yielded an estimation for the ambient species density at the position of the guided streamers, not only in the laminar, but also in the (standard) turbulent operating regime. Accurate measurements of the temporally averaged ambient species density and temperature in the plasma plume were obtained by quantitative Schlieren measurements. The method yields temperature values with sub-Kelvin accuracy and, through combination with computational fluid dynamics (CFD) simulations, allowed for an estimation of the calorimetric power of the jet. In order to obtain a defined environment for the jet to operate in, a shielding gas device was designed in this work, which creates a gas curtain of defined composition around the plasma plume. The plasma dynamics on the ns timescale was investigated by phase resolved optical measurements. The effect of different shielding compositions ranging from pure N2 to pure O2 on guided streamer propagation was investigated. An electrostatic focusing mechanisms was discovered, which promotes the propagation of guided streamers along the channels formed by a noble gas in the plume of plasma jets operating in electronegative gases (such as air or O2). Two zero-dimensional (volume averaged) models were developed: First, the local processes in the guided streamer were modeled using an electron impact reaction kinetic model, which is closely correlated to densities of metastable argon (Ar*) obtained by laser atom absorption measurements. This first model shows that Ar* is the species which dominantly drives the plasma chemistry in the plasma plume. This is exploited in the second plug-flow reaction kinetics model, which is employed to investigate the formation of long-living RONS and uses an Ar* source term as sole energy input. The model uses the previous experimental data on mass and heat transport and temporal dynamics as input and is in turn verified by quantitative FTIR absorption measurements on O3, NO2, N2O, HNO3 and N2O5 in the far-field of the jet, where large absorption lengths can be achieved using a multi pass cell. For the evaluation of the zero-dimensional model, the time-of-flight of RONS from their generation to reaching the multi pass cell was determined using CFD simulations. The insight gained through this combined experimental-modeling approach on the reaction networks revealed relevant control parameters and enabled adjusting the plasma chemistry towards a desired RONS output. Through choosing appropriate feed-gas admixtures and shielding gas compositions, it is possible to generate an NOx-dominated plasma chemistry, although the jet usually produces a strongly O/O3-dominated chemistry. Understanding and controlling the plasma chemistry of cold atmospheric plasma sources for medical applications is not only essential for research, but is also the key for designing future plasma sources for specific medical applications that yield an optimum efficacy and avoid potential side effects of plasma treatment.
Due to a variety of plasma sources in terms of type of discharge, energy yield, working gas or geometric factors, it is recommended to standardize the study protocol by choosing a plasma source and easy access to rugged tumor surfaces as demonstrated by the CAP-plasma-jet. The intention of the trial shall be to optimize the plasma jet for tumor site capability and operating room implementation.
It makes sense to start clinical trials in plasma medicine with the treatment of head and neck squamous cell carcinoma patients of infected wounds and ulcerations.
CAP is able to reduce contamination of cancer ulcerations and the typical fetid odor that often accompanies head and neck cancer patients. The intention of the trial shall be to evaluate the efficiency of decontamination in head and neck cancer ulcerations in terms of pathogenic species, amount of reduction and reliability.
Standardize study protocol:
Phase I, clinical explorative single-arm, randomized, open, multicenter
Primary objective
Reduction of microbial burden of cancer ulcerations by application of CAP
Secondary objective:
Reduction of tumor following local CAP application
Inclusion:
20 Patients suffering from locally advanced oral cavity carcinoma with open tumor surfaces, treated with palliative intention and no more curative treatment options
Exclusion:
No wish for treatment, no compliance and understanding the protocol of the clinical study
Efficacy:
reduction of microbial burden; Documentation of visible changes by photography; Pathohistological and biochemical examination of specimen, taken from the tumor area and control areas
Procedure:
Plasma is applied for 1 minute per cm², spot area of 3 mm diameter distance between nozzle and tumor surface of 14 mm. 3 times/week with a break of 1 week followed by a repeated cycle for another week.
Conclusion:
The most important intention of the trial from the clinician’s point of view shall be to make CAP-treatment an effective and well-accepted addition to standard cancer therapy based upon EBM at least in palliative medicine.
Plasma medical oncology: Immunological interpretation in head and neck squamous cell carcinoma
(2020)
Over the past several years, various important articles focusing on cancer therapy
approaches in head and neck squamous cell carcinomas (HNSCCs) using cold
atmospheric plasma (CAP) have been published (SEMMLER et al. 2020 [53],
METELMANN et al. 2018 [44], KEIDAR et al. 2011 [33]). This doctoral thesis presents
selected results from a prospective observational clinical study in CAP therapy of
palliative HNSCC patients, carried out at the Department of Oral and Maxillofacial
Surgery/Plastic Surgery of the Greifswald University Medicine. For oral and
maxillofacial surgeons, ulcerated surfaces of locally advanced head and neck squamous
cell carcinomas (UICC IV) offer a challenging treatment assignment with microbial
contamination and tumour progression. The clinical attempt appears to eradicate
microbial contamination and to initiate tumour regression. This doctoral thesis will
describe the processes of human tumour biology and tumour immunology in HNSCCs
and the extent of present knowledge concerning plasma medical oncology as an
anticancer modality. In the introduction of the doctoral thesis clinical results of plasma
therapy in locally advanced HNSCCs (UICC IV) are set out. This mainly includes the
investigation of a therapeutic concept, the treatment phases, the tumour size development
and the morphological changes of the infected tumour surface following cold atmospheric
plasma therapy. In the main part, a detailed immunological interpretation is proposed on
the basis of present preclinical and clinical immunological knowledge. Finally,
unexplored questions in plasma medical oncology are highlighted. This is highly
significant for future plasma research and clinical anticancer therapy.