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Photodynamic Therapy in Barrett's Esophagus with High Grade Dysplasia and Intra-Mucosal Carcinoma


Go, Jorge T. MD; Dumot, John A. DO; Lopez, Rocio MS; Vargo, John MD; Zuccaro, Greg MD; Falk, Gary MD; Rice, Thomas MD

American Journal of Gastroenterology: September 2006 - Volume 101 - Issue - p S64
Abstracts: ESOPHAGUS

Internal Medicine, Cleveland Clinic, Cleveland, OH; Gastroenterology and Hepatology; Quantitative Health Sciences and Cardiothoracic Surgery.

Purpose: Photodynamic therapy (PDT) is indicated for Barrett's esophagus (BE) with high grade dysplasia (HGD) as alternative to esophagectomy in patients unfit for surgery. Results of PDT for intra-mucosal carcinoma (IMCA) are lacking.

The aim of the study is to compare the remission rates of PDT for HGD and/or IMCA in a single center.

Methods: Patients with BE and HGD or IMCA confirmed by two experienced pathologists received Photofrin 2 mg/kg followed by 220–300 J/cm laser light. The outcome measure was remission (negative esophageal biopsy for intestinal metaplasia, dysplasia or cancer) at last follow-up.

Results: Seventeen patients (11 men) age 78.9 years (SD ± 5.1) were treated with PDT. Twelve had IMCA and 5 had HGD. Mean length of BE was 5.8 cm (SD ± 2.2). One patient had 2 sessions of PDT, time between sessions was 2 years. The second PDT session was utilized as a separate salvage treatment when the patient showed persistent disease. The rest had a single session of PDT.

Seven patients had PDT alone during the course of treatment. Ten had multimodal endoscopic therapies in the form of endoscopic mucosal resection (EMR), argon plasma coagulation (APC) or BICAP electrocautery before or after PDT.

Out of the 7 patients treated with PDT alone, 5 went into remission in a mean follow-up of 2.3 years. The remission at last follow-up in this group was 29% (5/17). Including patients who received other endoscopic therapies, the total remission rate increased to 59% (10/17).

Regardless of first treatment, the remission rate for HGD patients was 40% (2/5) compared to IMCA 66.7% (8/12), p= NS (0.59).

In addition, a multivariable Cox proportional hazards analysis suggested that the length of Barrett's esophagus is significantly associated with recurrence after PDT. For every 1 cm increase in length of the Barrett's esophagus, the hazards of having recurrence increases 1.79 times (95% CI: 1.12, 2.84).

Conclusions: PDT in a single session has a low remission rate (29%) even when used in conjunction with other endoscopic therapy (59%). Alternative ablative and salvage methods are needed for PDT failures.

IMCA and HGD response to PDT is similar.

Barrett's esophagus length increases the risk of recurrence of HGD and/or IMCA after PDT.

© The American College of Gastroenterology 2006. All Rights Reserved.