Barrett's esophagus: Treatment with photodynamic therapy
- Marta Davila, MD
Marta Davila, MD
- Professor of Medicine
- The University of Texas MD Anderson Cancer Center
- Jacques Van Dam, MD, PhD
Jacques Van Dam, MD, PhD
- Professor of Medicine
- USC School of Medicine, Los Angeles, CA
The management of patients with Barrett's esophagus with high-grade dysplasia is controversial. Those who are good operative candidates have traditionally been offered surgical resection because of the high risk that adenocarcinoma is already present or will soon develop [1-4]. On the other hand, progression to adenocarcinoma is not universal, suggesting that an intensive surveillance program may be sufficient for some patients. Furthermore, esophagectomy is associated with significant short- and long-term morbidity and a 3 to 13 percent rate of surgical mortality depending in part upon surgical expertise and hospital volume. (See "Management of superficial esophageal cancer" and "Barrett's esophagus: Surveillance and management".)
An alternative approach is based upon the observation that the destruction of intestinal metaplasia using a variety of chemical and thermal methods may be accompanied by regrowth of normal-appearing squamous epithelium, particularly if the patients are treated with proton pump inhibitors to keep them achlorhydric. Of the many endoscopic techniques that are capable of ablating columnar mucosa containing high-grade dysplasia, photodynamic therapy has attracted attention due to its novel approach and early success [5-10].
This topic review will focus on the efficacy of photodynamic therapy in the treatment of high-grade dysplasia, including patients with superficial cancers. Alternative approaches to patients with Barrett's esophagus are presented separately. (See "Barrett's esophagus: Surveillance and management" and "Barrett's esophagus: Treatment with radiofrequency ablation" and "Barrett's esophagus: Treatment of high-grade dysplasia or early cancer with endoscopic resection".)
Photodynamic therapy is based upon the ability of chemical agents, known as photosensitizers, to produce cytotoxicity in the presence of oxygen after stimulation by light of an appropriate wavelength. The most commonly used photosensitizer in the United States (and the only one approved by the US Food and Drug Administration for use in humans) is porfimer sodium (Photofrin, Pinnacle Biologics Inc). The usual dose for the treatment of esophageal cancer and Barrett's esophagus is 2 mg/kg of body weight given as an intravenous bolus over three to five minutes. However, the recommended duration of light exposure is shorter for Barrett's esophagus than for patients with known esophageal cancer.
After systemic injection, the photosensitizer is absorbed by most tissues, but for reasons not yet clearly understood, it is selectively retained at a higher concentration by neoplastic tissue. Approximately 48 hours after injection, the ratio of photosensitizer in neoplastic tissue compared with non-neoplastic tissue is approximately 2:1 . However, residual photosensitizer may remain in the skin for up to 30 days rendering the patient sensitive to ambient sunlight and even strong indoor lighting. Thus, patients should be warned to avoid direct sunlight for four weeks after injection.
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