Consult the medical resource doctors trust

UpToDate is one of the most respected medical information resources in the world, used by over 360,000 doctors and thousands of patients to find answers to medical questions.

  • Content written by a faculty of over 4,000 physicians from leading medical institutions
  • Unbiased: free of advertising or pharmaceutical funding
  • Evidence-based treatment recommendations
  • Continuously updated to incorporate new medical findings

Photodynamic therapy for ablation of Barrett's esophagus

INTRODUCTION

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 "Management of Barrett's esophagus".)

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. An approach to patients with non-dysplastic Barrett's esophagus is presented separately. (See "Management of Barrett's esophagus".) A discussion of endoscopic mucosal resection for management of early cancer and high-grade dysplasia in Barrett's esophagus is discussed elsewhere. (See "Endoscopic mucosal resection for treatment of high-grade dysplasia and early cancer in Barrett's esophagus".)

TECHNIQUE

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 Food and Drug Administration for use in humans) is porfimer sodium (Photofrin®, Lederle Parenterals). 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 3 to 5 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. At approximately 48 hours after injection, the ratio of photosensitizer in neoplastic tissue compared to non-neoplastic tissue is approximately 2:1 [11]. However, residual photosensitizer may remain in the skin for up to 30 days rendering the patient sensitive to ambient light and even strong indoor lighting. Thus, patients should be warned to avoid direct sunlight for up to four weeks after injection.
To continue reading this article you need to subscribe.

Read the rest of this article and others like it

The content on the UpToDate website is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. Always seek the advice of your own physician or other qualified health care professional regarding any medical questions or conditions. The use of this website is governed by the UpToDate Terms of Use (click here) ©2009 UpToDate, Inc.
References Top
  1. Heitmiller, RF, Redmond, M, Hamilton, SR. Barrett's esophagus with high-grade dysplasia. An indication for prophylactic esophagectomy. Ann Surg 1996; 224:66.
  2. Bonavina, L. Early oesophageal cancer: Results of a European multicentre survey. Group Europeen pour l'Etude des Maladies de l'Oesophage. Br J Surg 1995; 82:98.
  3. Edwards, MJ, Gable, DR, Lentsch, AB, Richardson, JD. The rationale for esophagectomy as the optimal therapy for Barrett's esophagus with high-grade dysplasia. Ann Surg 1996; 223:585.
  4. Menke-Pluymers, MB, Schoute, NW, Mulder, AH, et al. Outcome of surgical treatment of adenocarcinoma in Barrett's oesophagus. Gut 1992; 33:1454.
  5. Kovacs, BJ, Chen, YK, Lewis, TD, et al. Successful reversal of Barrett's esophagus with multipolar electrocoagulation despite inadequate acid suppression. Gastrointest Endosc 1999; 49:547.
  6. Sharma, P, Jaffe, PE, Bhattacharyya, A, Sampliner, RE. Laser and multipolar electrocoagulation ablation of early Barrett's adenocarcinoma: Long-term follow-up. Gastrointest Endosc 1999; 49:442.
  7. Byrne, JP, Armstrong, GR, Attwood, SE. Restoration of the normal squamous lining in Barrett's esophagus by argon beam plasma coagulation. Am J Gastroenterol 1998; 93:1810.
  8. Grade, AJ, Shah, IA, Medlin, SM, Ramirez, FC. The efficacy and safety of argon plasma coagulation therapy in Barrett's esophagus. Gastrointest Endosc 1999; 50:18.
  9. Johnston, CM, Schoenfeld, LP, Mysore, JV, Dubois, A. Endoscopic spray cryotherapy: A new technique for mucosal ablation in the esophagus. Gastrointest Endosc 1999; 50:86.
  10. Gossner, L, May, A, Stolte, M, et al. KTP laser destruction of dysplasia and early cancer in columnar-lined Barrett's esophagus. Gastrointest Endosc 1999; 49:8.
  11. Nishioka, NS. Drug, light, and oxygen: A dynamic combination in the clinic. Gastroenterology 1998; 114:604.
  12. Barr, H, Shepherd, NA, Dix, A, et al. Eradication of high-grade dysplasia in columnar-lined (Barrett's) oesophagus by photodynamic therapy with endogenously generated protoporphyrin IX. Lancet 1996; 348:584.
  13. Gossner, L, Stolte, M, Sroka, R, et al. Photodynamic ablation of high-grade dysplasia and early cancer in Barrett's esophagus by means of 5-aminolevulinic acid. Gastroenterology 1998; 114:448.
  14. Ackroyd, R, Brown, N, Vernon, D, et al. 5-Aminolevulinic acid photosensitization of dysplastic Barrett's esophagus: A pharmacokinetic study. Photochem Photobiol 1999; 70:656.
  15. Overholt, BF, Lightdale, CJ, Wang, KK, Canto, MI. Photodynamic therapy with porfimer sodium for ablation of high-grade dysplasia in Barrett's esophagus: international, partially blinded, randomized phase III trial. Gastrointest Endosc 2005; 62:488.
  16. Overholt, BF, Wang, KK, Burdick, JS, et al. Five-year efficacy and safety of photodynamic therapy with Photofrin in Barrett's high-grade dysplasia. Gastrointest Endosc 2007; 66:460.
  17. Overholt, BF, Panjehpour, M, Haydek, JM. Photodynamic therapy for Barrett's esophagus: Follow-up in 100 patients. Gastrointest Endosc 1999; 49:1.
  18. Overholt, BF, Panjehpour, M, Halberg, DL. Photodynamic therapy for Barrett's esophagus with dysplasia and/or early stage carcinoma: Long-term results. Gastrointest Endosc 2003; 58:183.
  19. Panjehpour, M, Overholt, BF, Phan, MN, Haydek, JM. Optimization of light dosimetry for photodynamic therapy of Barrett's esophagus: Efficacy vs. incidence of stricture after treatment. Gastrointest Endosc 2005; 61:13.
  20. Prasad, GA, Wang, KK, Buttar, NS, et al. Predictors of stricture formation after photodynamic therapy for high-grade dysplasia in Barrett's esophagus. Gastrointest Endosc 2007; 65:60.
  21. Yachimski, P, Puricelli, WP, Nishioka, NS. Patient predictors of esophageal stricture development after photodynamic therapy. Clin Gastroenterol Hepatol 2008; 6:302.
  22. Lecleire, S, Di Fiore, F, Antonietti, M, et al. Nonoperable patients with superficial esophageal cancer treated by photodynamic therapy after chemoradiotherapy have more severe complications than patients treated in primary intent. Am J Gastorenterol 2008; 103:2215.
  23. Pacifico, RJ, Wang, KK, Wongkeesong, LM, et al. Combined endoscopic mucosal resection and photodynamic therapy versus esophagectomy for management of early adenocarcinoma in Barrett's esophagus. Clin Gastroenterol Hepatol 2003; 1:252.
  24. Buttar, NS, Wang, KK, Lutzke, LS, et al. Combined endoscopic mucosal resection and photodynamic therapy for esophageal neoplasia within Barrett's esophagus. Gastrointest Endosc 2001; 54:682.
  25. Yano, T, Muto, M, Minashi, K, et al. Photodynamic therapy as salvage treatment for local failures after definitive chemoradiotherapy for esophageal cancer. Gastrointest Endosc 2005; 62:31.
  26. Foroulis, CN, Thorpe, JA. Photodynamic therapy (PDT) in Barrett's esophagus with dysplasia or early cancer. Eur J Cardiothorac Surg 2006; 29:30.
  27. Prasad, GA, Wang, KK, Buttar, NS, et al. Long-term survival following endoscopic and surgical treatment of high-grade dysplasia in Barrett's esophagus. Gastroenterology 2007; 132:1226.
  28. Prasad, GA, Wang, KK, Halling, KC, et al. Utility of biomarkers in prediction of response to ablative therapy in Barrett's esophagus. Gastroenterology 2008; 135:370.
  29. Ackroyd, R, Brown, NJ, Davis, MF, et al. Photodynamic therapy for dysplastic Barrett's oesophagus: A prospective, double blind, randomized, placebo controlled trial. Gut 2000; 47:612.
  30. Ackroyd, R, Kelty, CJ, Brown, NJ, et al. Eradication of Dysplastic Barrett's Oesophagus Using Photodynamic Therapy: Long-Term Follow-Up. Endoscopy 2003; 35:496.
  31. Hage, M, Siersema, PD, van Dekken, H, et al. 5-aminolevulinic acid photodynamic therapy versus argon plasma coagulation for ablation of Barrett's oesophagus: a randomised trial. Gut 2004; 53:785.
  32. Pech, O, Gossner, L, May, A, et al. Long-term results of photodynamic therapy with 5-aminolevulinic acid for superficial Barrett's cancer and high-grade intraepithelial neoplasia. Gastrointest Endosc 2005; 62:24.
  33. Vij, R, Triadafilopoulos, G, Owens, DK, et al. Cost-effectiveness of photodynamic therapy for high-grade dysplasia in Barrett's esophagus. Gastrointest Endosc 2004; 60:739.
  34. Shaheen, NJ, Inadomi, JM, Overholt, BF, Sharma, P. What is the best management strategy for high grade dysplasia in Barrett's oesophagus? A cost effectiveness analysis. Gut 2004; 53:1736.
  35. Ferguson, MK, Naunheim, KS. Resection for Barrett's mucosa with high-grade dysplasia: Implications for prophylactic photodynamic therapy. J Thorac Cardiovasc Surg 1997; 114:824.
  36. Overholt, BF, Lightdale, CJ, Wang, K,e ta l. International, multicenter, partially blinded, randomised study of the efficacy of photodynamic therapy (PDT) using porfimer sodium (POR) for the ablation of high-grade dysplasia (HGD) in Barrett's esophagus (BE): results of 24-month follow-up (abstract). Gastroenterology 2003; Abstract ID 103609.
  37. Panjehpour, M, DeNovo, RC, Petersen, MG, et al. Photodynamic therapy using Verteporfin (benzoporphyrin derivative monoacid ring A, BPD-MA) and 630 nm laser light in canine esophagus. Lasers Surg Med 2002; 30:26.
  38. Maier, A, Tomaselli, F, Anegg, U, et al. Combined photodynamic therapy and hyperbaric oxygenation in carcinoma of the esophagus and the esophago-gastric junction. Eur J Cardiothorac Surg 2000; 18:649.
  39. Maier, A, Anegg, U, Fell, B, et al. Hyperbaric oxygen and photodynamic therapy in the treatment of advanced carcinoma of the cardia and the esophagus. Lasers Surg Med 2000; 26:308.
white circle LOG IN
white circle DEMO