3475 The association of endoscopic mucosal resection and photo-dynamic therapy in the treatment of nodular dysplastic areas arising in barrett s esophagus.

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Introduction: Barrett s esophagus (BE) is a precursor to adenocarcinoma (ACA) of the esophagus. Dysplasia identifies a subset of patients at greater risk of developing ACA. Nearly 50% of patients with high-grade dysplasia (HGD) have coexisting ACA. Photodynamic therapy (PDT) is appealing to selectively eliminate HGD. Endoscopic mucosal resection (EMR) is effective for en bloc removal of early cancer of the GI tract. Aim: To evaluate the efficacy of a combined EMR and PDT for endoscopically detectable HGD lesions in patients with BE. PDT is aimed at destroying undetectable areas of dysplasia. Methods: EMR was performed by polypectomy snare excision of grossly abnormal tissue. Patients underwent EUS staging prior to EMR. PDT was performed 5 weeks after EMR with porfimer sodium(Photofrin) (2mg/kg I.V.) using 630 nm monochromatic light delivered via a 2 to 5 cm diffusing tip fiber (power density 400 mW/cm; energy density 100 to 250 J/cm).Targeting of the lesion was obtained by using a bronchoscope, placed into the esophagus through a transparent overtube, with the laser fiber passed into the endoscope operative channel. All patients received 40 mg of omeprazole daily following PDT. Results: From July 1997 until September 1999, 4 patients (3 males, 1 female)(mean age 70.7 yrs;range 66-75 yrs) with HGD in BE were treated. The mean BE length was 9.2 cm (range 8-11 cm). Dysplastic lesions were nodular, with a diameter from 5 to 13 mm. Two patients had two lesions. Combined treatment (EMR+PDT) was initially performed in all patients. The mean follow-up was 15 (range:4-24) months. Large areas of squamous re-epithelialization were detected in all patients. Two patients had macroscopic sessile regrowth of HGD, at the resection site, and underwent combination re-treatment. In one patient EMR was not possible despite isolation with injected submucosal saline. This lesion was destroyed with monopolar electrocoagulation prior to PDT. The two patients were free of disease at two and three months from the second treatment. Conclusions: Combination EMR and PDT is an attractive therapy for BE patients with macroscopic dysplastic lesions. Preliminary EMR of the dysplastic lesion permits an adequate histologic examination and may facilitate subsequent PDT. PDT is essential in eliminanting invisible multiple dysplastic areas, frequently observed in patients with HGD, and in reducing the risk of local recurrence. However, repeat therapy may be necessary. Introduction: Barrett s esophagus (BE) is a precursor to adenocarcinoma (ACA) of the esophagus. Dysplasia identifies a subset of patients at greater risk of developing ACA. Nearly 50% of patients with high-grade dysplasia (HGD) have coexisting ACA. Photodynamic therapy (PDT) is appealing to selectively eliminate HGD. Endoscopic mucosal resection (EMR) is effective for en bloc removal of early cancer of the GI tract. Aim: To evaluate the efficacy of a combined EMR and PDT for endoscopically detectable HGD lesions in patients with BE. PDT is aimed at destroying undetectable areas of dysplasia. Methods: EMR was performed by polypectomy snare excision of grossly abnormal tissue. Patients underwent EUS staging prior to EMR. PDT was performed 5 weeks after EMR with porfimer sodium(Photofrin) (2mg/kg I.V.) using 630 nm monochromatic light delivered via a 2 to 5 cm diffusing tip fiber (power density 400 mW/cm; energy density 100 to 250 J/cm).Targeting of the lesion was obtained by using a bronchoscope, placed into the esophagus through a transparent overtube, with the laser fiber passed into the endoscope operative channel. All patients received 40 mg of omeprazole daily following PDT. Results: From July 1997 until September 1999, 4 patients (3 males, 1 female)(mean age 70.7 yrs;range 66-75 yrs) with HGD in BE were treated. The mean BE length was 9.2 cm (range 8-11 cm). Dysplastic lesions were nodular, with a diameter from 5 to 13 mm. Two patients had two lesions. Combined treatment (EMR+PDT) was initially performed in all patients. The mean follow-up was 15 (range:4-24) months. Large areas of squamous re-epithelialization were detected in all patients. Two patients had macroscopic sessile regrowth of HGD, at the resection site, and underwent combination re-treatment. In one patient EMR was not possible despite isolation with injected submucosal saline. This lesion was destroyed with monopolar electrocoagulation prior to PDT. The two patients were free of disease at two and three months from the second treatment. Conclusions: Combination EMR and PDT is an attractive therapy for BE patients with macroscopic dysplastic lesions. Preliminary EMR of the dysplastic lesion permits an adequate histologic examination and may facilitate subsequent PDT. PDT is essential in eliminanting invisible multiple dysplastic areas, frequently observed in patients with HGD, and in reducing the risk of local recurrence. However, repeat therapy may be necessary.