Should Complete Ablation of Barrett's Esophagus (BE) Be the Goal of Photodynamic Therapy (PDT)?

Abstract

Background: PDT has been approved for the treatment of BE with high-grade dysplasia. The complete elimination of BE has been suggested as the goal of ablation therapy but the outcomes of complete ablation in a large cohort of patients with a long duration of follow-up has not been described. Aim: To compare the outcomes who achieved complete ablation of BE to those with residual BE after PDT. Methods: We reviewed the prospectively maintained database of patients treated with PDT for BE begun in 1991 in the Barrett's Esophagus Unit. Only patients followed for more than a year were included to allow a reasonable post-treatment surveillance period. Patients were treated with PDT using either sodium porfimer at a dose of 2 mg/kg. 48 hours after therapy, patient were photoradiated at a dose of 175-200 J/cm fiber at a power output of 400 mW/cm fiber using a 630 nm laser. Surveillance was done every 3-6 months by a single endoscopist with biopsies taken in four quadrants every centimeter of Barrett's esophagus. Two experienced gastrointestinal pathologists reviewed all pathology. Results: A total of 167 patients (139 males, mean age 64+/−1 years) were identified who had been followed for a mean of 54+/−3 months (range 12-148 months). These patients were treated for high-grade dysplasia in 90 (54%), adenocarcinoma in 22 (13%), low grade dysplasia in 42 (25%), and no dysplasia in 14 (8%). These patients had a mean BE length of 6+/−1 cm. 84 (50%) of the patients achieved complete ablation that was confirmed histologically 24+/−3 months after treatment. Of those that achieved a complete ablation, 93% (78) remained in histological remission during surveillance, 4% (3) developed non-dysplastic mucosa, 1% (1) developed low grade dysplasia, and 2% (2) developed high grade dysplasia. In the other 83 patients who had residual Barrett's mucosa, 6% (5) developed cancer and 8% (7) developed high-grade dysplasia. Patients who have complete elimination of Barrett's mucosa have a significantly lower likelihood of progressing to high-grade dysplasia or cancer (p<0.01). Conclusions: Complete ablation of BE is still associated with recurrence of Barrett's mucosa but the incidence of high grade dysplasia or cancer was only 2%. However, residual Barrett's mucosa after PDT was associated with a 14% incidence of high-grade dysplasia and cancer. Complete elimination of Barrett's mucosa should be the goal of ablation therapy as it reduces the risk of advanced neoplasia by 85%. Background: PDT has been approved for the treatment of BE with high-grade dysplasia. The complete elimination of BE has been suggested as the goal of ablation therapy but the outcomes of complete ablation in a large cohort of patients with a long duration of follow-up has not been described. Aim: To compare the outcomes who achieved complete ablation of BE to those with residual BE after PDT. Methods: We reviewed the prospectively maintained database of patients treated with PDT for BE begun in 1991 in the Barrett's Esophagus Unit. Only patients followed for more than a year were included to allow a reasonable post-treatment surveillance period. Patients were treated with PDT using either sodium porfimer at a dose of 2 mg/kg. 48 hours after therapy, patient were photoradiated at a dose of 175-200 J/cm fiber at a power output of 400 mW/cm fiber using a 630 nm laser. Surveillance was done every 3-6 months by a single endoscopist with biopsies taken in four quadrants every centimeter of Barrett's esophagus. Two experienced gastrointestinal pathologists reviewed all pathology. Results: A total of 167 patients (139 males, mean age 64+/−1 years) were identified who had been followed for a mean of 54+/−3 months (range 12-148 months). These patients were treated for high-grade dysplasia in 90 (54%), adenocarcinoma in 22 (13%), low grade dysplasia in 42 (25%), and no dysplasia in 14 (8%). These patients had a mean BE length of 6+/−1 cm. 84 (50%) of the patients achieved complete ablation that was confirmed histologically 24+/−3 months after treatment. Of those that achieved a complete ablation, 93% (78) remained in histological remission during surveillance, 4% (3) developed non-dysplastic mucosa, 1% (1) developed low grade dysplasia, and 2% (2) developed high grade dysplasia. In the other 83 patients who had residual Barrett's mucosa, 6% (5) developed cancer and 8% (7) developed high-grade dysplasia. Patients who have complete elimination of Barrett's mucosa have a significantly lower likelihood of progressing to high-grade dysplasia or cancer (p<0.01). Conclusions: Complete ablation of BE is still associated with recurrence of Barrett's mucosa but the incidence of high grade dysplasia or cancer was only 2%. However, residual Barrett's mucosa after PDT was associated with a 14% incidence of high-grade dysplasia and cancer. Complete elimination of Barrett's mucosa should be the goal of ablation therapy as it reduces the risk of advanced neoplasia by 85%.