The Outcomes of Porfimer Sodium Photodynamic Therapy in Barrettʼs Dysplasia and Neoplasia: A Tertiary Center Experience

Abstract

Purpose: Porfimer sodium photodynamic therapy (Ps-PDT) has been used to eradicate Barrett's dysplasia and neoplasia as an alternative to esophagectomy. The aim of this study was to assess the outcomes after Ps-PDT in patients with Barrett's esophagus with high grade dysplasia (HGD) or adenocarcinoma (ACA). Methods: This was a retrospective, observational study using large Ps-PDT database in a tertiary referral center. We reviewed the medical records of 136 patients (85 HGD; 51 ACA) with a median age of 73 (13% females). They were referred to our tertiary care center for PDT between 2001 and 2012. Initial evaluation included computed tomography and endosonography. Follow up endoscopy was performed 4-6 weeks after PDT with ablation of any residual Barrett's mucosa using argon plasma coagulation (APC). Patients were then followed thereafter every 3-6 months with computed tomography, endosonography and endoscopic surveillance with every 1-2 cm biopsies from the treated area. Results: The median follow up period was 15 months (range, 2-125 months). Eighteen of 136 patients underwent endoscopic mucosal resection (EMR) for nodular glandular mucosa prior to Ps-PDT. Ps-PDT was the only ablation treatment utilized in 28/136 patients. Of these patients, 12/28 (43%) achieved complete remission of intestinal metaplasia (CRIM). The other 7/28 patients had their histopathology downgraded after Ps-PDT. Nine other patients underwent Ps-PDT as palliative treatment for locally advanced neoplasia. One patient was lost for follow up immediately after PDT. Thirty out of 51 ACA patients (60%) achieved CRIM while 62/85 HGD patients (73%) achieved CRIM. The rate of recurrence of HGD was 10% (9/85) while that of ACA was 11% (6/50). Additional endoscopic therapy was required in a subset of patients including 14 patients who underwent EMR for persistent nodular disease after Ps-PDT and 41 patients treated with RFA for persisent or recurrent cases of BE. Complications after Ps-PDT included symptomatic strictures requiring endoscopic dilation in 43% (58 patients), while 7 patients had severe photosensitivity reactions. Conclusion: Overall, 83% of patients with esophageal HGD and ACA were successfully ablated or downgraded by Ps-PDT, either as a sole treatment or followed by focal ablation using argon plasma coagulation. These treatments were associated with a low rate of disease recurrence. Notable complications persist after PS-PDT, however, including strictures and cutaneous photosensitivity reactions. However, Ps-PDT remains an important endoscopic, minimally invasive treatment alternative to esophageal resection surgery for patients with Barrett's dysplasia and neoplasia. Disclosure - Dr. Waseem David - Research Fellow; Pinnacle Biologics, Grant/Research Support. This research was supported by an industry grant from Pinnacle Biologics.