Jamieson, N.F.; Thorpe, S.; Mosse, A.; Bown, S.G.; Lovat, L.B.
April 2003
Gut;Apr2003 Supplement 1, Vol. 52, pA20
Academic Journal
Background: Oesophagectomy is considered first line therapy for high grade dysplasia (HGD) in Barrett's oesophagus but has considerable morbidity and mortality. Photodynamic therapy (PDT) using 5-aminolaevulinic acid (ALA) offers a minimally-invasive method for mucosal ablation of HGD. No published studies have attempted to optimise treatment conditions. Our aim was to confirm safety and determine the effect of light dose and treatment regime on outcome. Methods: With ethical approval, 22 patients with HGD (Vienna category 4) were treated from 1998. HGD was confirmed and carcinoma excluded by multiple biopsies, CT and EUS. Oesophagectomy was inappropriate because of co-morbidity or patient refusal. Patients received 60 mg/kg ALA orally (DUSA Pharmaceuticals Inc.) At endoscopy 4-6 h later, laser light (wavelength 633 nm) was delivered by diffuser fibre through an oesophageal balloon or silicone bolster at a dose of 500, 750 or 1000J/cm diffuser fibre. Follow up was by endoscopy and multiple biopsies after 1,3,6,9 and 12 months. PDT was repeated up to three times if HGD persisted. Results: Overall, 12/22 (55%) patients are clear of HGD, after a median follow up of 18 months. However, 9/12 (75%) patients treated with 1000 J are clear v 3/10 with lower light-doses (500-750 J) (p < 0.02). Two 1000 J treatments scheduled 4 weeks apart appears optimal: 8/9 (89%) clear of HGD at a median follow-up 7 months. HGD eradication was more likely when associated with a shorter Barrett's segment: median length 4 cm in successful treatments, 6 cm in failures (p < 0.02). There have been no deaths or oesophageal strictures. In a total follow-up of 40 patient-years, 4 HGD progressed to carcinoma but are clear of carcinoma after surgery (2), chemo-DXT (1) or PDT with a more potent agent (1). Conclusions: Photodynamic therapy using ALA is a safe initial approach to HGD in Barrett's oesophagus. Intensive therapy with two 1000 J/cm treatments 4 weeks apart appears the most effective...


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