Long-term survival after photodynamic therapy for esophageal cancer

Photodynamic Therapy

ALA-PDT is a safe, well-tolerated, and effective treatment for many dermatologic conditions. Current data most strongly support its use in the treatment of actinic damage, but further investigation into alternative uses continues. Current efficacy is limited primarily by the depth of penetration of the photosensitizing agent and the activating light source. Even with this limitation, the potential applications of PDT are numerous. As new technology is developed to overcome current restraints, the future of PDT is wide open.

Can clinical and endoscopic findings accurately predict early-stage adenocarcinoma?

BACKGROUND

The presentation and management of esophageal cancer are changing, as more patients are diagnosed at an earlier stage of the disease in which endoscopic treatment methods may be contemplated. Therefore, we conducted a study to determine whether symptomatic and endoscopic findings can accurately identify node-negative early-stage adenocarcinoma.

METHODS

A total of 213 consecutive patients (171 men and 42 women) with resectable esophageal adenocarcinoma seen from 1992 to 2002 were evaluated. None of these patients received neoadjuvant chemotherapy or radiation therapy. Using a multivariable model, model-based probabilities of early-stage disease (T1 im/sm N0) were calculated for each combination of the following three features: no dysphagia as main symptom at presentation, tumor length <or=2 cm, and noncircumferential lesion.

RESULTS

Eighty-two percent of the patients with all three characteristics presented with early-stage disease. Even in the setting of small, visible, noncircumferential tumors/nodules in patients without dysphagia, 14% of the patients harbored node metastasis.

CONCLUSIONS

Simple clinical and endoscopic findings predicted early-stage disease in 82% of cases, whereas a small but significant percentage had node metastasis. Because node metastasis predisposes to local failure in nonresectional treatment options such as endoscopic mucosal resection and photodynamic therapy, such findings should have a significant bearing on treatment decisions.

Esophageal palliation--photodynamic therapy/stents/brachytherapy

The optimal treatment for malignant dysphagia should be safe, effective,cost-effective, and have minimal morbidity. Photodynamic therapy,brachytherapy, and esophageal stenting all represent viable options for the palliation of malignant dysphagia. Characterization of the patients and their tumors allows individualization of the treatment and the selection of the optimal treatment for each individual patient. Institutional resources and expertise also are significant factors in treatment. Further comparative studies may help further delineate the relative merits of these treatments and the optimal treatment of patients with malignant obstruction.

Photodynamic therapy for early oesophageal cancer

BACKGROUND

Photodynamic therapy is an endoscopic treatment of early cancers based on the photosensitisation of neoplasms following the administration of a photosensitiser prior to laser light-induced tissue destruction.

AIM

To assess the results of photodynamic therapy using Photofrin(Axcan Pharma Inc., Quebec, Canada) in patients with an early oesophageal cancer.

PATIENTS

Twenty-four patients with early oesophageal cancer presenting as a not well-demarcated irregular dyschromic area of mucosa and unsuitable for any other treatment underwent photodynamic therapy. RESULTS.: Seventy-five per cent were successfully treated; three of them recurred and two died from head and neck cancer. To date, 54% of patients are alive without recurrence; the average follow-up is 21 months. There were one oesophageal lethal perforation and six stenosis. Results of photodynamic therapy were limited in this series by three failures, three recurrences and three deaths from previous head and neck cancers.

CONCLUSION

This study provides some promising data for photodynamic therapy of oesophageal carcinomas in selected patients. It also emphasises the need for a best delivery device of laser light.

EUS followed by EMR for staging of high-grade dysplasia and early cancer in Barrett's esophagus

BACKGROUND

Accurate staging of high-grade dysplasia and of early cancer in Barrett's esophagus is important in the selection of patients for endoscopic therapy.

METHODS

Patients with Barrett's esophagus and biopsy specimen proven high-grade dysplasia and adenocarcinoma in focal nodular lesions or in endoscopically unapparent flat lesions in short-segment Barrett's esophagus were initially staged with EUS. In patients with disease limited to the mucosa on EUS, cap-assisted EMR was performed. The depth of tumor invasion on EMR specimens was classified in a similar manner to squamous-cell cancer of the esophagus: m1 (epithelial layer, dysplasia), m2 (lamina propria invasion), m3 (muscularis mucosae invasion), sm (submucosal invasion).

RESULTS

EUS was performed in 48 consecutive patients (27 with focal nodular lesions and 21 with microscopic lesions), and submucosal invasion was diagnosed in 8 (confirmed in 7/8 at surgery). EMR was carried out in the remaining 40 patients without significant complications. In the 25 patients with high-grade dysplasia on prior biopsy specimens, EMR confirmed m1 disease in 19; whereas in 6 (24%), invasive adenocarcinoma was detected (to m2 in 4; to m3 in 2). In the 15 patients with invasive cancer on prior biopsy specimens and staged as intramucosal cancer on EUS, intramucosal carcinoma was confirmed in 9 (m2 in 3; m3 in 6); whereas, in 6 patients (40%), submucosal invasion was found. Overall, EUS provided accurate staging in 41/48 patients (85%) with one patient overstaged and 6 patients understaged compared with pathologic staging obtained by surgery or EMR. Of the 34 patients with m1 to m3 staging after EMR, 29 were treated endoscopically and had no evidence of cancer after a mean follow-up of 22.9 months(standard deviation 9.2 months).

CONCLUSIONS

EMR provides pathologic staging information that, in addition, may be helpful after EUS if a stage-determined approach is used in the management of high-grade dysplasia and of early cancer in Barrett's esophagus. EMR may be particularly useful for staging of focal nodules or in short-segment Barrett's esophagus with microscopic lesions when endoscopic therapy is an option.

Photodynamic therapy as salvage treatment for local failures after definitive chemoradiotherapy for esophageal cancer

BACKGROUND

Although definitive chemoradiotherapy for esophageal cancer shows a high response rate, persistent or recurrent locoregional disease remains a major problem. Salvage esophagectomy is the only curative intent treatment option; however, it carries higher morbidity and mortality rates than primary esophagectomy. Response to second-line chemotherapy is quite dismal.

METHODS

From December 2002 to November 2003, we applied salvage photodynamic therapy to 13 patients with local failures after completion of chemoradiotherapy, 4 patients had local recurrence after achieving a complete response, and 9 had a persistent tumor after chemoradiotherapy. The decision to treat was based on patients' refusal of salvage surgery or chemotherapy. After the intravenous administration of 2 mg/kg of Photofrin, photoradiation treatment with an excimer dye laser was performed for 48 hours and 72 hours after the injection. Written informed consent was obtained from all patients.

RESULTS

Eight patients (62%) achieved a complete response. After a median follow-up period of 12 months after photodynamic therapy, 6 patients were still free of disease, and the overall survival rate at 1 year was 68.4%. There were no treatment-related deaths.

CONCLUSIONS

Our results show that salvage photodynamic therapy could be a promising curative intent treatment option with low morbidity and mortality rates.

Cell-cycle-dependent efficacy of photodynamic therapy with ATX-S10(Na)

Photodynamic therapy (PDT) is a useful strategy for treating various cancers. Details of the mechanisms of PDT have not been made clear yet. We intended to study the efficacy of PDT in relation to the cell cycle. HeLa S3 cells were synchronized by the thymidine block method. Cells in different cell cycle phases after release were treated with the water-soluble photosensitizer, ATX-S10(Na). The cellular viability after PDT was determined by the MTT assay. Intracellular levels of ATX-S10(Na) in different cell cycle phases were also determined. We found that cells in the S and G(2)/M phases were hypersensitive to PDT with ATX-S10(Na) in comparison with those in the G(1) phase, and that cellular levels of ATX-S10(Na) were increased in cells in the S and G(2)/M phases compared to those in the G(1) phase. We conclude that cellular ATX-S10(Na) levels differ among the different cell cycle phases, which is associated with the cell-cycle-dependent efficacy of PDT with ATX-S10(Na).

Palliative gastroenterology

Continuous improvements in endoscopic imaging and accessories have opened up a field of interventional endoscopy. This highly technical offshoot of gastroenterology uses not just standard endoscopic techniques but also newer endoscopic ultrasound (EUS) imaging or fluoroscopic monitoring to facilitate procedures that were once performed either surgically or percutaneously, if at all. This review will update the role of these novel procedures that can be used to assist in the palliative care of patients whose malignancies involve the gastrointestinal tract. The emphasis will be on those palliative interventions that are used to overcome intestinal obstruction in the gastrointestinal tract and restore luminal patency. The role of EUS-guided celiac plexus neurolysis to assist in pain control, especially in patients with pancreatic malignancies, will also be detailed.

[Radiotherapy and chemotherapy in the treatment of oesophageal carcinoma]

Surgery, chemotherapy and radiotherapy are the three major arms of treatment for cancer of the oesophagus, and combined modality therapy is required to treat advanced disease. Exclusive chemoradiotherapy is a feasible option for locoregionally advanced disease in responder patients. Elective surgery as a palliative procedure should not be regarded as a standard option in patients with metastatic or non-resectable oesophageal cancer. Surgery appears more and more as an adjuvant therapy in the curative treatment of oesophageal cancer, especially for advanced tumours.

Cost-effectiveness of photodynamic therapy for high-grade dysplasia in Barrett's esophagus

BACKGROUND

Photodynamic therapy appears to be effective in ablating high-grade dysplasia in Barrett's esophagus. Our aim was to identify the most effective and cost-effective strategy for managing high-grade dysplasia in Barrett's esophagus without associated endoscopically visible abnormalities.

METHODS

By using decision analysis, the lifetime costs and benefits of 4 strategies for which long-term data exist were estimated by us: esophagectomy, endoscopic surveillance, photodynamic therapy, followed by esophagectomy for residual high-grade dysplasia; and photodynamic therapy followed by endoscopic surveillance for residual high-grade dysplasia. It was assumed by us that there was a 30% prevalence of cancer in high-grade dysplasia patients and a 77% efficacy of photodynamic therapy for high-grade dysplasia and early cancer.

RESULTS

Esophagectomy cost 24,045 dollars, with life expectancy of 11.82 quality-adjusted life years. In comparison, photodynamic therapy followed by surveillance for residual high-grade dysplasia was the most effective strategy, with a quality-adjusted life expectancy of 12.31 quality-adjusted life years, but it also incurred the greatest lifetime cost (47,310 dollars) for an incremental cost-effectiveness of 47,410 dollars/quality-adjusted life years. The results were sensitive to post-surgical quality of life and survival, and to cancer prevalence if photodynamic therapy efficacy for cancer was less than 50%.

CONCLUSIONS

Photodynamic therapy followed by endoscopic surveillance for residual high-grade dysplasia appears to be cost effective compared with esophagectomy for patients diagnosed with high-grade dysplasia in Barrett's esophagus. Clinical trials directly comparing these strategies are warranted.

Photodynamic therapy of superficial esophageal cancer with a transparent hood

BACKGROUND

To improve the effectiveness of photodynamic therapy, the further development of endoscopic devices is essential. For photodynamic therapy of superficial esophageal cancer, a transparent hood was used to obtain precise laser irradiation.

METHODS

The transparent hood was attached to the tip of an upper endoscope. Forty-eight hours after the injection of porfimer sodium, cancerous lesions were irradiated with an excimer-dye laser (4 mJ, 80 Hz). Twenty-four hours later, additional irradiation was applied to lesions when the response to the initial irradiation appeared insufficient. Fifteen neoplastic lesions in 7 patients were treated.

RESULTS

The initial size of the lesions ranged from 5 to 30 mm in diameter. Histopathologically, there were 9 squamous-cell carcinomas and 6 high-grade squamous dysplastic lesions. All treated lesions disappeared after the first or the second laser irradiation (total energy range 39.1-193.5 J/cm(2)). During follow-up (range 4-51 months), there was no recurrence of the initial lesion in any patient. There was no severe photodynamic therapy related complication.

CONCLUSIONS

Photodynamic therapy with a transparent hood is an acceptable option for the treatment of superficial esophageal cancer.

Photodynamic therapy with green light and m-tetrahydroxyphenyl chlorin for intramucosal adenocarcinoma and high-grade dysplasia in Barrett's esophagus

BACKGROUND

The eradication of early stage neoplastic lesions in Barrett's esophagus is imperative to prevent invasive adenocarcinoma. Early stage lesions have an extremely low risk of lymph node metastasis, thereby, making local treatment feasible. Photodynamic therapy destroys malignant cells by a photochemical effect. The aims of this study were to evaluate the efficacy and tolerance of photodynamic therapy with green light and a new photosensitizer, temoporfin or m-tetrahydroxyphenyl chlorin in patients with Barrett's esophagus and early stage neoplastic lesions.

METHODS

Four days after injection of m-tetrahydroxyphenyl chlorin, lesions were illuminated at a wavelength of 514 nm through non-circumferential windowed diffusers. Follow-up endoscopy with biopsies was performed at regular intervals.

RESULTS

Fourteen lesions (7 high-grade dysplasia, 7 intramucosal adenocarcinoma) in 12 patients were treated. For all lesions, efficacy was 100% and squamous re-epithelialization was complete. Side effects were of moderate severity (one stricture). Mean follow-up was 34 (15) months (range 12-68 months).

CONCLUSIONS

Green light photodynamic therapy with m-tetrahydroxyphenyl chlorin can eradicate early stage neoplastic lesions in Barrett's esophagus and may be proposed as an alternative first-line therapy or a second-line therapy after failure of other endoscopic treatments. The efficacy and patient tolerance of the procedure justify further studies of the method in larger groups of patients.

High-Energy Laser Therapy of Barrett’s Esophagus: Preliminary Results

We present the preliminary results obtained by our research group utilizing Nd:YAG and diode lasers to treat Barrett's esophagus (BE). A total of 15 patients with BE (mean age 58 years) underwent endoscopic laser therapy: 11 with intestinal metaplasia, 2 with low-grade dysplasia, and 2 with high-grade dysplasia. The mean length of BE was 4 cm (range 1-12 cm). Six of these patients also underwent antireflux surgery, and nine were prescribed acid-suppressive medication. Endoscopic Nd:YAG laser treatment was carried out from 1997 to 1999; thereafter, diode laser was employed. The mean follow-up of these patients after the first laser session was 28 months. Patients underwent a mean of 6.5 laser sessions (range 3-17 sessions), with no apparent complications. The mean energy per session was 1705 JJ. Only six of these patients (40%) showed complete endoscopic and histologic remission, but a mean of 77% (SD 23.8%) of the total metaplastic tissue in all these patients was ablated. The percentage of healed mucosa was higher in patients with short-segment BE (92%) ( p < 0.05) and in subjects treated by two or more laser sessions per centimeter of BE length (89%) ( p < 0.05). All four patients with dysplasia showed histologic regression to nondysplastic BE or to squamous epithelium, without recurrence during a mean follow-up of 30 months. The patients who underwent antireflux surgery and those prescribed pharmacologic treatment had similar results. Nd:YAG and diode laser treatment of BE is a safe, effective procedure; it required two sessions per centimeter of metaplasia; and it achieved complete regression of the dysplasia. Further studies are necessary to quantify its effect on cancer incidence.

EUS-guided photodynamic therapy of the pancreas: a pilot study

BACKGROUND

Photodynamic therapy of pancreatic cancer by using percutaneously placed light catheters has been reported. The feasibility and safety of EUS-guided photodynamic therapy of the pancreas was studied in a porcine model.

METHODS

After injection of porfimer sodium, a 19-gauge needle was inserted into the pancreas, the liver, the spleen, and the kidney under EUS guidance. A small diameter quartz optical fiber was passed through the EUS needle and used to illuminate the tissue with laser light. The tissue response to photodynamic therapy was examined.

RESULTS

Localized tissue necrosis was achieved in all organs, without significant complication. There was no significant difference in inflammation induced by photodynamic therapy within the various organs.

CONCLUSIONS

EUS-guided photodynamic therapy is a safe and simple technique that can induce small areas of focal tissue ablation within the liver, the pancreas, the kidney, and the spleen, and potentially could be used to treat a variety of benign and malignant conditions.

High grade dysplasia: surveillance, mucosal ablation, or resection?

Barrett's esophagus is a common premalignant condition that results from chronic gastroesophageal reflux. High grade dysplasia in the metaplastic esophagus is thought to be the last step in the metaplasia-to-carcinoma sequence that characterizes this disease. The management of high grade dysplasia in Barrett's esophagus is controversial. Some investigators advocate a rigorous endoscopic surveillance program with biopsies, but this approach has been questioned because of its clinical impracticality, high cost, possibility of sampling errors, and difficulty demonstrating effectiveness on a reproducible basis. Others advocate mucosal ablative therapy to eradicate the dysplastic and metaplastic epithelium. This approach, still in its infancy, cannot be accepted as standard therapy at the present time because of limited follow-up, its questionable ability to completely eradicate the abnormal mucosa, the phenomenon of pseudoregression, and the patients require continued rigorous endoscopic surveillance. Esophagectomy, on the other hand, can be accomplished with a low mortality rate in these patients. We advocate this approach because a large number of them have invasive cancer in the esophagus despite a preoperative diagnosis of only high grade dysplasia. In addition, the 5-year survival is excellent even if invasive cancer is present, and these patients are liberated from rigorous endoscopic surveillance for the rest of their lives. For patients with high grade dysplasia in Barrett's esophagus who are poor operative risks, less invasive approaches such as mucosal ablation may play a role, but longer follow-up information is needed before this technique can be accepted even in this setting.

Photodynamic therapy in Barrett's esophagus

Photodynamic therapy (PDT) was one of the earliest ablative techniques applied to Barrett's esophagus. The rationale for this use was the ability to treat large amounts of esophageal mucosa in a single rapid application. Additionally, PDT has the ability to treat early carcinoma and dysplastic tissue. Because a small carcinoma in dysplastic Barrett's esophagus cannot not be excluded, PDT therapy is a reasonable treatment in this setting. The treatment involves the use of a light and drug combination that must be administered with close attention to dosimetry, since tissue effects of the therapy are delayed and cannot be observed at the time of treatment. Drug administration of sodium porfimer should precede photoradiation by 48 hours. Overall results with this treatment have been good. Case series have established a success rate of 88% to 100% in elimination of high-grade dysplasia. The only randomized multi-center prospective trial in the treatment of Barrett's esophagus with high-grade dysplasia has established that the treatment eliminates high-grade dysplasia better than administration of proton pump inhibitors alone. Unfortunately, there are significant adverse events, including cutaneous photosensitivity, odynophagia, stricture formation, and lack of response.

Neoadjuvant photodynamic therapy as a new approach to treating hilar cholangiocarcinoma: a phase II pilot study

BACKGROUND

Only 20-30% of patients with hilar cholangiocarcinomas (CC) are candidates for potentially curative resection. However, even after curative (R0) resection, these patients have a disease recurrence rate of up to 76%. The current prospective Phase II study investigated photodynamic therapy (PDT) as a neoadjuvant treatment for CC.

METHODS

Seven patients with advanced proximal bile duct carcinoma were evaluated. Patients were treated with PDT at the area of tumor infiltration and 2 cm beyond and underwent surgery after a median period of 6 weeks (range, 3-44 weeks).

RESULTS

One patient had a Bismuth-Corlette Type II tumor, two patients had Type IIIa, one patient had Type IIIb, and three patients had Type IV. Cholestasis parameters after PDT decreased significantly. No relevant adverse events from PDT occurred except for minor intraoperative phototoxicity in one patient. Three patients underwent right-sided liver resections, two patients underwent left-sided liver resections, and one patient received a combined hilar resection with partial pancreatoduodenectomy (PD) due to tumor extension into the distal bile duct. Liver transplantation and PD were performed in another patient. In all patients, R0 resection was achieved. Four patients developed minor surgical complications, even though the bilioenteric anastomoses were sewn to PDT-pretreated bile ducts. No viable tumor cells were found in the inner 4 mm layer of the surgical specimens. The PDT-pretreated epithelium of the tumor-free proximal resection margins exhibited only minimal inflammatory infiltration. Tumors recurred in 2 patients 6 and 19 months after surgery. The 1-year recurrence free survival rate was 83%.

CONCLUSIONS

Neoadjuvant PDT for hilar CC is a low-risk procedure with efficient selective destruction of the superficial 4 mm layer of bile duct tumor without complications exceeding series without neoadjuvant PDT. Neoadjuvant PDT should be evaluated prospectively to determine whether it reduces the rate of local disease recurrence after potentially curative resection.

Mucosal ablation with photodynamic therapy in the esophagus: optimization of light dosimetry in the sheep model

BACKGROUND

Photodynamic therapy is an attractive technique for mucosal ablation in patients with superficial squamous cell carcinoma of the esophagus, or high-grade dysplasia or early stage adenocarcinoma arising in Barrett's esophagus. Although illumination with green light is assumed to be safe, choice of the light has been empirical in clinical studies; light dose is often reduced to avoid potential complications. The present study assessed the safety of green and blue lights during photodynamic therapy in the esophagus by progressively administrating increasing doses in an attempt to standardize the dose and determine a safe upper limit. This would considerably simplify photodynamic therapy and improve therapeutic results.

METHODS

The sheep model was chosen because of similarities with humans regarding the thickness and histologic structure of the esophagus. Irradiation with a 180 degrees windowed cylindrical light distributor was performed in 19 sheep 4 days after injection of 0.15 mg/kg of tetra(m-hydroxyphenyl) chlorin. Light doses ranged from 10 to 500 J/cm(2) at 514 nm (argon ion laser) and from 5 to 250 J/cm(2) at 413 nm (krypton laser).

RESULTS

Follow-up endoscopies revealed a tissue response with a fibrinous area at almost all light doses, whereas application of extremely high light doses tended to induce circumferential necrosis with subsequent stenosis. Three months after irradiation with green light, histologic examination of the resected specimens revealed transmural scarring at doses higher than 100 J/cm(2). After illumination with blue light, partial or more extensive fibrosis of the muscular layer was observed only at light doses of 175 to 250 J/cm(2).

CONCLUSIONS

Application of high doses of green light after sensitization with tetra(m-hydroxyphenyl) chlorin led to severe complications in the esophagus of the sheep that are highly likely to occur in humans as well. Blue light causes significantly less damage than green light and may, therefore, be considered as an alternative for photodynamic therapy of early stage superficial esophageal cancer.

Surgical management of esophageal malignancy

Esophageal carcinoma is a highly lethal disease with increasing prevalence and an equally dramatic epidemiologic shift. Its causal association with gastroesophageal reflux disease and adenocarcinoma of the esophagus is well established, and the molecular events underlying this progression from mucosal injury to metaplasia to dysplasia to carcinoma are now becoming clear. Current diagnostic modalities and preoperative staging systems have significant limitations. The extent of surgical resection for esophageal carcinoma remains controversial. Disease confined to the mucosa and submucosa is more common, and endoscopic ablative techniques have been proposed. However, preoperative evaluation of tumor depth and regional nodal metastases remains inadequate in these very early lesions and urges caution before adoption of therapies that may compromise cure. Patients with disease confined to the mucosa or submucosa should undergo resectional therapy aimed at removing the entire esophageal wall, including the periesophageal and perihiatal lymph nodes. For disease penetrating the submucosa, the extent of surgical therapy must be tailored to the objectives of treatment (cure vs palliation) and preoperative stage. Although data from seven prospective, randomized trials are encouraging, no clear survival benefit has been documented for neoadjuvant combined-modality therapy. Surgical resection remains the standard of care and best chance for cure in the treatment of esophageal malignancy, with combined-modality therapy reserved for prohibitive surgery candidates.

Photodynamic therapy for esophageal cancer: a useful and realistic option

The use of light therapy for tissue destruction is highly attractive for the endoscopic and minimally invasive therapy of esophageal cancer. Photodynamic therapy (PDT) offers the possibility of palliation of advanced obstructing tumors. However, there are other competing techniques, which can be used to open the esophageal lumen. It has also proved very effective in providing prolonged palliation of patients with advanced irresectable cancer. Completely obstructing tumors, tortuous and long lesions, and tumors near the upper end of the esophagus are particularly suitable for photodynamic therapy. Patients with obstruction to an esophageal prosthesis are also well palliated with PDT. A more interesting and exciting development is its use for the eradication of early asymptomatic mucosal disease. Photodynamic therapy is particularly useful for the eradication of field cancerous change in patients with pre-malignant Barrett's esophagus, or early tumors in patients unfit for radical therapy.

Impact of antireflux operation on columnar-lined esophagus

BACKGROUND

The effect of antireflux operation on the natural history of columnar-lined esophagus (CLE) is not fully understood. The aim of this study was to assess a single center's experience and review the literature on the impact of antireflux operation on CLE without high-grade dysplasia.

STUDY DESIGN

The medical records of 26 patients with CLE but without high-grade dysplasia who underwent antireflux operation in our unit were retrospectively analyzed at longterm followup with detailed endoscopic investigation. Thirteen patients presented with intestinal metaplasia (6 had short segments, and 1 had preoperative laser ablation) and 13 without intestinal metaplasia. For the group of 13 patients presenting with intestinal metaplasia, the mean endoscopic followup was 74.7 months (median 46 months). Three of six with short-segment lesion and two of seven with circumferential involvement had complete regression of intestinal metaplasia (one after laser therapy). None had progression to dysplasia or carcinoma.

RESULTS

For the group of 13 patients without intestinal metaplasia, mean endoscopic followup was 43.9 months (median 28 months). One had complete regression of CLE, and none developed intestinal metaplasia during surveillance.

CONCLUSIONS

Our study suggests that antireflux operation can alter the natural history of CLE, allowing disease stabilization in a substantial proportion of patients. After antireflux operation, total regression of CLE is possible, but in an unpredictable manner.

Fluorescence endoscopy and photodynamic therapy

Fluorescence endoscopy is a new technique which allows a better detection of non-visible malignant or premalignant lesions or, those which are difficult to detect. Exogenously applied sensitisers accumulate selectively in malignant lesions and induce fluorescence after illumination with light of adequate wavelength. However, also endogenous fluorophores, different located in malignant or benign lesions, induce a different autofluorescence in these lesions. Tissue fluorescence can be detected by optical sampling of the mucosa using fluorescence spectroscopy or by generating real time fluorescence images with specialised camera systems. Compared to point fluorescence spectroscopy the latter technique enables the screening of large surface areas of mucosa. Meanwhile, fluorescence endoscopy is a widely used technique in urology employing 5-aminolaevulinic acid sensitisation. In gastroenterology, this technique seems promising for the detection of early cancers or dysplasia in patients with Barrett's oesophagus or ulcerative colitis. Using different sensitisers, photodynamic therapy seems to be a promising option for patients with advanced oesophageal cancer and in the palliative treatment of non-resectable bile duct cancer, furthermore for patients with early gastric cancer and dysplasia in Barrett's oesophagus. Probably, by laser light fractionation or a combination of different sensitisers, an enhanced effect can be expected.

Systemic photodynamic therapy with aminolevulinic acid induces apoptosis in lesional T lymphocytes of psoriatic plaques

Photodynamic therapy (PDT) is a recently approved treatment modality that involves the sequential administration of a photosensitizer or its precursor and light to generate singlet oxygen for treating diseased tissue. The use of topical aminolevulinic acid (ALA) and blue light for nonhypertrophic actinic keratoses currently represents the only approved dermatologic application for PDT in the U.S.A. ALA is a photosensitizer precursor that is metabolized by cells into protoporphyrin IX (PpIX), which can be subsequently activated by visible light. PDT with topical ALA has been shown to improve psoriasis, but post-treatment hyperpigmentation as well as inconsistent clinical responses despite repeated PDT sessions have limited the development of this treatment approach for psoriasis. Furthermore the use of topical PDT photosensitizers becomes somewhat impractical for treating larger body surface areas in patients with extensive psoriasis. We have recently shown that oral administration of ALA induces preferential accumulation of PpIX in psoriatic plaques. The objectives of this study were to evaluate the effects of PDT with blue light on psoriatic plaques after systemic ALA administration as well as to determine whether systemic ALA-PDT induces apoptosis in lesional T lymphocytes. It has been suggested that induction of apoptosis in lesional T lymphocytes may be indicative of longer remission time following treatment of psoriasis.

Photodynamic effects on rabbit auricular veins after photosensitization with porfimer sodium: Implications of the results with respect to the treatment of esophageal varices with photodynamic therapy

BACKGROUND

There are numerous clinical applications for photodynamic therapy in the GI tract. The principal reason for the wide variety of lesions amenable to photodynamic therapy is the ability to treat large areas of mucosa without the need for complete visualization. This report describes observed hemodynamic and histologic changes in rabbit auricles after photodynamic therapy and the feasibility of photodynamic therapy for esophageal varices.

METHODS

Porfimer sodium and an argon-dye laser (630 nm, 300 mW/cm(2)) were used. Twenty rabbits were grouped according to porfimer sodium dose: group 1 (2.0 mg/kg, n = 10); group 2 (1.0 mg/kg, n = 6); group 3 (0.2 mg/kg, n = 4). Rabbit auricular veins were classified according to time duration of laser illumination: V(0), no illumination; V(5), 5 minutes; V(10), 10 minutes; V(15), 15 minutes. Hemodynamic changes were observed with a laser Doppler blood flow meter. Histologic changes were evaluated by light microscopy.

RESULTS

For groups 1 and 2, there was a significant decrease in blood flow for V(15) after photodynamic therapy, but not in group 3. There was a significant difference in the grade of thrombus between V(5) and V(15) in groups 1 and 2, and between V(10) and V(15) in group 2. There was a significant difference in the grade of venous dilation (congestion) for V(15) between groups 1 and 3 (p < 0.05, Kruskal-Wallis test).

CONCLUSIONS

Endoscopic photodynamic therapy could possibly improve the outcome for endoscopic treatment of esophageal varices beyond that achieved by sclerotherapy or band ligation alone.

Potential efficacy of a delta 5-aminolevulinic acid thermosetting gel formulation for use in photodynamic therapy of lesions of the gastrointestinal tract

Photodynamic therapy (PDT) using 5-aminolevulinic acid (ALA)-induced protoporphyrin IX may play a role in the treatment of dysplastic Barrett's oesophagus. An ALA thermosetting gel Pluronic F-127) was developed and evaluated in an in vivo mouse model for potential use in PDT of Barrett's mucosa. In vitro studies of the influence of Pluronic F-127 percentage on thermosetting gel temperature, followed by the influence of ALA concentration on thermosetting temperature and ALA-gel stability as a function of time or temperature were studied. In vivo relationships between ALA doses and fluorescence were studied to determine the optimal concentration. Fluorescence measurement in vivo showed that ALA concentration and time had a nonlinear influence on protoporphyrin IX synthesis. For ALA-gel applications longer than 30 min a plateau fluorescence was reached, the maximum fluorescence being obtained after 4 h whatever the time of contact. The maximum intensity (2824 counts s(-1)) was found with 40 mg mL(-1) ALA-gel, and fluorescence intensities differed with time, reaching a maximum after 3-4 h. ALA-Pluronic F-127 is a suitable formulation for treatment of Barrett's oesophagus, allowing easy application in liquid form at 4 degrees C and good adhesion in the oesophagus in gel form, with efficient diffusion of ALA into treated mucosa.

Clinical aspects of photodynamic therapy

Photodynamic therapy is a method for local destruction of tissue or organisms by generating toxic oxygen and other reactive species using light absorbed by an administered or an endogenously generated photosensitiser. It is a highly promising treatment for patients with cancer. More recently it has found increasing use as a method of therapy for non-cancerous illnesses. It depends on the exploitation of natural and vital reactions widespread in nature that have driven and preserved life on this planet. Following administration of a photosensitiser or its precursor there is an accumulation or retention in areas of cancer and disease relative to adjacent normal tissue. The photosensitiser is inactive until irradiated by light, following which cellular destruction occurs. The clear attraction of this method is the possibility of some targeting of the disease by drug and by the area irradiated. This explanation although oversimplified has been the reason for the scientific and clinical interest in photodynamic therapy. An understanding of evolutionary photobiology is enormously helpful to understand disease response and clinical outcomes.

Photodynamic therapy with 5-aminolevulinic acid is not effective in bile duct cancer

BACKGROUND

The results of preliminary studies of photodynamic therapy (PDT) for palliation of patients with bile duct cancer with hematoporphyrin derivative have been good. Rapid elimination of a photosensitizer could potentially shorten the time requirement for shielding from light. This would enhance the benefit of this form of palliative treatment. Therefore the feasibility of PDT was investigated for nonresectable bile duct cancer by using 5-aminolevulinic acid.

METHODS

Four patients with nonresectable bile duct cancer underwent cholangiography, cholangioscopy, and intraductal US before PDT. Light activation was performed 5 to 7 hours after oral administration of 5-aminolevulinic acid. All patients had an endoprosthesis placed in the bile duct after PDT.

RESULTS

Cholangioscopy 72 hours after PDT revealed superficial fibrinoid necrosis. However, 4 weeks after PDT there was no significant reduction in bile duct stenoses. Two patients had infectious complications develop, but phototoxicity was not observed.

CONCLUSIONS

Although superficial tumor necrosis was evident, PDT with 5-aminolevulinic acid failed to significantly reduce malignant bile duct obstruction. Therefore 5-aminolevulinic acid-PDT cannot be recommended for the palliative treatment of bile duct cancer.

Clinicopathologic characteristics and survival of patients with clinical Stage I squamous cell carcinomas of the thoracic esophagus treated with three-field lymph node dissection

OBJECTIVE

Clinicopathologic characteristics and survival rates of patients with clinical Stage I tumors treated with three-field lymph node dissection have not been well investigated. This report documents the results of a series of cases of clinical Stage I squamous cell carcinomas treated with this surgical procedure in our institute.

METHODS

From January 1988 to March 1997, 326 patients with carcinomas of the thoracic esophagus underwent transthoracic esophagectomy with three-field lymph node dissection. Two hundred and ninety-seven (91%) of these had squamous cell carcinomas. Fifty-seven (18%) patients with clinical Stage I squamous cell carcinomas of the thoracic esophagus were retrospectively reviewed here.

RESULTS

Among 57 clinical Stage I squamous cell carcinomas, ten (18%) were diagnosed as T1-mucosal and 47 (83%) as T1-submucosal. Seventy percent of the patients with clinical T1-mucosal tumors had additional primary esophageal lesions. The operative morbidity and in-hospital mortality rates were 63 and 0%, and the overall 1-, 3-, 5-, and 10-year survival rates were 95, 86, 78, and 70%, respectively. Of the 57 tumors assessed pathologically, 12 (21%) were T1-mucosal, 42 (74%) were T1-submucosal, and three (5%) were T2. Nineteen (33%) exhibited lymph node metastasis. The 1-, 3-, 5-, and 10-year survival rates for patients with lymph node metastasis were 90, 79, 73, and 58%, respectively, as compared with 97, 90, 80, and 76, respectively for patients without lymph node metastasis (P=0.24). The accuracy of preoperative staging, based on both wall penetration and the status regarding lymph node metastasis, was 63%. With reference to the 1997 UICC-TNM staging system, 36 (63%) were pStage I, two (4%) were pStage IIA, 18 (28%) were pStage IIB, and three (6%) were pStage IVB. The 1-, 3-, 5-, and 10-year survival rates for patients with pStage I disease were 97, 92, 85, and 81%, respectively. In those with pStage II or IV disease, the values were 91, 76, 65, and 52%, respectively.

CONCLUSIONS

Three-field lymph node dissection may be indicated even for patients with clinical Stage I squamous cell carcinoma requiring surgical intervention because this surgical procedure provides for possible cure by removing unsuspected lymph node metastasis.

The history of photodetection and photodynamic therapy

Light has been employed in the treatment of disease since antiquity. Many ancient civilizations utilized phototherapy, but it was not until early last century that this form of therapy reappeared. Following the scientific discoveries by early pioneers such as Finsen, Raab and Von Tappeiner, the combination of light and drug administration led to the emergence of photochemotherapy as a therapeutic tool. The isolation of porphyrins and the subsequent discovery of their tumor-localizing properties and phototoxic effects on tumor tissue led to the development of modern photodetection (PD) and photodynamic therapy (PDT). This review traces the origins and development of PD and PDT from antiquity to the present day.

Oral aminolevulinic acid induces protoporphyrin IX fluorescence in psoriatic plaques and peripheral blood cells

Photodynamic therapy (PDT) with topical aminolevulinic acid (ALA) has been shown in previous studies to improve psoriasis. However, topical ALA-PDT may not be practical for the treatment of extensive disease. In order to overcome this limitation we have explored the potential use of oral ALA administration in psoriatic patients. Twelve patients with plaque psoriasis received a single oral ALA dose of 10, 20 or 30 mg/kg followed by measurement of protoporphyrin IX (PpIX) fluorescence in the skin and circulating blood cells. Skin PpIX levels were determined over time after ALA administration by the quantification of the 635 nm PpIX emission peak with in vivo fluorescence spectroscopy under 442 nm laser excitation. Administration of ALA at 20 and 30 mg/kg induced preferential accumulation of PpIX in psoriatic as opposed to adjacent normal skin. Peak fluorescence intensity in psoriatic and normal skin occurred between 3 and 5 h after the administration of 20 and 30 mg/kg, respectively. Ratios of up to 10 for PpIX fluorescence between psoriatic versus normal skin were obtained at the 30 mg/kg dose of ALA. Visible PpIX fluorescence was also observed on normal facial skin, and nonspecific skin photosensitivity occurred only in patients who received the 20 or 30 mg/kg doses. PpIX fluorescence intensity was measured in circulating blood cells by flow cytometry. PpIX fluorescence was higher in monocytes and neutrophils as compared to CD4+ and CD8+ T lymphocytes. PpIX levels in these cells were higher in patients who received higher ALA doses and peaked between 4 and 8 h after administration of ALA. There was only a modest increase in PpIX levels in circulating CD4+ and CD8+ T lymphocytes. In conclusion oral administration of ALA induced preferential accumulation of PpIX in psoriatic plaques as compared to adjacent normal skin suggesting that PDT with oral ALA should be further explored for the treatment of psoriasis.

Photodynamic therapy for palliation of nonresectable bile duct cancer--preliminary results with a new diode laser system

OBJECTIVES

Preliminary results of photodynamic therapy (PDT) of bile duct cancer have shown astonishingly good results in the reduction of cholestasis, improvement of quality of life, and even prolongation of the survival time. Unfortunately, the existing dye laser systems are large and costly, and their maintenance is expensive. Therefore, we investigated the feasibility of a diode laser system for PDT of nonresectable bile duct cancer.

METHODS

Eight patients with nonresectable bile duct cancer were treated. Forty-eight hours after i. v. application of 2 mg/kg body weight of Photosan-3, light activation was performed by a transpapillary (four patients) or percutaneus (four patients) access. We used a cylindrical diffusor tip and illuminated using a wavelength of 633+/-3 nm and a total energy of 200 J/cm2. All patients were additionally provided with bile duct endoprostheses after PDT.

RESULTS

Four weeks after initial PDT all patients showed a marked reduction of bile duct stenosis. The median serum bilirubin value declined from 5.8 mg/dl (2.0-10.1) to 1.0 mg/dl (0.8-4.4). The median survival time at the time of writing is 119 days (52-443). Five patients are still alive. In four patients we could change from percutaneous to transpapillary drainage after PDT, two patients showed infectious complications.

CONCLUSION

PDT with the diode laser system seems to be effective in reducing malignant bile duct stenosis. This treatment is minimally invasive and has a low specific complication rate. Randomized, controlled studies comparing PDT with the insertion of endoprostheses and long term follow-up of results are needed to confirm the promising short term results.

Photodynamic therapy and the alimentary tract

Photodynamic therapy offers the possibility of relatively selective tumour necrosis and normal tissue healing. It has many potential applications but as yet no clear role. Articles, editorials and case reports published primarily in English and listed in Medline/ISI up to April 2000 or identified by a manual search have been reviewed in an attempt to provide a comprehensive overview of the use of photodynamic therapy in the alimentary tract. It is concluded that photodynamic therapy can be an effective treatment for superficial pre-malignant mucosal lesions and early cancers, especially in diffuse disease. Suitable patients include those wishing to avoid surgery, high risk subjects or those in whom other forms of treatment have failed. Superiority over other methods of ablation has not so far been demonstrated. Cheaper and more effective photosensitizers and improved techniques of light delivery are likely to increase the application of photodynamic therapy.

Current status of ablative therapies in esophageal disorders

Endoscopic ablative therapies for esophageal diseases have been used for palliation of inoperable esophageal cancer, but their use in eradication of early esophageal cancer and Barrett's esophagus (with and without dysplasia) has been reported in recent publications. Pharmacologic and surgical treatment of reflux symptoms in patients with Barrett's esophagus has not consistently reversed the metaplastic epithelium. This has led investigators to try different modalities of local injury to the columnar mucosa in an acid-reduced environment. Endoscopic reversal of Barrett's esophagus (visual replacement of columnar mucosa by squamous mucosa) is more readily achievable than complete histologic reversal. Preliminary data show that endoscopic reversal of Barrett's esophagus can be achieved, but intestinal metaplasia underlying the new squamous mucosa is reported in almost all series. Incidence of adenocarcinoma in patients with Barrett's without dysplasia is probably so low that endoscopic ablation as a therapy cannot be advocated outside of study protocols. Endoscopic therapy as a definitive treatment for patients with high-grade dysplasia (HGD) and/or early adenocarcinoma holds promise, especially in older patients with comorbid illnesses. Future long-term randomized studies are needed to determine whether ablative therapies can provide an alternative approach for patients with HGD and early cancer. Advanced cancers that are not resectable for cure can be effectively treated by endoscopic therapy for palliation of dysphagia.

Squamous cell cancer of the oesophagus

Squamous cell cancer is the most common neoplasm of the oesophagus worldwide, with an enormous variation in its global incidence. Several risk factors, such as achalasia, Plummer-Vinson syndrome, coeliac disease and nutritional factors, have been identified. The surveillance of patients, especially those with tylosis or caustic ingestion, has been recommended. Vital staining with iodine may improve the diagnosis of early cancer. The endoscopic management of early cancer and dysplasia by minimal invasive techniques such as photodynamic therapy or mucosal resection has become attractive for many of these patients with co-morbidity.

Review article: the potential role for photodynamic therapy in the management of upper gastrointestinal disease

Photodynamic therapy involves the activation of an exogenously administered, or an endogenously generated, photosensitizer with light to produce localized tissue destruction. It is an attractive, predominantly endoscopic technique for the palliation of advanced upper gastrointestinal cancer and the eradication of early neoplastic and pre-neoplastic lesions. The nature of the biological response allowing safe healing and the exploitation of tissue threshold effects mean that adjacent tissue damage can be minimized. This review used a database of 368 papers. The nature of the photosensitizer is critical to the depth of tissue damage and the risk of adjacent tissue damage and stricture formation. The generation of protoporphyrin IX following administration of 5-aminolaevulinic acid has proved useful for the treatment of high-grade dysplasia in Barrett's oesophagus. A double-blind randomized placebo controlled trial has confirmed that it is a safe and effective method for the ablation of low-grade dysplasia. The treatment of more advanced lesions requires exogenously administered photo-sensitizers. However, recent data indicate that the neoplastic potential remains in some patients and continued follow-up is necessary. Photodynamic therapy can be used to eradicate early neoplasia and palliate advanced cancer, but caution is required before a definitive cure can be claimed.

Combined photodynamic therapy and hyperbaric oxygenation in carcinoma of the esophagus and the esophago-gastric junction

OBJECTIVES

The photochemical reaction of photodynamic therapy (PDT) depends on the presence of molecular oxygen. Due to anoxic regions in tumor tissue and vascular shutdown during PDT the efficiency is limited. Therefore, the use of hyperbaric oxygen which increases the oxygen in tumor tissue, as well as the amount of singlet oxygen, may enhance the efficiency of PDT.

PATIENTS AND METHODS

After diagnostic work-up, photosensitization was carried out with a hematoporphyrin-derivate 2 mg/kg BW 48 h prior to PDT. The light dose was calculated as 300 J/cm fiber tip. Thirty-one patients were treated by PDT alone and 44 patients received PDT under hyperbaric oxygen at a level of two absolute atmospheric pressure.

RESULTS

Improvement regarding stenosis-diameter could be obtained in both treatment arms with no significant difference (P=0.82). The dysphagia-score and tumor-length also decreased in both groups and showed a significant difference in favour of the PDT/HBO-group (P=0. 0064 and P=0.0002, respectively). The median overall survival for the PDT-group was 7 months and for the PDT/HBO-group 12 months (P=0. 0098).

CONCLUSION

According to this prospective non-randomized study, combined PDT/HBO represents a new approach in the treatment of esophageal and cardia cancer which appears to have enhanced the efficiency of PDT.

Optimizing endoscopic biopsy detection of early cancers in Barrett's high-grade dysplasia

OBJECTIVE

The of high-grade dysplasia management (HGD) in Barrett's esophagus remains controversial, in part, because of uncertainty about the ability of endoscopic biopsies to consistently detect early, curable cancers.

METHODS

Here we report cancers we have diagnosed in 45 patients with Barrett's HGD using a protocol involving serial endoscopies with four-quadrant biopsies taken at 1-cm intervals. We compare these results to a modeled endoscopic biopsy protocol in which four-quadrant biopsies are taken every 2 cm in the Barrett's segment.

RESULTS

Thirteen cancers were detected at the baseline endoscopy and 32 in surveillance. In 82% of patients, cancer was detected at a single 1-cm level of the esophagus, and in 69% the cancer was detected in a single endoscopic biopsy specimen. A 2-cm protocol missed 50% of cancers that were detected by a 1-cm protocol in Barrett's segments 2 cm or more without visible lesions. The maximum depth of cancer invasion was intramucosal in 96% of patients. Only 39% of patients who had endoscopic biopsy cancer diagnoses had cancer detected in the esophagectomy specimen. Adverse outcomes included the development of regional metastatic disease during surveillance (1 of 32), operative mortality (3 of 36), including two patients who had their primary surgeries at other institutions, and death from metastatic disease after endoscopic ablation performed at another institution (1 of 3).

CONCLUSIONS

A four-quadrant, 1-cm endoscopic biopsy protocol performed at closely timed intervals consistently detects early cancers arising in HGD in Barrett's esophagus and should be used in patients with HGD who do not undergo surgical resection.

Advances in diagnostic and therapeutic endoscopy

Endoscopy is extremely valuable in the evaluation of disorders of the luminal gastrointestinal tract, pancreas, and biliary system. Endoscopy as a medical discipline continues to evolve and is becoming increasingly therapeutic in nature. Minimally invasive endoscopic intervention now is effective in a wide variety of disorders, including gastrointestinal hemorrhage, obstructive diseases of the intestinal or biliary tree, and early detection or prevention of neoplastic disease of the colon and esophagus. The development of EUS technology has expanded greatly the potential utility of endoscopy as a diagnostic and a therapeutic modality, and further technologic advances are anticipated.

Cervical lymph node metastasis in patients with submucosal carcinoma of the thoracic esophagus

BACKGROUND AND OBJECTIVES

The effect of esophagectomy with three-field lymph node dissection for submucosal carcinoma of the thoracic esophagus remains controversial. The aim of this study was to evaluate the effect of esophagectomy with three-field lymph node dissection for submucosal carcinoma of the thoracic esophagus.

METHODS

From January 1983 to December 1997, the records of 101 consecutive patients who underwent transthoracic esophagectomy with three-field lymph node dissection were retrospectively analyzed.

RESULTS

The incidence of the operative complications was 70%. The 30-day and overall hospital mortality rates were 1.0% and 2.0%, respectively. The positive rate of histological cervical nodal metastasis was 17%. The 5-year survival rates for the patients with and those without cervical nodal metastasis were 55% and 71%, respectively. The difference between patients with and those without cervical nodal metastasis was not statistically significant. Cumulative 5-year survival rates for the patients with metastasis in the cervical, upper mediastinal, or abdominal lymph nodes were 55%, 65%, and 46%, respectively. There was no statistically significant difference between each survival.

CONCLUSIONS

Three-field lymph node dissection may be indicated for patients requiring esophagectomy for submucosal carcinoma of the thoracic esophagus because the frequency of cervical lymph node metastasis is not negligible and acceptable overall hospital mortality and favorable survival rates of patients with histologically positive cervical nodes can be achieved.

Effect of photodynamic therapy in a multimodal approach for advanced carcinoma of the gastro-esophageal junction

Background and Objective We wanted to determine the role of additional photodynamic therapy in a multimodal approach for the treatment of patients with advanced cancer of the gastro-esophageal junction. Study Design/Materials and Methods We reviewed 53 patients, after endoluminal palliation, with advanced cancer of the gastro-esophageal junction. Combined dilatation and retrograde tumor disobliteration with Nd-YAG laser before photodynamic therapy (PDT), brachyradiotherapy, or both, became necessary in 12 patients. Brachyradiotherapy was carried out in all patients. PDT before brachyradiotherapy was performed in 25 patients. The endoluminal treatment was completed by external beam irradiation in 30 patients (15 cases with PDT and 15 without PDT) with an at least fair performance status.

RESULTS

Photodynamic therapy showed a significant difference regarding the mean opening of the tumor stenosis (mean, 6.4 mm; P = 0.0002), the mean decrease in tumor length (3.1 cm; P = 0.00001) and the increase in median survival (13. 8 months; P = 0.001). The combined multimodal approach by using PDT, brachyradiotherapy and external beam irradiation showed a median survival of 16.8 months. However, additional external beam irradiation showed no significant difference (P = 0.11). The rate of severe complications was 5.7%. The mortality rate was 1.9%.

CONCLUSION

Photodynamic therapy has been shown to be an effective treatment for palliation of advanced cancer at the gastro-esophageal junction. The use of PDT combined with irradiation was associated with an acceptable survival rate, low rates of complications and reasonable quality of life.