Photodiagnosis and Photodynamic Therapy (2006) 3, 11—14
Salvage photodynamic therapy for persistent esophageal cancer after chemoradiation therapy Herbert C. Wolfsen MD ∗, Lois L. Hemminger Division of Gastroenterology and Hepatology, Mayo Clinic, 4500 San Pablo Road, Jacksonville, FL 32224, USA
KEYWORDS Esophageal cancer; Photodynamic therapy; Chemoradiation therapy; Endoscopic ablation
∗
Summary Background: Locally advanced esophageal cancer may not be completely eradicated after chemoradiation therapy (CRT) and further treatment options are limited. Since 1998, we have used porfimer sodium photodynamic therapy (PDT) for inoperable patients with persistent mucosal carcinoma after CRT. Methods: Seven patients have undergone PDT after CRT: median age 75 (range 68—85), four patients male, three patients female. After upper endoscopy with biopsies documented neoplasm after CRT, patients were evaluated with contrastenhanced computed tomography of the chest and abdomen as well as endoscopic ultrasound to confirm persistence/recurrence of only mucosal disease. Results: Two patients had squamous carcinoma while five patients had Barrett’s adenocarcinoma (Barrett’s median segment length = 8 cm; range 5—10 cm). PDT was performed after infusion of 2 mg/kg porfimer sodium using a median light dose of 150 J/cm (range 100—200) using the bare fiber method. After PDT, all patients developed strictures requiring dilation (median number of dilations required = 5, range 1—18). These patients have subsequently been followed with endoscopy every 3—6 months (mean follow up = 30 months, range 12—50 months). After an initial response, the two patients with squamous cell carcinoma have subsequently been found to have recurrent disease and are being treated with erlotinib. The other five patients treated for Barrett’s carcinoma have remained disease free although one had died 33 months from metastatic colon cancer. Conclusion: In selected patients, PDT may be useful in the treatment of persistent/recurrent mucosal esophageal cancer after incomplete response to CRT. © 2006 Elsevier B.V. All rights reserved.
DOIs of related articles:10.1016/S1572-1000(06)00003-2, 10.1016/S1572-1000(06)00004-4, 10.1016/S1572-1000(06)00005-6. Corresponding author. Tel. +1 904 953 2221; fax: +1 904 953 7260. E-mail address: [email protected] (H.C. Wolfsen).
1572-1000/$ — see front matter © 2006 Elsevier B.V. All rights reserved. doi:10.1016/S1572-1000(06)00002-0
12
H.C. Wolfsen, L.L. Hemminger
Introduction Although many esophageal cancers can be surgically resected with curative intent (so-called R0 resections), a significant percentage of patients later develop local recurrence related to pre- or postoperative tumor cell dissemination [1,2]. Similarly, multimodality therapy without surgery using external beam radiation combined with cisplatin and fluorouracil has been associated with long-term survival in 14—26% of patients with locally advanced esophageal cancer [3]. These patients remain at risk, however, for the persistence of isolated, disseminated tumor cells with local mucosal infiltration [4]. While adjuvant chemotherapy has been studied as a means to minimize tumor relapse and improve prognosis in these patients with minimal residual malignant disease [5], there have been no reports following the initial descriptions of the use of photodynamic therapy (PDT) as an adjuvant or salvage technique [6]. The aim of the current study was to review our experience using porfimer sodium PDT for salvage adjuvant therapy in patients with persistent or recurrent mucosal carcinoma after chemoradiation therapy.
Methods Since 1997, we have used PDT with the photosensitizer porfimer sodium (Photofrin® ; Axcan, Mount St. Hilaire, Quebec, Canada) for endoscopic ablation and palliation of Barrett’s high-grade dysplasia and upper gut neoplasms. After approval of the Mayo Foundation Institutional Review Board, we reviewed our electronic database for patients diagnosed with persistent or recurrent esophageal adenocarcinoma or squamous cell carcinoma after chemoradiation therapy. Pre-treatment records, including other diagnostic imaging studies and
Table 1
pathology reports were reviewed to determine the clinical disease stage. While the standard treatment protocol at our Institution for locally advanced esophageal cancer is CRT followed by surgical resection, many patients refuse or are not medically fit to undergo surgery after completing CRT. All patients were evaluated with contrast-enhanced computed tomography and endosonography in order to select patients with persistent or recurrent neoplastic disease limited to the mucosa or submucosa, without involvement of the deeper muscle layers, para-esophageal lymph nodes or adjacent mediastinal structures. Fine needle aspiration with cytology analysis via endosonography (EUS) or endobronchial ultrasonography (EB-US) was used to evaluate abnormal appearing para-esophageal lymph nodes. The patients included in this study constitute a small percentage of all esophageal cancer patients treated with CRT at our Institution (
Salvage photodynamic therapy for persistent esophageal cancer after chemoradiation therapy Herbert C. Wolfsen MD ∗, Lois L. Hemminger Division of Gastroenterology and Hepatology, Mayo Clinic, 4500 San Pablo Road, Jacksonville, FL 32224, USA
KEYWORDS Esophageal cancer; Photodynamic therapy; Chemoradiation therapy; Endoscopic ablation
∗
Summary Background: Locally advanced esophageal cancer may not be completely eradicated after chemoradiation therapy (CRT) and further treatment options are limited. Since 1998, we have used porfimer sodium photodynamic therapy (PDT) for inoperable patients with persistent mucosal carcinoma after CRT. Methods: Seven patients have undergone PDT after CRT: median age 75 (range 68—85), four patients male, three patients female. After upper endoscopy with biopsies documented neoplasm after CRT, patients were evaluated with contrastenhanced computed tomography of the chest and abdomen as well as endoscopic ultrasound to confirm persistence/recurrence of only mucosal disease. Results: Two patients had squamous carcinoma while five patients had Barrett’s adenocarcinoma (Barrett’s median segment length = 8 cm; range 5—10 cm). PDT was performed after infusion of 2 mg/kg porfimer sodium using a median light dose of 150 J/cm (range 100—200) using the bare fiber method. After PDT, all patients developed strictures requiring dilation (median number of dilations required = 5, range 1—18). These patients have subsequently been followed with endoscopy every 3—6 months (mean follow up = 30 months, range 12—50 months). After an initial response, the two patients with squamous cell carcinoma have subsequently been found to have recurrent disease and are being treated with erlotinib. The other five patients treated for Barrett’s carcinoma have remained disease free although one had died 33 months from metastatic colon cancer. Conclusion: In selected patients, PDT may be useful in the treatment of persistent/recurrent mucosal esophageal cancer after incomplete response to CRT. © 2006 Elsevier B.V. All rights reserved.
DOIs of related articles:10.1016/S1572-1000(06)00003-2, 10.1016/S1572-1000(06)00004-4, 10.1016/S1572-1000(06)00005-6. Corresponding author. Tel. +1 904 953 2221; fax: +1 904 953 7260. E-mail address: [email protected] (H.C. Wolfsen).
1572-1000/$ — see front matter © 2006 Elsevier B.V. All rights reserved. doi:10.1016/S1572-1000(06)00002-0
12
H.C. Wolfsen, L.L. Hemminger
Introduction Although many esophageal cancers can be surgically resected with curative intent (so-called R0 resections), a significant percentage of patients later develop local recurrence related to pre- or postoperative tumor cell dissemination [1,2]. Similarly, multimodality therapy without surgery using external beam radiation combined with cisplatin and fluorouracil has been associated with long-term survival in 14—26% of patients with locally advanced esophageal cancer [3]. These patients remain at risk, however, for the persistence of isolated, disseminated tumor cells with local mucosal infiltration [4]. While adjuvant chemotherapy has been studied as a means to minimize tumor relapse and improve prognosis in these patients with minimal residual malignant disease [5], there have been no reports following the initial descriptions of the use of photodynamic therapy (PDT) as an adjuvant or salvage technique [6]. The aim of the current study was to review our experience using porfimer sodium PDT for salvage adjuvant therapy in patients with persistent or recurrent mucosal carcinoma after chemoradiation therapy.
Methods Since 1997, we have used PDT with the photosensitizer porfimer sodium (Photofrin® ; Axcan, Mount St. Hilaire, Quebec, Canada) for endoscopic ablation and palliation of Barrett’s high-grade dysplasia and upper gut neoplasms. After approval of the Mayo Foundation Institutional Review Board, we reviewed our electronic database for patients diagnosed with persistent or recurrent esophageal adenocarcinoma or squamous cell carcinoma after chemoradiation therapy. Pre-treatment records, including other diagnostic imaging studies and
Table 1
pathology reports were reviewed to determine the clinical disease stage. While the standard treatment protocol at our Institution for locally advanced esophageal cancer is CRT followed by surgical resection, many patients refuse or are not medically fit to undergo surgery after completing CRT. All patients were evaluated with contrast-enhanced computed tomography and endosonography in order to select patients with persistent or recurrent neoplastic disease limited to the mucosa or submucosa, without involvement of the deeper muscle layers, para-esophageal lymph nodes or adjacent mediastinal structures. Fine needle aspiration with cytology analysis via endosonography (EUS) or endobronchial ultrasonography (EB-US) was used to evaluate abnormal appearing para-esophageal lymph nodes. The patients included in this study constitute a small percentage of all esophageal cancer patients treated with CRT at our Institution (
