Combined endoscopic mucosal resection and photodynamic therapy versus esophagectomy for management of early adenocarcinoma in Barrett's esophagus

Background & Aims: Although esophagectomy is the standard of care for treating early adenocarcinoma in Barrett's esophagus, the procedure is associated with significant morbidity and mortality. For these patients, the multimodal approach of endoscopic mucosal resection and photodynamic therapy (EMR/ PDT) may be a viable, less invasive option. Methods: A retrospective review (1996-2001) of all patients undergoing either combined EMR/PDT group or esophagectomy (SURG) for early-stage Barrett's adenocarcinoma was performed. Data were collected on patient demographics, tumor staging, procedure-related morbidity and mortality, persistence or recurrence of cancer, and cancer-related deaths after therapy. Differences in outcomes between the 2 groups were assessed. Results: Twenty-four patients were identified in the EMR/PDT group and 64 in the SURG group. The SURG group was found to have a significantly higher procedure-related complication rate compared with the EMR/PDT group (31 vs. 4; P < 0.01). There were no procedure-related deaths in the EMR/PDT group, whereas one death occurred in the SURG group as a result of complications. Eighty-three percent of patients (20 of 24) in the EMR/PDT group and all patients in the SURG group remained free of cancer over a follow-up of 12 ± 2 and 19 ± 3 months, respectively. Four patients in the EMR/PDT group failed to respond to therapy; 2 of them underwent alternate therapies and are free of disease, whereas the other 2 died of unrelated causes. Conclusions: The combination of EMR/PDT seems to be a viable and less morbid alternative to standard esophagectomy in patients presenting with early Barrett's esophageal adenocarcinoma. A prospective randomized, controlled trial of EMR/PDT compared with esophagectomy for managing early adenocarcinoma in Barrett's esophagus may be warranted.