Salvage photodynamic therapy for persistent esophageal cancer after chemoradiation therapy

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 contrast-enhanced 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.