Photodynamic therapy (PDT) theoretically can be applied in the presence of a coagulopathy because of its ability to cause thrombosis of small vessels and ischemic necrosis. However, this has not been reported to be useful on a clinical basis. AIM: To determine if severe coagulopathy would limit the application of PDT in the treatment of a superficial esophageal carcinoma. METHODS: A 74 year old female patient with HCV related Childs C cirrhosis was referred for treatment of an esophageal cancer associated with Barrett's esophagus. The coagulopathy was manifested by an elevated prothrombin time with INR>2.0 and platelet counts <30,000, Prior endoscopic biopsies had caused gastrointestinal hemorrhage requiring 2 units of blood despite fresh frozen plasma and platelets. This coagulopathy was felt to contraindicate surgical resection. The patient had an endoscopic ultrasound that demonstrated that she had a 10 cm Barrett segment with a 3 cm diameter tumor in the middle of the segment. The tumor was staged as a T2 lesion that on biopsy was a grade 3 adenocarcinoma. Due to the good functional status of the patient, compassionate use of photodynamic therapy was approved by the IRB. The patient was given 5.0 mg/kg of hematoporphyrin derivative IV. Forty-eight hours following injection, photodynamic therapy was performed at a light dose of 200 J/cm fiber using a 1.5 cm length fiber delivering 630 nm light at a power of 400 mW. Treatment was confined to the tumor and proximal Barrett's segment. The patient was not given any coagulation factors. RESULTS: The patient experienced nausea and odynophagia for a period of 2 weeks following the therapy. No clinical evidence of gastrointestinal hemorrhage occurred and the patient recovered completely in a month with ingestion of a normal diet. Follow-up endoscopy three months following treatment revealed an esophageal ulcer, regression of 4 cm of the Barrett's segment, and absence of a mass on EUS. Biopsies of the epithelium did reveal Barrett's epithelium but no evidence of carcinoma. CONCLUSIONS: Photodynamic therapy for esophageal carcinoma can be conducted in the setting of severe coagulopathy and may be a viable treatment for patients who are not candidates for surgery.
ASJC Scopus subject areas
- Radiology Nuclear Medicine and imaging