The Patient Support Network of Barrett's Oesophagus Foundation
Photodynamic Therapy
What is high-grade dysplasia?
Dysplasia is the term for the precancerous changes that develop in Barrett's oesophagus. High-grade dysplasia is the change immediately before becoming cancer. It can, however, take up to 10 years for dysplasia to develop into cancer, although it's not possible to predict in any individual patient how long it will take for this change to occur. In some people, cancer may have already started developing within the area of high-grade dysplasia at the time it is diagnosed.
How is high-grade dysplasia usually treated?
The standard treatment for high-grade dysplasia is an operation to remove the gullet called oesophagectomy. This is the only proven treatment for the condition, but unfortunately, it is very major surgery and usually involves opening both the stomach and the chest. It takes some months for people to return to full health after this. Therefore, alternative treatments are being investigated. These treatments involve removing the abnormal lining of the gullet at an endoscopy. The current experimental treatments include Argon Plasma Coagulation (APC), endoscopic mucosa resection (EMR) and photodynamic therapy (PDT).
What is Photodynamic Therapy (PDT)?
Photodynamic Therapy (PDT) is a new, experimental, type of laser treatment. Patients are given a drug, which makes them sensitive to light. There are different photosensitisers which may be used. The drug being used most commonly in the UK at the current time is ALA which makes people light sensitive for 36 hours. During this time they stay in a semi-darkened room. About 5 hours after taking the drug patients go to the Endoscopy Unit and have an endoscopy examination when a very bright laser light is shone into the oesophagus. The combination of light and drug causes the lining of the oesophagus, which is abnormal to be destroyed. This is replaced by more normal lining, which should result in a cure of the underlying problem.
Who is it for?
This experimental treatment is for people with high-grade dysplasia (pre-cancerous changes) arising in Barrett's columnar-lined oesophagus who are unable or who do not wish to have surgery. It is sometimes offered to people with widespread low-grade dysplasia as well.
How long does the operation take?
The whole procedure usually takes about one hour. It is done using sedation. This is not a general anaesthetic but the patient is sleepy and does not remember anything about the procedure.
What is the success rate?
Success rate depends on a number of factors including how extensive the dysplasia is, how well the acid from the stomach is suppressed from coming to the oesophagus using medicines and how many treatments are given. At present, the success rate is in the region of 50-70%.
Are there any risks?
ALA photodynamic therapy is a very safe procedure. The risks of the procedure itself are similar to a normal endoscopy test. With photodynamic therapy using other drugs, narrowing (strictures) of the oesophagus does occur, but this has never been reported with ALA PDT.
Are there any side effects?
ALA seems to have three major types of side effects:
A small number of people develop low blood pressure after ALA is given, but these can be prevented in most people by adequate intravenous fluid replacement before the procedure.
The second side effect, which occurs in most people is chest discomfort on swallowing for up to a week after the treatment.
The third side effect, which also occurs in many people, is mild depression, which can last for up to four weeks after treatment. This resolves spontaneously.
What is the recovery period?
The recovery period is approximately two to four weeks after the operation.
The following images show Barrett's prior to Photodynamic Therapy, Necrosis of oesophageal mucosa after one day of PDT, and Squamous regeneration and dysplasia eradicated one month after PDT.
During the recovery period, what impact will there be on normal lifestyle?
With this drug, there is no worry about light sensitivity, so people can go out in the light within 36 hours of the treatment. Many people feel washed out and therefore do not want to go back to work. We encourage everybody to go walking and to potter around the garden if they feel up to it within three days of the treatment, and they should be back to completely normal activity within two to four weeks.
Is there any monitoring after treatment?
The endoscopy test is usually repeated every three months for the first year, six monthly for the next year and annually after this. We do not know the long-term outcome following PDT as it is a new treatment, so patients are monitored very carefully.
If the laser treatment is not successful, is any other treatment possible?
Yes, laser treatment does not interfere with any other type of treatment such as surgery. If a person is fit to undergo an operation to remove the gullet (oesophagectomy), this can still be done after photodynamic therapy.
For people who are not fit for surgery, we do have an alternative experimental treatment called chemo-radiotherapy. If we think it is appropriate, we can recommend this treatment should laser fail.
Is ALA PDT the right treatment for me?
You will be assessed by the doctors who will be performing the treatment. They will perform an assessment endoscopy and sometimes they need to do other confirmatory tests.
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