Invasive carcinoma after endoscopic ablative therapy for high-grade dysplasia in Barrett's oesophagus

Background: Patients with high-grade dysplasia (HGD) in Barrett's oesophagus carry a significant risk of developing adenocarcinoma. Endoscopic mucosal resection (EMR) and photodynamic therapy (PDT) aim at the radical ablation of the dysplastic area.

Methods: We used EMR to resect the macroscopic area of dysplastic mucosa followed by PDT to eliminate residual disease. PDT was performed after oral administration of 5-aminolevulinic acid (ALA, 40 mg/kg), using fractionated illumination 3 and 6 h later with 630 nm light at 100 J/cm(2) through an endoscopic balloon diffuser.

Results: We report 2 patients who developed adenocarcinoma shortly after incomplete endoscopic ablation of Barrett's epithelium. In a 61-year-old man with HGD in 8-cm Barrett's segment, HGD persisted 3 months after treatment. The oesophagectomy specimen showed a 2.3-cm pT2N0M0 adenocarcinoma in Barrett's. In a 69-year-old woman with extensive HGD in 5-cm Barrett's, HGD persisted after 3 PDT sessions in 1 year. Adenocarcinoma occurred 6 months after treatment. The oesophagectomy showed a pT1bN0M0 adenocarcinoma and extensive multifocal HGD in Barrett's.

Conclusions: The combination of EMR and PDT may be a promising option for local treatment of patients with HGD in Barrett's oesophagus, provided all dysplastic tissue can be removed. Currently it should be offered only to patients who are willing to participate in a clinical trial with an intensive endoscopic follow-up programme.