Combined endoscopic mucosal resection and photodynamic therapy for high-grade dysplasia and early cancer in Barrett's esophagus

The treatment of early neoplastic lesions in Barrett's esophagus may require a combination of therapies. Although both photodynamic therapy and mucosal resection have been demonstrated to have efficacy in treating early cancers and high dysplasia, the difficulty has been that removal of the most neoplastic visible lesions still permits unstable mucosa behind that may be histologically more benign. Although it is assumed that nondysplastic Barrett's mucosa has very little risk of further evolution to high-grade dysplasia or cancer, this has been taken in the context of patients who have never developed high-grade lesions. Multiple case series have shown that leaving behind Barrett's mucosa with or without dysplasia after removal of an early cancer leaves patients at increased risk of re-development of cancer. The treatment of these lesions is controversial. Further ablation of this residual tissue has been the preferred strategy by several experts with the use of extensive mucosectomy techniques or combining mucosectomy techniques with ablative strategies such as photodynamic therapy. Extensive mucosectomy would seem to have the theoretical advantage of completing eliminating neoplastic tissue, although this is difficult to achieve with current techniques. Photodynamic therapy can also be used in conjunction with mucosectomy with good results in small case series. Other possible combination therapies might include the use of chemoprevention agents, which is appealing but unproven at the present time.