Current Status of PDT in Gastroenterology 2015: Esophageal Carcinoma & Cholangiocarcinoma Herbert C....
-
Upload
patricia-joseph -
Category
Documents
-
view
215 -
download
0
Transcript of Current Status of PDT in Gastroenterology 2015: Esophageal Carcinoma & Cholangiocarcinoma Herbert C....
![Page 1: Current Status of PDT in Gastroenterology 2015: Esophageal Carcinoma & Cholangiocarcinoma Herbert C. Wolfsen pdt@mayo.edu Mayo Clinic, Jacksonville, Florida.](https://reader036.fdocuments.in/reader036/viewer/2022062518/56649ea95503460f94bacd91/html5/thumbnails/1.jpg)
Current Status of PDT in Gastroenterology 2015:
Esophageal Carcinoma & Cholangiocarcinoma
Herbert C. [email protected] Clinic, Jacksonville, Florida
Linda R. JonesDepartment of PhysicsCollege of CharlestonCharleston, South Carolina
![Page 2: Current Status of PDT in Gastroenterology 2015: Esophageal Carcinoma & Cholangiocarcinoma Herbert C. Wolfsen pdt@mayo.edu Mayo Clinic, Jacksonville, Florida.](https://reader036.fdocuments.in/reader036/viewer/2022062518/56649ea95503460f94bacd91/html5/thumbnails/2.jpg)
Early Esophageal Cancer Treatment: Is it Now an Endoscopic Disease?
Ngamruengphong S, Wolfsen HC, Wallace MB. Clin Gastro Hep 2013
![Page 3: Current Status of PDT in Gastroenterology 2015: Esophageal Carcinoma & Cholangiocarcinoma Herbert C. Wolfsen pdt@mayo.edu Mayo Clinic, Jacksonville, Florida.](https://reader036.fdocuments.in/reader036/viewer/2022062518/56649ea95503460f94bacd91/html5/thumbnails/3.jpg)
Porfimer sodium PDT for Esophageal Carcinoma and HGD
High-GradeDysplasia
LaserFiber
Spacing Balloon
![Page 4: Current Status of PDT in Gastroenterology 2015: Esophageal Carcinoma & Cholangiocarcinoma Herbert C. Wolfsen pdt@mayo.edu Mayo Clinic, Jacksonville, Florida.](https://reader036.fdocuments.in/reader036/viewer/2022062518/56649ea95503460f94bacd91/html5/thumbnails/4.jpg)
Photodynamic Therapy:The PHOBAR Trial
RCT of 208 subjects with HGD
• Intervention: PDT+PPI or PPI alone (2:1)
• Follow-up: mean of 24.2 (PDT) and 18.6 (PPI) months
• Assessment: Bx’s every 6 months
• 1° Outcome: Ablation of all HGD • 77% of PDT, 39% of PPI only
• 2° Outcome: 52% had complete eradication of IM
0
5
10
15
20
25
30
Cancer Incidence (%)
PPI
PDT + PPI
Overholt BF et al, Gastrointest Endosc 2005;62:488-98.
28%
13%
![Page 5: Current Status of PDT in Gastroenterology 2015: Esophageal Carcinoma & Cholangiocarcinoma Herbert C. Wolfsen pdt@mayo.edu Mayo Clinic, Jacksonville, Florida.](https://reader036.fdocuments.in/reader036/viewer/2022062518/56649ea95503460f94bacd91/html5/thumbnails/5.jpg)
Early Esophageal Cancer Survival
1618 pts HGD or T1aN0: 1998-2009 U.S. Population
Stage, treatment, outcome from CMS-linked SEER database
• 306 (19%) Endoscopic Rx
• 1312 (81%) Surgical Rx
![Page 6: Current Status of PDT in Gastroenterology 2015: Esophageal Carcinoma & Cholangiocarcinoma Herbert C. Wolfsen pdt@mayo.edu Mayo Clinic, Jacksonville, Florida.](https://reader036.fdocuments.in/reader036/viewer/2022062518/56649ea95503460f94bacd91/html5/thumbnails/6.jpg)
Barrett’s esophagus with Adenocarcinoma
![Page 7: Current Status of PDT in Gastroenterology 2015: Esophageal Carcinoma & Cholangiocarcinoma Herbert C. Wolfsen pdt@mayo.edu Mayo Clinic, Jacksonville, Florida.](https://reader036.fdocuments.in/reader036/viewer/2022062518/56649ea95503460f94bacd91/html5/thumbnails/7.jpg)
©2011 MFMER | slide-7
![Page 8: Current Status of PDT in Gastroenterology 2015: Esophageal Carcinoma & Cholangiocarcinoma Herbert C. Wolfsen pdt@mayo.edu Mayo Clinic, Jacksonville, Florida.](https://reader036.fdocuments.in/reader036/viewer/2022062518/56649ea95503460f94bacd91/html5/thumbnails/8.jpg)
©2011 MFMER | slide-8
![Page 9: Current Status of PDT in Gastroenterology 2015: Esophageal Carcinoma & Cholangiocarcinoma Herbert C. Wolfsen pdt@mayo.edu Mayo Clinic, Jacksonville, Florida.](https://reader036.fdocuments.in/reader036/viewer/2022062518/56649ea95503460f94bacd91/html5/thumbnails/9.jpg)
©2011 MFMER | slide-9
![Page 10: Current Status of PDT in Gastroenterology 2015: Esophageal Carcinoma & Cholangiocarcinoma Herbert C. Wolfsen pdt@mayo.edu Mayo Clinic, Jacksonville, Florida.](https://reader036.fdocuments.in/reader036/viewer/2022062518/56649ea95503460f94bacd91/html5/thumbnails/10.jpg)
Balloon-based Bipolar Electrode350 W at 465 kHz
Short RF burst ~300 msec
Standardized energy densityControls depth of ablationEnables uniform ablation
Eliminates point-and-shoot
![Page 11: Current Status of PDT in Gastroenterology 2015: Esophageal Carcinoma & Cholangiocarcinoma Herbert C. Wolfsen pdt@mayo.edu Mayo Clinic, Jacksonville, Florida.](https://reader036.fdocuments.in/reader036/viewer/2022062518/56649ea95503460f94bacd91/html5/thumbnails/11.jpg)
Ps-PDT RFAn= 208, 30 centers n= 127, 19 centers
Drug therapy Omeprazole 20 mg bid Esomep 40 mg bid
Nodular disease Additional 50 J/cm Endoscopic mucosal PDT light dose resection
Ablation Tx Up to 3 sessions, Up to 4 sessionscircumferential only (circum and focal)(mean 2.3) (mean 3.5)
CR-IM 52% 77%CR-HGD 77% 81%
Progression to 13% (28% Con) 2% (19% Con)cancer
Stricture 36% 6%Follow-up 24 months 12 months
![Page 12: Current Status of PDT in Gastroenterology 2015: Esophageal Carcinoma & Cholangiocarcinoma Herbert C. Wolfsen pdt@mayo.edu Mayo Clinic, Jacksonville, Florida.](https://reader036.fdocuments.in/reader036/viewer/2022062518/56649ea95503460f94bacd91/html5/thumbnails/12.jpg)
Primary endpoint: occurrence of complete remission of intestinal metaplasia
At 24 months, likelihood of CRIM was higher after Ps-PDT (92%) compared to RFA (56%; RR: 4.47, p<0.001) & EMR-RFA (75%, RR: 2.69, p<0.001)
![Page 13: Current Status of PDT in Gastroenterology 2015: Esophageal Carcinoma & Cholangiocarcinoma Herbert C. Wolfsen pdt@mayo.edu Mayo Clinic, Jacksonville, Florida.](https://reader036.fdocuments.in/reader036/viewer/2022062518/56649ea95503460f94bacd91/html5/thumbnails/13.jpg)
Conclusions
• Ps-PDT patients achieved remission from BE faster than EMR-RFA and RFA groups without a substantially higher recurrence rate
• Ps-PDT patients had fewer complications compared to EMR treated patients
• Bleeding significantly more common in EMR-RFA patients (12.2%) than both RFA patients (0.8%, P<0.001) and PDT patients (1.6%, P=0.001)
• Strictures less common in RFA patients (2.4%) compared to both EMR-RFA patients (13.3, P=0.001) and PDT patients (10.4%, P=0.043)
• Photosensitivity was reported in 10.4% of Ps-PDT patients.
![Page 14: Current Status of PDT in Gastroenterology 2015: Esophageal Carcinoma & Cholangiocarcinoma Herbert C. Wolfsen pdt@mayo.edu Mayo Clinic, Jacksonville, Florida.](https://reader036.fdocuments.in/reader036/viewer/2022062518/56649ea95503460f94bacd91/html5/thumbnails/14.jpg)
![Page 15: Current Status of PDT in Gastroenterology 2015: Esophageal Carcinoma & Cholangiocarcinoma Herbert C. Wolfsen pdt@mayo.edu Mayo Clinic, Jacksonville, Florida.](https://reader036.fdocuments.in/reader036/viewer/2022062518/56649ea95503460f94bacd91/html5/thumbnails/15.jpg)
Diffuse reflectance Fluorescence
0
20
40
60
80
100
120
140
160
180
600 650 700 750
Barrett's
Normal esophagus
Determine Ps tissue content
![Page 16: Current Status of PDT in Gastroenterology 2015: Esophageal Carcinoma & Cholangiocarcinoma Herbert C. Wolfsen pdt@mayo.edu Mayo Clinic, Jacksonville, Florida.](https://reader036.fdocuments.in/reader036/viewer/2022062518/56649ea95503460f94bacd91/html5/thumbnails/16.jpg)
Determine desired depth of treatmentMucosal thickness
Esophageal wall 1.7 to 6.0 mm
Mucosal thickness 1.0 to 2.0 mm
![Page 17: Current Status of PDT in Gastroenterology 2015: Esophageal Carcinoma & Cholangiocarcinoma Herbert C. Wolfsen pdt@mayo.edu Mayo Clinic, Jacksonville, Florida.](https://reader036.fdocuments.in/reader036/viewer/2022062518/56649ea95503460f94bacd91/html5/thumbnails/17.jpg)
Use Monte Carlo simulation to predict the optimal light dosecreate enough singlet oxygen molecules to overcome the natural repair mechanisms and cause irreversible damage
![Page 18: Current Status of PDT in Gastroenterology 2015: Esophageal Carcinoma & Cholangiocarcinoma Herbert C. Wolfsen pdt@mayo.edu Mayo Clinic, Jacksonville, Florida.](https://reader036.fdocuments.in/reader036/viewer/2022062518/56649ea95503460f94bacd91/html5/thumbnails/18.jpg)
Optical Model for BE:
vasculaturescatterthickness:mucosawall
![Page 19: Current Status of PDT in Gastroenterology 2015: Esophageal Carcinoma & Cholangiocarcinoma Herbert C. Wolfsen pdt@mayo.edu Mayo Clinic, Jacksonville, Florida.](https://reader036.fdocuments.in/reader036/viewer/2022062518/56649ea95503460f94bacd91/html5/thumbnails/19.jpg)
Cholangiocarcinoma
19
2nd most common hepatic neoplasm; Most patients are not candidates for surgery
For non-resectable cases, the 5-year survival rate is 0% and less than 5% in general.
Overall median duration of survival is less than 6 months
Extra hepatic and hilar tumors are the focus of PDT
![Page 20: Current Status of PDT in Gastroenterology 2015: Esophageal Carcinoma & Cholangiocarcinoma Herbert C. Wolfsen pdt@mayo.edu Mayo Clinic, Jacksonville, Florida.](https://reader036.fdocuments.in/reader036/viewer/2022062518/56649ea95503460f94bacd91/html5/thumbnails/20.jpg)
Cholangiocarcinoma
20
![Page 21: Current Status of PDT in Gastroenterology 2015: Esophageal Carcinoma & Cholangiocarcinoma Herbert C. Wolfsen pdt@mayo.edu Mayo Clinic, Jacksonville, Florida.](https://reader036.fdocuments.in/reader036/viewer/2022062518/56649ea95503460f94bacd91/html5/thumbnails/21.jpg)
0 500 1000 1500 20000
50
100PDT + E*E *
p < 0.0001
Days
% S
urvi
val ti
me
Ortner et al. Gastroenterology 2003
N = 39
*E = EndoprosthesesPorfimer sodium 2 mg/kg i.v. 630nm, 180J/cm2
Ps-PDT Associated with Increased Survival Compared with Endoscopic Drainage AlonePatients with unsuccessful drainage, tumors > 3 cm, n= 39
CONFIDENTIAL
![Page 22: Current Status of PDT in Gastroenterology 2015: Esophageal Carcinoma & Cholangiocarcinoma Herbert C. Wolfsen pdt@mayo.edu Mayo Clinic, Jacksonville, Florida.](https://reader036.fdocuments.in/reader036/viewer/2022062518/56649ea95503460f94bacd91/html5/thumbnails/22.jpg)