ERADICATION OF HIGH-GRADE DYSPLASIA IN COLUMNAR-LINED (BARRETTS) ESOPHAGUS BY PHOTODYNAMIC THERAPY WITH ENDOGENOUSLY GENERATED PROTOPORPHYRIN-IX

Background High-grade dysplasia in columnar-lined (Barrett's) oesophag us presents a difficult therapeutic dilemma. Choices for management ar e endoscopic surveillance to detect a cancer or oesophagectomy. One ca rries the risk of missing invasive cancer, the other carries worrying morbidity and mortality. We have used endoscopic photodynamic therapy to eradicate high-grade dysplasia. Methods After the oral administrati on of 5-aminolaevulinic acid, the accumulation of the endogenously gen erated photosensitiser protoporphyrin IX was measured with quantitativ e fluorescence microscopy. Five patients with histologically confirmed high-grade dysplasia were treated with endoscopic photodynamic therap y with 630 nm laser light to activate the photosensitiser. Findings Pr otoporphyrin IX accumulated in the dysplastic epithelium rather than t he adjacent stroma. Selective necrosis of the dysplastic epithelium in columnar-lined oesophagus occurred after light activation. High-grade dysplasia was eradicated in all patients and squamous regeneration oc curred after acid suppression with a proton-pump inhibitor. There were no complications or recurrence of dysplasia after 26-44 months' endos copic and histological follow-up. In two cases we saw non-dysplastic B arrett's epithelium underneath regenerative squamous mucosa. Interpret ation High-grade dysplasia in columnar-lined oesophagus can be eradica ted by endoscopic photodynamic therapy with endogenously generated PpI X. Remaining non-dysplastic Barrett's epithelium will require surveill ance, but overall the technique has interrupted or delayed the worseni ng of the dysplasia through to carcinoma. This technique may prevent t he need for surgical excision in these patients.