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Photodynamic Therapy: Establishing Its Role in Palliation of Advanced Esophageal Cancer

The Korean Journal of Internal Medicine

The Korean Association of Internal Medicine

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      The physics, biophysics and technology of photodynamic therapy.

      Photodynamic therapy (PDT) uses light-activated drugs to treat diseases ranging from cancer to age-related macular degeneration and antibiotic-resistant infections. This paper reviews the current status of PDT with an emphasis on the contributions of physics, biophysics and technology, and the challenges remaining in the optimization and adoption of this treatment modality. A theme of the review is the complexity of PDT dosimetry due to the dynamic nature of the three essential components -- light, photosensitizer and oxygen. Considerable progress has been made in understanding the problem and in developing instruments to measure all three, so that optimization of individual PDT treatments is becoming a feasible target. The final section of the review introduces some new frontiers of research including low dose rate (metronomic) PDT, two-photon PDT, activatable PDT molecular beacons and nanoparticle-based PDT.
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        A controlled trial of an expansile metal stent for palliation of esophageal obstruction due to inoperable cancer.

        Esophageal obstruction due to cancer can produce debilitating dysphagia. Rapid palliation is usually possible with endoscopic placement of a plastic esophageal prosthesis, but this device has a high rate of complications. A new alternative is a metal-mesh stent that collapses to 3 mm in diameter at placement but can then expand up to 16 mm. Patients with esophageal carcinoma (39 patients) or malignant extrinsic obstruction (3 patients) were randomly assigned to treatment with either a plastic prosthesis (16 mm in diameter) or an expansile metal-mesh stent. The patients were evaluated every six weeks until death. The degree of palliation was expressed as a dysphagia score and a Karnofsky performance score. Complications were significantly less frequent with the metal stents than with the plastic prostheses (no complications vs. nine; P < 0.001). The dysphagia and Karnofsky scores improved significantly and to a similar degree in both treatment groups. The most common causes of recurrent dysphagia were migration of the plastic prostheses (five patients) and ingrowth or overgrowth of the metal stents by tumor (five patients). The rates of reintervention were similar in both treatment groups, as were the 30-day mortality rates. The period of hospitalization after placement of a prosthesis was significantly longer in the group given plastic prostheses than in the group given metal stents (mean +/- SE, 12.5 +/- 2.1 vs. 5.4 +/- 1.0 days; P = 0.005). Despite their higher initial cost, the metal stents were cost effective because of the absence of fatal complications and the decrease in the hospital stay. Expansile metal stents are a safe and cost-effective alternative to conventional plastic endoprostheses in the treatment of esophageal obstruction due to inoperable cancer.
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          Photodynamic therapy with porfimer sodium versus thermal ablation therapy with Nd:YAG laser for palliation of esophageal cancer: a multicenter randomized trial.

          Photodynamic therapy (PDT) is a different type of laser treatment from Nd:YAG thermal ablation for palliation of dysphagia from esophageal cancer. In this prospective, multicenter study, patients with advanced esophageal cancer were randomized to receive PDT with porfimer sodium and argon-pumped dye laser or Nd:YAG laser therapy. Two hundred thirty-six patients were randomized and 218 treated (PDT 110, Nd:YAG 108) at 24 centers. Improvement in dysphagia was equivalent between the two treatment groups. Objective tumor response was also equivalent at week 1, but at month 1 was 32% after PDT and 20% after Nd:YAG (p < 0.05). Nine complete tumor responses occurred after PDT and two after Nd:YAG. Trends for improved responses for PDT were seen in tumors located in the upper and lower third of the esophagus, in long tumors, and in patients who had prior therapy. More mild to moderate complications followed PDT, including sunburn in 19% of patients. Perforations from laser treatments or associated dilations occurred after PDT in 1%, Nd:YAG 7% (p < 0.05). Termination of laser sessions due to adverse events occurred in 3% with PDT and in 19% with Nd:YAG (p < 0.05). Photodynamic therapy with porfimer sodium has overall equal efficacy to Nd:YAG laser thermal ablation for palliation of dysphagia in esophageal cancer, and equal or better objective tumor response rate. Temporary photosensitivity is a limitation, but PDT is carried out with greater ease and is associated with fewer acute perforations than Nd:YAG laser therapy.
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            Author and article information

            Affiliations
            Division of Gastroenterology, Department of Internal Medicine, Korea University College of Medicine, Seoul, Korea.
            Author notes
            Correspondence to Jong-Jae Park, M.D. Division of Gastroenterology, Department of Internal Medicine, Korea University Guro Hospital, Korea University College of Medicine, 148 Gurodong-ro, Guro-gu, Seoul 152-703, Korea. Tel: 82-2-2626-1771, Fax: 82-505-115-1778, gi7pjj@ 123456yahoo.co.kr
            Journal
            Korean J Intern Med
            Korean J. Intern. Med
            KJIM
            The Korean Journal of Internal Medicine
            The Korean Association of Internal Medicine
            1226-3303
            2005-6648
            September 2012
            01 September 2012
            : 27
            : 3
            : 271-272
            3443717
            23019389
            10.3904/kjim.2012.27.3.271
            Copyright © 2012 The Korean Association of Internal Medicine

            This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License ( http://creativecommons.org/licenses/by-nc/3.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

            Categories
            Editorial

            Internal medicine

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