Mucosal ablation with photodynamic therapy in the esophagus: optimization of light dosimetry in the sheep model1

BACKGROUND: Photodynamic therapy is an attractive technique for mucosal ablation in patients with superficial squamous cell carcinoma of the esophagus, or high-grade dysplasia or early stage adenocarcinoma arising in Barrett's esophagus. Although illumination with green light is assumed to be safe, choice of the light has been empirical in clinical studies; light dose is often reduced to avoid potential complications. The present study assessed the safety of green and blue lights during photodynamic therapy in the esophagus by progressively administrating increasing doses in an attempt to standardize the dose and determine a safe upper limit. This would considerably simplify photodynamic therapy and improve therapeutic results. METHODS: The sheep model was chosen because of similarities with humans regarding the thickness and histologic structure of the esophagus. Irradiation with a 180 degrees windowed cylindrical light distributor was performed in 19 sheep 4 days after injection of 0.15 mg/kg of tetra(m-hydroxyphenyl) chlorin. Light doses ranged from 10 to 500 J/cm(2) at 514 nm (argon ion laser) and from 5 to 250 J/cm(2) at 413 nm (krypton laser). RESULTS: Follow-up endoscopies revealed a tissue response with a fibrinous area at almost all light doses, whereas application of extremely high light doses tended to induce circumferential necrosis with subsequent stenosis. Three months after irradiation with green light, histologic examination of the resected specimens revealed transmural scarring at doses higher than 100 J/cm(2). After illumination with blue light, partial or more extensive fibrosis of the muscular layer was observed only at light doses of 175 to 250 J/cm(2). CONCLUSIONS: Application of high doses of green light after sensitization with tetra(m-hydroxyphenyl) chlorin led to severe complications in the esophagus of the sheep that are highly likely to occur in humans as well. Blue light causes significantly less damage than green light and may, therefore, be considered as an alternative for photodynamic therapy of early stage superficial esophageal cance