Endoscopic combination therapy with photodynamic therapy and endoscopic resection for wide circumferential local recurrence after radiotherapy for esophageal cancer

Abstract

Background and aims: For wide-circumferential local recurrence after chemoradiotherapy or radiotherapy (RT) for esophageal squamous cell carcinoma (ESCC), salvage surgery is performed, but combination therapy with photodynamic therapy (PDT) and endoscopic resection (ER) could be an alternative treatment for a T1b-T2 lesion. The aim of this report is to present the case of a patient in whom we achieved local control with combination therapy.

Methods: The patient was an 86-year-old man who underwent RT for cT2N1M0 ESCC. After RT, a local residual lesion was found of 30 mm, three-fourths of the circumference, and type 0-Is+IIc. Laser illumination was first performed to focus on the 0-Is portion, suspected submucosal invasion, and, thereafter, treatments such as ER or additional PDT were planned for nontreated 0-IIc areas, depending on the response of 0-Is after PDT.

Results: After initial PDT, 0-Is markedly shrunk, and a significant response was achieved; therefore, ER was performed on 0-IIc lesions. Subsequently, local recurrence occurred in the laser-illuminated 0-Is; therefore, 2 additional PDT sessions were performed. After the last PDT, local control was achieved and the patient has survived without recurrence for more than 3 years. No severe adverse events occurred.

Conclusions: Combination therapy with PDT and ER may be a less-invasive and potentially curative treatment option for patients with wide-circumferential local recurrence.

Figure 1

Key images of the case report. A, The local residual lesion after radiotherapy. B, At 1 day after initial PDT. C, Nontreated lesions around the laser-illuminated area (yellow arrowheads). D, Lesions were resected using hybrid endoscopic submucosal dissection. E, No recurrence 1 year after the second additional PDT. PDT, Photodynamic therapy.

Figure 2

Endoscopic images before radiotherapy showing (A and B) white-light and chromoendoscopic images using 1% iodine solution displaying cT2 esophageal squamous cell carcinoma with a long-axis diameter of 80 mm and full circumference in the middle thoracic esophagus.

Figure 3

Endoscopic images after radiotherapy showing (A and B) the local residual lesion was delineated as 30 mm in size and three-fourths of the circumference of the middle thoracic esophagus during white-light and chromoendoscopic images using iodine solution. The lesion was composed of a sessile area (0-Is) on the anterior right wall with slightly depressed areas (0-IIc) extending to the left and posterior walls. C, High-frequency EUS corresponded to a hypoechoic lesion confined to the 2 to 3 layers in the 7-layer image (yellows arrowheads). The lesion was preserved in the third outermost layer of the EUS. EUS was performed using an endoscope with a 20-MHz mini-probe (UM-3R; Olympus, Tokyo, Japan) attached to an ultrasound image-processing unit equipped with a multifreezing system (EU-IP2; Olympus) using the water-filled balloon method. D, One day after initial photodynamic therapy, the laser-illuminated area was ulcerated, which appears as a white coating.

Figure 4

Endoscopic images after 3 months of initial photodynamic therapy showing (A) 0-IIc around the laser-illuminated area was delineated during chromoendoscopy using iodine solution (yellows arrowheads). B, 0-IIc lesions were resected using hybrid ESD with no remains, which involved a circumferential mucosal incision followed by snaring because of submucosal fibrosis. A single-channel endoscope (GIF-Q260J; Olympus) with an electrosurgical unit (VIO 300; Erbe, Tübingen, Germany), electrosurgical knife (DualKnife J; Olympus), and 33-mm snare (Captivator II; Boston Scientific Ltd, Marlborough, Mass, USA) were used for hybrid ESD.ESD, Endoscopic submucosal dissection.

Figure 5

Two additional PDTs were performed for local recurrence in the laser illuminated area, which was diagnosed as ESCC on biopsy. A, At 6 months after the initial PDT, the first additional PDT was performed on a lesion located in the anterior wall of the middle thoracic esophagus (yellows arrowheads). Total light dose was 300 J/cm². B, At 12 months after the initial PDT, a second PDT was performed for the lesion located in the anterior wall of the middle thoracic esophagus (yellows arrowheads). Total light dose was 100 J/cm2.

Figure 6

At 1 year after the second additional photodynamic therapy, chromoendoscopy using iodine solution showed no recurrence.