May 30, 2003

VICC offers new light therapy for esophageal, lung cancers

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Dr. Matthew Ninan

VICC offers new light therapy for esophageal, lung cancers

The Vanderbilt-Ingram Cancer Center is now offering a technique that uses a light-activated drug to help restore the ability to swallow in patients whose esophagus is blocked by cancer.

Photodynamic therapy (PDT) uses an injectable drug called porfimer sodium (Photofrin) that is taken up preferentially in tumor cells. A laser adjusted to a specific frequency of light is used to activate the drug, which then kills much of the tumor within about 48 hours.

“Esophageal cancer is one of the deadliest cancers, and many patients die not because of metastatic disease but because they can no longer swallow,” said Dr. Matthew Ninan, assistant professor of Cardiac and Thoracic Surgery. “We were looking for a palliative method to open the esophagus and allow these patients to eat and keep up their strength.”

Vanderbilt-Ingram will also use the technique to improve breathing in patients with lung cancer whose tumors obstruct their airways.

The technique has been around since the 1970s. Previous iterations of the instrumentation have been cumbersome but improvements in technology have made using PDT much more practical, Ninan said.

Still, the technique requires extensive education of staff in several areas of the medical center, including the surgical and recovery suites. It also requires extensive education of patients and caregivers to minimize the most important side effect, vulnerability to sunlight for two to three weeks.

For instance, in one facility, the recovery room team had not been adequately educated and used a heat lamp to warm the patient after surgery, leading to serious sunburn, Ninan said.

“The drug is also absorbed in skin cells, so these patients can sunburn very easily and very quickly,” Ninan said. “We must carefully select the patients for this procedure and it requires a real team effort and extensive patient education as well as education for the entire medical team.”

Patients receive their injection of Photofrin on an outpatient basis and then return for the laser procedure 48 hours later. The laser is inserted into the esophagus or the bronchus with a fiber optic tube and the laser then penetrates the tumor cells, activating the drug.

“It creates oxidation and a necrotizing effect,” Ninan said. “The tumor cells die and slough off within about 48 hours.”

The dead cells may be expelled through the gastrointestinal tract, in the case of esophageal cancer, or sucked out with an endo- or bronchoscope.

Patients, who may also experience some pain at the site of the tumor, typically stay in the hospital for three to four days. Once they are discharged, patient care managers oversee their care for the first two weeks.

The procedure may also be combined with the insertion of a stent a few weeks later to hold open the esophagus or airway, Ninan said.

No other center in Middle or West Tennessee is currently using the technology, according to Daisy Maurya-Smith, a representative of Axcan ScandiPharm Inc., the manufacturer. One physician in Knoxville uses the technology in early-stage esophageal cancers but not lung malignancies.

Esophageal cancer is not common, with only about 11,000 cases each year in the United States, Ninan said. Incidence patterns are changing, occurring in younger patients, many who do not smoke or use alcohol (previously the leading risk factors). Though the reason behind the incidence shift is unclear, stress, diet, obesity and a resulting increase in gastric reflux are suspected, Ninan said.

Because this type of cancer is so rare, it is important for patients to seek care at centers with significant experience in treating esophageal cancer. Several published studies have concluded that outcomes are better for patients in centers that perform the highest number of esophageal and lung cancer surgeries.

Vanderbilt-Ingram surgeons perform more than 100 lung cancer surgeries each year, and more than 40 esophageal cancer surgeries each year, putting Vanderbilt-Ingram squarely in the “high volume” category. When non-surgical cases are added, Vanderbilt-Ingram physicians treat about 100 esophageal cancer patients each year, he said.

In addition, because esophageal cancer is so rare, it is important that as many patients as possible be treated on research protocols so that more information can be obtained and used to improve therapies in the future, he said.

Patients at Vanderbilt-Ingram who are selected for PDT and who choose that option will be tracked carefully so that information to improve the technique and its use can be gathered and analyzed, Ninan said.

“These patients are taking on a lot of responsibility,” Ninan said. “There is no data to suggest that PDT will improve length of survival, but our goal is to make that survival more livable.”