Photodynamic therapy for esophageal cancer: a useful and realistic option

Localized Photodynamic Therapy Using a Chlorin e6-Embedded Silicone-Covered Self-Expandable Metallic Stent as a Palliative Treatment for Malignant Esophageal Strictures

Localized photodynamic therapy (PDT) uses a polymeric-photosensitizer (PS)-embedded, covered self-expandable metallic stent (SEMS). PDT is minimally invasive and a noteworthy potential alternative for treating esophageal strictures, where surgery is not a viable option. However, preclinical evidence is insufficient, and optimized irradiation energy dose ranges for localized PDT are unclear. Herein, we validated the irradiation energy doses of the SEMS (embedded in a PS using chlorin e6 [Ce6] and covered in silicone) and PDT-induced tissue changes in a rat esophagus. Cytotoxicity and phototoxicity in the Ce6-embedded SEMS piece with laser irradiation were significantly higher than that of the silicone-covered SEMS with or without laser and the Ce6-embedded silicone-covered SEMS without laser groups (all p < 0.001). Moreover, surface morphology, atomic changes, and homogeneous coverage of the Ce6-embedded silicone-covered membrane were confirmed. The ablation range of the porcine liver was proportionally increased with the irradiation dose (all p < 0.001). The ablation region was identified at different irradiation energy doses of 50, 100, 200, and 400 J/cm2. The in vivo study in the rat esophagus comprised a control group and 100, 200, and 400 J/cm2 energy-dose groups. Finally, histology and immunohistochemistry (TUNEL and Ki67) confirmed that the optimized Ce6-embedded silicone-covered SEMS with selected irradiation energy doses (200 and 400 J/cm2) effectively damaged the esophageal tissue without ductal perforation. The polymeric PS-embedded silicone-covered SEMS can be easily placed via a minimally invasive approach and represents a promising new approach for the palliative treatment of malignant esophageal strictures.

The role of redox-mediated lysosomal dysfunction and therapeutic strategies

Redox homeostasis refers to the dynamic equilibrium between oxidant and reducing agent in the body which plays a crucial role in maintaining normal physiological activities of the body. The imbalance of redox homeostasis can lead to the development of various human diseases. Lysosomes regulate the degradation of cellular proteins and play an important role in influencing cell function and fate, and lysosomal dysfunction is closely associated with the development of various diseases. In addition, several studies have shown that redox homeostasis plays a direct or indirect role in regulating lysosomes. Therefore, this paper systematically reviews the role and mechanisms of redox homeostasis in the regulation of lysosomal function. Therapeutic strategies based on the regulation of redox exerted to disrupt or restore lysosomal function are further discussed. Uncovering the role of redox in the regulation of lysosomes helps to point new directions for the treatment of many human diseases.

Utilization and Outcomes of Radiation in Stage IV Esophageal Cancer

Introduction

For patients with stage IV esophageal cancer, esophageal radiation may be used selectively for local control and palliation. We aimed to understand patterns of radiation administration among patients with stage IV esophageal cancer and any potential survival associations.

Methods

In this retrospective cohort study, the National Cancer Database was queried for patients with metastatic stage IV esophageal cancer diagnosed between 2016 and 2019. Patterns of radiation use were identified. Survival was determined through Kaplan-Meier analysis of propensity score-matched pairs of patients who did and did not receive radiotherapy and time-to-event models.

Results

Overall, 12,088 patients with stage IV esophageal cancer were identified, including 32.7% who received esophageal radiation. The median age was 65 (interquartile range [IQR]: 58-73) years, and 82.6% were male. Among the irradiated patients, the median total radiation dose was 35 (IQR: 30-50) Gy administered in a median of 14 (IQR: 10-25) fractions given in 22 (IQR: 14-39) days. Overall, esophageal radiation was not associated with better survival (log-rank p = 0.41). When stratified by radiation dose, a survival advantage (over no radiation) was found in the 1144 patients (29% of the irradiated patients) who received 45 to 59.9 Gy (time ratio = 1.28, 95% confidence interval: 1.20-1.37, p < 0.001) and the 88 patients (2.2%) who received 60 to 80 Gy (time ratio = 1.37, 95% confidence interval: 1.11-1.69, p = 0.003).

Conclusions

One-third of the patients with metastatic stage IV esophageal cancer in the National Cancer Database received esophageal radiation. Most received a radiation dose that, although consistent with palliative regimens, was not associated with a survival advantage. Further study is warranted to understand the indications for radiation in stage IV esophageal cancer and potentially reevaluate the most appropriate radiation dose for palliation.

Advancements in photodynamic therapy of esophageal cancer

The poor prognosis of patients with esophageal cancer leads to the constant search for new ways of treatment of this disease. One of the methods used in high-grade dysplasia, superficial invasive carcinoma, and sometimes palliative care is photodynamic therapy (PDT). This method has come a long way from the first experimental studies to registration in the treatment of esophageal cancer and is constantly being improved and refined. This review describes esophageal cancer, current treatment methods, the introduction to PDT, the photosensitizers (PSs) used in esophageal carcinoma PDT, PDT in squamous cell carcinoma (SCC) of the esophagus, and PDT in invasive adenocarcinoma of the esophagus. For this review, research and review articles from PubMed and Web of Science databases were used. The keywords used were "photodynamic therapy in esophageal cancer" in the years 2000-2020. The total number of papers returned was 1,000. After the review was divided into topic blocks and the searched publications were analyzed, 117 articles were selected.

A multifunctional SN38-conjugated nanosystem for defeating myelosuppression and diarrhea induced by irinotecan in esophageal cancer

A combination of chemotherapy and phototherapy has been proposed as a promising treatment for esophageal cancer (EC). Irinotecan as a first-line treatment option is widely prescribed for metastatic EC, however, its clinical application is extremely restricted by the low conversion rate to SN38, severe myelosuppression and diarrhea. As a more potent active metabolite of irinotecan, SN38 is a better substitution for irinotecan, but the poor water solubility and the difficulty of encapsulation hindered its medical application. Herein, a multifunctional SN38-conjugated nanosystem (FA-PDA@PZM/SN38@BSA-MnO2, denoted as FA-PPSM) is designed for overcoming the above-mentioned drawbacks and achieving collaborative chemotherapy, photodynamic therapy (PDT) and photothermal therapy (PTT). The tumor acidic microenvironment induces decomposition of BSA-MnO2 nanoparticles into O2 and Mn2+, thus enhancing oxygen-dependent PDT efficacy; meanwhile, Mn2+ can be employed as a magnetic resonance imaging (MRI) contrast agent. Under 650 and 808 nm laser irradiation, the FA-PPSM nanocomposites exhibit superior antitumor efficacy in Eca-109-tumor bearing mice. Notably, there is low gastrointestinal toxicity and myelosuppression in the FA-PPSM treated mice compared with those treated with irinotecan (alone). Taken together, this work highlights the great potential of the FA-PPSM nanocomposites for MRI-guided chemotherapy in combination with endoscopic light therapy for esophageal cancer.

Manganese-Based Nanoplatform As Metal Ion-Enhanced ROS Generator for Combined Chemodynamic/Photodynamic Therapy

Reactive oxygen species (ROS) with strong oxidizing and high activity have been regarded as an effective "weapon" for antitumor therapy, since it can induce organelle injury, oxidative damage, and cell death. Herein, hollow structured manganese carbonate (MnCO₃) nanocubes are fabricated and loaded with photosensitizer (chlorin e6, Ce6), obtaining a responsive nanoplatform H-MnCO₃/Ce6-PEG (HMCP NCs). Two different approaches to upregulate intracellular ROS level were realized by HMCP NCs. On one hand, with irradiation of external laser, Ce6 could generate singlet oxygen (¹O₂) through a multistep photochemical process applied in photodynamic therapy (PDT). On the other hand, MnCO₃ could be specifically degraded into Mn²⁺ in an acidic tumor microenvironment (TME), triggering Mn²⁺-activated Fenton-like reaction to convert endogenous H₂O₂ into hydroxyl radical (•OH). In vitro combined chemodynamic therapy (CDT) and PDT showed that the metal ion-enhanced ROS production could break the intracellular redox equilibrium, thus leading to cell death. In vivo combined CDT/PDT with HMCP NCs exhibited remarkably enhanced therapeutic efficacy in inhibiting tumor growth, without resulting in noticeable damage to normal tissues. This work presents a unique type of manganese-based nanoplatform for efficiently generating ROS in solid tumors, favorable for ROS-involved therapeutic strategies.

Evaluation on Short-Term Therapeutic Effect of 2 Porphyrin Photosensitizer-Mediated Photodynamic Therapy for Esophageal Cancer

Purpose:

To analyze and study the short-term therapeutic effects and main adverse effects of 2 Porphyrin photosensitizer-mediated photodynamic therapy for esophageal cancer.

Methods:

We apply the hematoporphyrin derivative and hematoporphyrin injection produced by different manufacturers at different periods as photosensitizers in therapy of 79 esophageal cancer cases, with the administration dosage of 5 mg/kg and intravenous drip 24 hours before irradiation. We apply the gold vapor laser and semiconductor laser, respectively, as treatment light source, with the power density of 100 to 300 mW/cm² and energy density of 100 to 300 J/cm². After treatment for 1 to 4 sessions, we evaluate the short-term therapeutic effects as complete response, partial response, minor response, or no change, and then make comparative study on therapeutic effects and adverse effects.

Results:

There were 47 patients in hematoporphyrin derivative group, including 3 (6.4%) patients with complete response, 31 (66.0%) patients with partial response, 10 (21.3%) patients with minor response, and 3 (6.4%) patients with no change. The dysphagia score was reduced from 2.53 (1.16) before treatment to 1.32 (1.20; P < .01) after treatment. There were 32 patients in the hematoporphyrin injection group, including 3 (9.4%) patients with complete response, 19 (59.4%) patients with partial response, 6 (18.8%) patients with minor response, and 4 (12.5%) patients with no change. The dysphagia score was reduced from 2.41 (1.13) before treatment to 1.18 (0.99; P < .01) after treatment. The dysphagia scores of 2 groups after treatment were significantly reduced compared to those before treatment. Both groups did not display serious adverse effect.

Conclusions:

Two porphyrin photosensitizers in treatment of esophageal cancer at different clinical stages all had good effect with similar therapeutic effect, mild adverse effect, and good tolerance, which implies it is a preferable palliative therapy means.

Role of endoscopy in early oesophageal cancer

Incidence of oesophageal adenocarcinoma has increased exponentially in the West over the past few decades. Following detection of advanced cancers, 5-year survival rates remain bleak, making identification of early neoplasia, which has a better outcome, important. Detection of subtle oesophageal lesions during endoscopy can be challenging, and advanced imaging techniques might improve their detection. High-definition endoscopy has become a standard in most endoscopy centres, and this technology probably provides better delineation of mucosal features than standard-definition endoscopy. Various image enhancement techniques are now available with the development of new electronics and software systems. Image enhancement with chromoendoscopy using dyes has been a cost-effective option for many years, yet these techniques have been replaced in some contexts by electronic chromoendoscopy, which can be used with the press of a button. However, Lugol's chromoendoscopy remains the gold standard to identify squamous dysplasia. Identification and characterization of subtle neoplastic lesions could help to target biopsies and perform endoscopic resection for better local staging and definitive therapy. In vivo histology with techniques such as confocal endomicroscopy could make endotherapy feasible within a shorter timescale than when relying on histology on tissue samples. Once early neoplasia is identified, treatments include endoscopic resection, endoscopic submucosal dissection or various ablative techniques. Endotherapy has the advantage of being a less invasive technique than oesophagectomy, and is associated with lower mortality and morbidity. Endoscopic ablation therapies have evolved over the past few years, with radiofrequency ablation showing the best results in terms of success rates and complications in Barrett dysplasia.

Patient Responses to Cytoluminescent Therapy ® for Cancer: An Investigative Report of Early Experiences and Adverse Effects of an Unconventional Form of Photodynamic Therapy

Cytoluminescent Therapy ®(CLT) is an unconventional form of photodynamic therapy (PDT), utilizing a secondgeneration chlorophyll-derived photosensitizing agent and whole-body illumination. Starting in late 2002, CLT was administered in Ireland to 48 patients. Illumination with lasers and light-emitting diodes followed the administration of an initial bolus IV. After returning home, patients continued self-administered treatment using oral agent activated by infrared lamps. CLT proponents claimed that these procedures were beneficial to patients with advanced cancer. An organization devoted to making information on alternative therapies available to the public was engaged to contact these CLT patients and assess the outcome. In informal contacts, patients reported that initial side effects were generally mild and transient. However, especially after commencing self-treatment, many reported unanticipated effects, including fatigue and general weakness, increased pain, cough, dyspnea, diminished appetite and weight loss, tissue necrosis, and other major symptoms. At a minimum of 6 months after initial CLT, no patient has reported an objective response, and some have complained of deterioration on the home treatment. There have been 17 deaths among the 48, with a mean survival after initial treatment among decedents of 4.2 months. CLT, in this group, was a qualified failure, with a high incidence of aftereffects. The mode of action of these aftereffects has yet to be explored. In the future, CLT should be administered to patients only in carefully managed medical facilities, by fully trained and licensed professionals, under the supervision of relevant regulatory agencies, and with meticulous follow-up care.

Photodynamic therapy mediated by 5-aminolevulinic acid suppresses gliomas growth by decreasing the microvessels

Although 5-aminolevulinic acid (5-ALA)-mediated photodynamic therapy (PDT) has been demonstrated to be a novel and effective therapeutic modality for some human malignancies, its effect and mechanism on glioma are still controversial. Previous studies have reported that 5-ALA-PDT induced necrosis of C6 rat glioma cells in vitro. The aim of this study was to further investigate the effect and mechanism of 5-ALA-PDT on C6 gliomas implanted in rats in vivo. Twenty-four rats bearing similar size of subcutaneously implanted C6 rat glioma were randomly divided into 3 groups: receiving 5-ALA-PDT (group A), laser irradiation (group B), and mock procedures but without any treatment (group C), respectively. The growth, histology, microvessel density (MVD), and apoptosis of the grafts in each group were determined after the treatments. As compared with groups B and C, the volume of tumor grafts was significantly reduced (P<0.05), MVD was significantly decreased (P<0.001), and the cellular necrosis was obviously increased in group A. There was no significant difference in apoptosis among the three groups. The in vivo studies confirmed that 5-ALA-PDT may be an effective treatment for gliomas by inhibiting the tumor growth. The mechanism underlying may involve increasing the cellular necrosis but not inducing the cellular apoptosis, which may result from the destruction of the tumor microvessels.

Photodynamic Therapy for Barrett's Esophagus and Esophageal Carcinoma

This paper reviews the use of photodynamic therapy (PDT) in patients with Barrett's esophagus and esophageal carcinoma. We describe the history of PDT, mechanics, photosensitizers for PDT in patients with esophageal disease. Finally, we discuss its utility and limitations in this setting.

Retrospective study of photodynamic therapy for upper gastrointestinal cancers during past 25 years in China

AIM: To find out the status of photodynamic therapy (PDT) for upper gastrointestinal cancers, and then discuss how to solve the problems that hinder the development of PDT.

METHODS: A total of 30 pertinent literatures about PDT for upper gastrointestinal cancers during past 25 years were collected through the retrieval of several related medical databases (Chinese Medical Current Contents, China BioMedical Bibliographic Database, China Journal Fulltext Database). The data, including the gender, age of patients, tumor position, pathologic findings, treatment efficacy, adverse effects and the applied laser and photosensitizer, were statistical analyzed.

RESULTS: For all the 1687 cases with upper gastrointestinal cancers, the excellently-effective rate (complete remission or prominent remission) and effective rate (complete remission or prominent remission or minor remission) were 53.2% and 87%, respectively. The therapeutic effect of combined treatment (PDT with other methods) was superior to that of PDT (u = 4.456, P < 0.01). All the involved pathological types were sensitive to PDT. Different photosensitizers and lasers were used by different authors, but all of them were effective without any serious side effect.

CONCLUSION: PDT shows a radical effect on the tumors of early stage and a favorable palliative effect on the tumors of advanced stage, so it is one of the optional strategies for the treatment of upper gastrointestinal cancers.

Selective delivery of therapeutic agents for the diagnosis and treatment of cancer

Research activity aimed towards achieving specific and targeted delivery of cancer therapeutics has expanded tremendously in the last decade, resulting in new ways of directing drugs to tumours, as well as new types of drugs. The available strategies exploit differences in the nature of normal and cancer cells and their microenvironment. The discovery and validation of cancer-associated markers, as well as corresponding ligands, is pivotal for developing selective delivery technology for cancer. Although most current clinical trials are either monoclonal antibody- or gene-based, methodological advances in combinatorial libraries of peptides, single chain variable fragments and small organic molecules are expected to change this scenario in the near future. Nanotechnology platforms today allow systematic and modular combinations of therapeutic agents and tumour-binding moieties that may generate novel, personalised agents for selective delivery in cancer. This paper discusses recent developments and future prospects of targeted delivery technologies in the management of cancer.

Photodynamic Therapy for Urological Malignancies: Past to Current Approaches

PURPOSE

Modern PDT for urological tumors is a potentially selective approach in which in situ photosensitization by a nontoxic drug, locally activated by light, generates cytotoxic reactive oxygen species, causing cell death. While urological clinical experience with PDT is largely limited to treatment for superficial bladder cancer, the advent of novel photosensitizers and technologies for treatment planning, light delivery and dosimetry, PDT for prostate and other urological cancers appears increasingly realistic.

MATERIALS AND METHODS

We reviewed the current literature on PDT for urological tumors, in addition to recent emerging data from our laboratory and elsewhere.

RESULTS

Remarkable progress has been made in the field of photochemistry and photobiology. Together with improved optical delivery and imaging systems PDT holds promise as an alternative, minimally invasive and potentially curative treatment for localized solid tumors as well as for palliative treatment for isolated, clinically problematic metastases.

CONCLUSIONS

Current experience with photodynamic therapy using contemporary photosensitizing agents and light sources is mainly restricted to in vivo experimental models and early phase clinical trails. However, ongoing preclinical work and clinical trials indicate that safer and effective PDT treatments in uro-oncology are imminent.

Photodynamic therapy for Barrett's esophagus with high-grade dysplasia

This article describes advances in photodynamic therapy for patients with Barrett's esophagus and high-grade dysplasia-an important, minimally invasive treatment option proven to safely and durably ablate Barrett's dysplasia and prevent carcinoma while preserving the gastroesophageal junction.

Induction of cell death by photodynamic therapy with a new synthetic photosensitizer DH-I-180-3 in undifferentiated and differentiated 3T3-L1 cells

To examine the photodynamic therapy (PDT) effect on adipocytes, we investigated whether PDT using DH-I-180-3, a new synthetic lipophilic photosensitizer, induced cell death of both undifferentiated and differentiated 3T3-L1. 3T3-L1 pre-adipocytes were differentiated into adipocytes in the culture medium containing pantothenate, insulin, dexamethasone, isobutylmethylxanthine, and troglitazone. PDT was applied to both undifferentiated and differentiated 3T3-L1. Photosensitizer uptake in fat cells was determined by measuring its mean fluorescence intensity. DH-I-180-3 mediated effectively PDT-induced cell death of both pre-adipocytes and adipocytes. And the photosensitizer was accumulated more rapidly in 3T3-L1 adipocytes, compared with other cancer cell lines. These results demonstrate that PDT is a potent cell death inducer in pre-adipocytes and adipocytes. Thus, PDT with DH-I-180-3 may be applied for a new therapeutic modality for obesity treatment.

Palliative gastroenterology

Continuous improvements in endoscopic imaging and accessories have opened up a field of interventional endoscopy. This highly technical offshoot of gastroenterology uses not just standard endoscopic techniques but also newer endoscopic ultrasound (EUS) imaging or fluoroscopic monitoring to facilitate procedures that were once performed either surgically or percutaneously, if at all. This review will update the role of these novel procedures that can be used to assist in the palliative care of patients whose malignancies involve the gastrointestinal tract. The emphasis will be on those palliative interventions that are used to overcome intestinal obstruction in the gastrointestinal tract and restore luminal patency. The role of EUS-guided celiac plexus neurolysis to assist in pain control, especially in patients with pancreatic malignancies, will also be detailed.

Present status of photodynamic therapy for high-grade dysplasia in Barrett's esophagus

GOALS

Review recent developments in Barrett's dysplasia including regulatory approval of porfimer sodium photodynamic therapy.

BACKGROUND

Barrett's esophagus is thought to be the result of long-standing gastroesophageal reflux disease and is known to be the most important risk factor for the development of esophageal adenocarcinoma. The natural history of Barrett's esophagus is not well known, but the annual incidence of invasive adenocarcinoma is estimated to be 0.5% (reported range, 0.2%-2.0%). This represents an increased risk for esophageal cancer of 30 to 60 times higher than normal subjects. As for colorectal cancer, malignant degeneration is Barrett's esophagus is thought to occur through a continuum of histologic stages: metaplasia, dysplasia and neoplasia. Barrett's high-grade dysplasia (formerly referred to as carcinoma in situ) is the histologic stage of disease that immediately precedes the development of invasive carcinoma.

CONCLUSIONS

Previously, Barrett's high-grade dysplasia patients were routinely referred for esophageal resection surgery based upon the assumption of inevitable progression to cancer, the high rate of undiagnosed synchronous cancers, and few treatment alternatives. Important developments in Barrett's high-grade dysplasia include recent publications regarding the natural history of Barrett's high-grade dysplasia and the regulatory approval for endoscopic ablation therapy using porfimer sodium photodynamic therapy (Photofrin PDT).

Clinical experience of patients undergoing photodynamic therapy for Barrett's dysplasia or cancer

INTRODUCTION

Barrett's oesophagus is the most important risk factor in the increase in incidence of oesophageal adenocarcinoma. Photodynamic therapy using porfimer sodium is the only approved endoscopic treatment for use in patients with Barrett's high-grade dysplasia.

AIM

To determine clinical characteristics, endoscopic findings and treatment complications in Barrett's high-grade dysplasia patients undergoing photodynamic therapy.

METHODS

We reviewed our experience using porfimer sodium photodynamic therapy to treat patients with Barrett's oesophagus and high-grade dysplasia or mucosal carcinoma. Data collected included patients characteristics, presentation symptoms, endoscopic findings, subsequent use of surveillance endoscopy and outcome after photodynamic therapy.

RESULTS

Since 1997, 102 patients with Barrett's high-grade dysplasia (69 patients) or mucosal adenocarcinoma (33 patients) have been treated with photodynamic therapy using porfimer sodium as an alternative to oesophagectomy (median series follow-up time = 1.6 years). Almost half (46%) of patients had high-grade dysplasia or carcinoma detected on their first endoscopy and the remainder (54%) were found during surveillance of known Barrett's oesophagus. Symptoms typically associated with oesophageal disease were only found in 29 of 47 (62%) patients in whom dysplasia/carcinoma was detected on the initial endoscopy - chest pain in 13 patients, dysphagia in nine patients and chronic gastro-oesophageal disease in seven patients. Comparison of endoscopic characteristics found the median Barrett's glandular segment length was significantly shorter in adenocarcinoma patients (median 3 cm; range: 1-12) vs. Barrett's high-grade dysplasia patients (median 5 cm; range: 1-16, P < 0.001). Overall treatment results found complete ablation of glandular epithelium with one course of photodynamic therapy in most patients (56%). Stricture requiring dilation occurred in 20 patients (20%) was the most common serious adverse event. Photodynamic therapy failed to ablate dysplasia or carcinoma in four patients and subsequent oesophagectomy was curative in three of these patients.

CONCLUSIONS

Approximately 40% of newly diagnosed patients with Barrett's associated dysplasia or carcinoma had no oesophageal symptoms and had carcinoma associated with short segment (3 cm or less). Photodynamic therapy is a highly effective, safe and minimally invasive first-line treatment for patients with Barrett's dysplasia and mucosal adenocarcinoma.

EUS-guided photodynamic therapy of the pancreas: a pilot study

BACKGROUND

Photodynamic therapy of pancreatic cancer by using percutaneously placed light catheters has been reported. The feasibility and safety of EUS-guided photodynamic therapy of the pancreas was studied in a porcine model.

METHODS

After injection of porfimer sodium, a 19-gauge needle was inserted into the pancreas, the liver, the spleen, and the kidney under EUS guidance. A small diameter quartz optical fiber was passed through the EUS needle and used to illuminate the tissue with laser light. The tissue response to photodynamic therapy was examined.

RESULTS

Localized tissue necrosis was achieved in all organs, without significant complication. There was no significant difference in inflammation induced by photodynamic therapy within the various organs.

CONCLUSIONS

EUS-guided photodynamic therapy is a safe and simple technique that can induce small areas of focal tissue ablation within the liver, the pancreas, the kidney, and the spleen, and potentially could be used to treat a variety of benign and malignant conditions.

Standardizing dosimetry in esophageal PDT: an argument for use of centering devices and removal of misleading units

A simple standardization of esophageal photodynamic therapy light dosimetry is proposed. Calculations of the effect on local treatment dose of using non-centered diffusing fibers have been made and the methods of calculating light energy dose to the treatment area within a centering balloon are discussed. A requirement for centering devices and standard units of Joules per cm(2) of treatment area are indicated.