Effect of radiotherapy on anorectal function in patients with cervical cancer

Health-related quality of life for early-stage cervical cancer survivors after primary radical surgery followed by radiotherapy versus radical surgery alone

This study compared the quality of life (QoL) of 265 stage IA2-IIA cervical cancer patients treated with radical surgery alone (group 1: 137 patients) versus those who underwent primary radical surgery followed by radiotherapy (group 2: 128 patients) and identified clinical characteristics that predict the poor quality of life. All participants completed quality of life questionnaires: EORTC QLQ-C30 and CMU cervical cancer QoL. For the EORTC QLQ-C30, the study groups were comparable regarding global health status/QoL scale and summary scores. Group 1 participants had better scores on the physical functioning domain and some symptom scales/items. For the CMU Cervical Cancer QoL, group 1 participants had better scores on gastrointestinal, lymphatic, and sexual/hormonal domains. In multivariable analysis, adjuvant radiation was consistently associated with poor quality of life in most domains. In general, early-stage cervical cancer survivors had a satisfactory quality of life. The clinical significance of the quality of life score differences between the study groups remains debateable.Impact statementWhat is already known on this subject? For women with early cervical cancer, surgery is the main treatment providing not only a good chance for a cure by total removal of the cancer but also an opportunity to preserve the hormone-producing function of the ovary as well as the flexibility of the vagina. However, radiation treatment may be indicated after surgery in some patients depending on the findings from surgery. Because of the concern about increased complications and decreased long-term quality of life following the combined treatments, some may elect to avoid surgery and receive radiation alone in the first place. In this study, we compared the quality of life of women who had surgery alone to those who had surgery followed by radiation. This information is currently lacking in the medical literature.What do the results of this study add? We found that, in general, women with early cervical cancer had a satisfactory quality of life. For a patient who is surgically fit and chooses to receive primary surgery, if radiation is subsequently required, she could still expect the acceptable long-term quality of life-although slightly less satisfactory than receiving surgery alone but not inferior to those who receive primary radiation treatment.What are the implications of these findings for clinical practice and/or further research? These findings will be useful for pre-treatment counselling and posttreatment supportive care. The information regarding disease-related and treatment-induced morbidity should be thoroughly discussed with the patients before and after treatment. Also, the use of questionnaires examining general well-being together with a cancer-specific quality of life is recommended for the systematic evaluation of cancer survivors.

Long-Term Morbidity and Quality of Life in Cervical Cancer Survivors: A Multicenter Comparison Between Surgery and Radiotherapy as Primary Treatment

Objective

To compare long-term morbidity and quality of life after primary surgery or primary radiotherapy for stage IB/II cervical cancer.

Methods

A cross-sectional study was performed. Patients treated for stage IB/II cervical cancer between 2000 and 2010 were approached to participate. Primary treatment consisted of radical hysterectomy with pelvic lymphadenectomy (RHL), for selected cases followed by adjuvant (chemo-)radiotherapy, or primary (chemo)radiotherapy (PRT). European Organization for Research and Treatment of Cancer-C30 and European Organization for Research and Treatment of Cancer-CX24 questionnaires were administered. A multivariable analysis was performed to identify factors associated with morbidity/quality of life. In a subgroup analysis, we compared patients with RHL + adjuvant radiotherapy with those after PRT.

Results

Three hundred twenty-three cervical cancer survivors were included (263 RHL/60 PRT). In the PRT group, International Federation of Gynecology and Obstetrics stage was higher and women were older. In the RHL group, more women had a partner. Women treated with PRT reported lower physical (β, −6.01) and social functioning (β, −15.2), more financial problems (β, 10.9), diarrhea (β, 9.98), symptom experience (β, 6.13), sexual worry (β, 11.3), and worse sexual/vaginal functioning (β, 11.4). Women treated with RHL reported significantly more lymphedema (β, −16.1). No differences in global health were found. In the subgroup analysis, women after PRT (n = 60) reported poorer social functioning, less sexual enjoyment, and higher symptoms experience than women after RHL and adjuvant radiotherapy (n = 60). The latter reported more lymphedema.

Conclusions

Although global health scores are not significantly different, women after PRT report more physical, social, and sexual symptoms. These results can be well used by physicians to inform their patients about treatment-related morbidity.

Reduced luminal circumference of tumors plays a key role in anorectal function during the early period after neoadjuvant chemoradiation therapy in rectal cancer patients

PURPOSE

The deterioration of anorectal function after neoadjuvant chemoradiation therapy (nCRT) combined with surgery for rectal cancer has not been well defined. The aim of this study was to evaluate the relationship between the tumor response to nCRT and changes in anorectal function during a short-term period after nCRT.

METHODS

We analyzed 100 consecutive patients with available preoperative anorectal manometry data, both before and after nCRT, from 2010 to 2013.

RESULTS

Comparing the manometric data before and after nCRT, the values reflecting rectal sensory function after nCRT was significantly lower than those before nCRT. However, in patients who experienced changed tumor morphology and a reduction in luminal circumferential ratio (LCIR) of tumor after nCRT, the values reflecting rectal sensory function were significantly less decreased after nCRT. On multivariate analysis, the reduction of LCIR after nCRT was a very important factor preventing the impairment of anorectal function during the short-term period in terms of the first rectal sensory threshold (RST) (P = 0.002), the RST of "desire to defecate" (P = 0.006), and rectal compliance (P = 0.003). Additionally, in linear regression analysis, the RST for the desire to defecate was positively affected by tumor morphology (P = 0.015) and the reduced LCIR (P = 0.025), and rectal compliance was positively affected by the reduced LCIR (P = 0.001).

CONCLUSION

The nCRT impaired significantly rectal sensory function during the short-term period after nCRT and before a radical operation. However, this reduced LCIR of tumors after nCRT may prevent or minimize impediments to anorectal function during the short-term period after nCRT.

Dosimetric coverage of the external anal sphincter by 3-dimensional conformal fields in rectal cancer patients receiving neoadjuvant chemoradiation: implications for the concept of sphincter-preserving radiation therapy

Background. We evaluated the anatomic location of the external anal sphincter (EAS) to pelvic bony landmarks related to 3-dimensional conformal radiotherapy (3DRT) and studied the dosimetric coverage of the EAS in patients undergoing neoadjuvant chemoradiation for rectal cancer. Methods. Sixty-four consecutive rectal cancer patients treated with neoadjuvant chemoradiation were included. All patients were treated in a prone position on a bellyboard by 3DRT. The inferior border of the RT fields was at least 3–5 cm inferior to the gross tumorous volume (GTV) or at the inferior border of the obturator foramen (IBOF), whichever was more inferior. The EAS was contoured and dose distributions were determined using dose-volume histograms. Results. In 53 out of 64 cases (82.8%), the EAS was completely inferior to the IBOF. In the remaining 11 cases, the EAS was either overlapping the IBOF (10 cases; 15.6%) or completely superior to the IBOF (1 case; 1.7%). The average mean dose delivered to the EAS was 2795 cGy. Lower mean doses were delivered to the EAS when the center of the EAS was located more distant from the GTV. Conclusions. Meticulous planning to define the inferior border of the RT field is recommended to avoid irradiating the EAS.

Short-term effects of neoadjuvant chemoradiation therapy on anorectal function in rectal cancer patients: a pilot study

Background

Neoadjuvant chemoradiation therapy followed by curative surgery has gained acceptance as the therapy of choice in locally advanced rectal cancer. However, deterioration of anorectal function after long-course neoadjuvant chemoradiation therapy combined with surgery for rectal cancer is poorly defined. The aim of this study was to evaluate the physiological and clinical change of anorectal function after neoadjuvant chemoradiation therapy for rectal cancer.

Methods

We analyzed 30 patients on whom preoperative anorectal manometry data were available both before and after chemoradiation from October 2010 to September 2011. All patients underwent long-course neoadjuvant chemoradiation therapy. We compared manometric parameters between before and after neoadjuvant chemoradiation therapy.

Results

Of 30 patients, 20 were males and 10 females. The mean age was 64.9 ± 9.9 years (range, 48-82). Before nCRT, the rectal compliance was higher in patients with ulceroinfiltrative type (P = 0.035) and greater involvement of luminal circumference (P = 0.017). However, there was the tendency of increased rectal sensory threshold for desire to defecate when the patient had decreased circumferential ratio of the tumor (P = 0.099), down-graded T stage (P = 0.016), or reduced tumor volume (P = 0.063) after neoadjuvant chemoradiation.

Conclusions

Neoadjuvant chemoradiation therapy did not significantly impair overall sphincter function before radical operation. The relationship between tumor response of chemoradiation and sensory threshold for desire to defecate may suggest that neoadjuvant chemoradiation may be helpful for defecatory function as well as local disease control, at least in the short-term period after the radiation in locally advanced rectal cancer patients.

Short-term effects of neoadjuvant chemoradiotherapy on internal anal sphincter function: a human in vitro study

BACKGROUND

Neoadjuvant chemoradiotherapy is recommended in the treatment of locally advanced rectal cancer. Studies have suggested that chemoradiotherapy adversely affects anorectal function. However, the functional implication and the underlying neuromyogenic changes involved in radiation-induced damage are poorly understood.

OBJECTIVE

This study evaluated the functional changes following chemoradiotherapy on the internal anal sphincter.

DESIGN AND PATIENTS

This article describes an in vitro study on the internal anal sphincter collected from patients undergoing abdominoperineal resection or proctectomy. Five patients were treated by surgery alone (control group), and 6 received preoperative chemoradiotherapy (treatment group). Sphincter strips were mounted in organ bath, and the responses to electrical field stimulation and drugs were monitored.

SETTINGS

The study was performed at the University of Oxford.

MAIN OUTCOME MEASURES

The end points of this study were to investigate whether chemoradiotherapy has any significant effects on internal anal sphincter function and, subsequently, to establish the type of injury induced.

RESULTS

Chemoradiotherapy strips developed similar tone, but significantly lower spontaneous activity (p = 0.001) than controls. Electrical field stimulation induced relaxation, followed by contraction. At 50 Hz, electrical field stimulation produced 25.6 ± 4.9% (mean ± SE) of maximum relaxation followed by a contraction of 5.5 ± 0.9% of basal tone in chemoradiotherapy strips i9n comparison with 47.0 ± 6.2% (p = 0.009) and 17.7 ± 4.0% (p = 0.007) in controls. Relaxation was significantly attenuated by N-nitro-L-arginine. Significant differences were found in responses to carbachol (p = 0.018) and phenylephrine (p = 0.022), but not to sodium nitroprusside.

LIMITATIONS

This work was limited by the relatively small number of patients enrolled, because of the difficulty of finding human tissue for laboratory studies, and the lack of long-term results.

CONCLUSIONS

Chemoradiotherapy significantly impairs internal anal sphincter function and intrinsic nerves seem more susceptible than smooth muscle. The exclusion of anal canal from the radiation field is recommended, when oncologically safe.

Evaluation of anal incontinence: minimal approach, maximal effectiveness

Anal incontinence is a symptom represented by the impaired ability to control the elimination of gas and stool, with an estimated incidence of 2.2 to 7.1% of the population. These numbers likely under-represent the true prevalence because physicians and patients are reluctant to discuss this problem. Evaluation of the patient with anal incontinence requires a fundamental knowledge of the etiologic factors. Careful history and physical examination is essential in every patient and can identify the cause of most cases of incontinence. Incontinence scoring systems are tools that provide objective data regarding the severity and quality of anal incontinence. Supplemental special tests for evaluating incontinence should be aimed at achieving three goals: (1) provide additional and confirmatory information regarding the diagnosis and cause of incontinence; (2) select appropriate treatment; and (3) predict treatment outcome. Numerous studies to evaluate anal incontinence exist; however, the most useful tests to achieve these goals are anal manometry, pudendal nerve terminal motor latency, and anal endosonography, because these studies can identify physiologic, neurologic, and anatomic abnormalities of the anorectum for which there may be effective treatments.

The short-term effect of neoadjuvant chemoradiation on anorectal function in low and midrectal cancer: analysis using preoperative manometric data

PURPOSE

The purpose of this study was to evaluate the short-term preoperative effects of neoadjuvant chemoradiation on anorectal function, excluding the bias of postoperative impairment.

METHODS

We analyzed 80 patients on whom preoperative anorectal manometry data were available for both prechemoradiation and postchemoradiation. Patients were divided into 2 groups according to the tumor location; lower rectum (n = 52) and mid rectum (n = 28). The paired t test was used to compare prechemoradiation and postchemoradiation parameters including the mean resting pressure, maximum squeeze pressure, percentage asymmetry of the resting and squeeze sphincter, length of the high-pressure zone, rectal sensory threshold, and rectal compliance.

RESULTS

In patients with a lower rectal cancer, there were significant differences in the percentage asymmetry of the squeeze sphincter (27.81 +/- 6.46 vs 25.38 +/- 5.93%, P < .01), length of the high-pressure zone (2.14 +/- 0.74 vs 2.33 +/- 0.72 cm, P = .05), and rectal compliance (1.14 +/- 0.41 vs 1.02 +/- 0.40 mL/mmHg, P = .04). In patients with midrectal cancer, only the mean resting pressure increased significantly (45.08 +/- 18.57 vs 52.83 +/- 17.87 mmHg, P < .01). Clinical symptom evaluation demonstrated a significant decrease in the number of defecations and the frequency of tenesmus.

CONCLUSION

Neoadjuvant chemoradiation did not impair overall short-term sphincter function significantly, regardless of the location of the primary tumor. Although there was a decrease in rectal compliance, it seemed that the tumor-downsizing effect compensated the expected worsening of anorectal function in the early postchemoradiation period.

Radiation damage to the gastrointestinal tract: mechanisms, diagnosis, and management

PURPOSE OF REVIEW

To summarize current knowledge about gastrointestinal radiation toxicity, with emphasis on mechanisms and clinical diagnosis and management.

RECENT FINDINGS

While there has been only modest change in cancer incidence and cancer mortality rates during the past 30 years, the number of cancer survivors has more than doubled. Moreover, the recognition of uncomplicated cancer cure as the ultimate goal in oncology has intensified efforts to prevent, diagnose, and manage side effects of radiation therapy. These efforts have been facilitated by recent insight into the underlying pathophysiology.

SUMMARY

The risk of injury to the intestine is dose limiting during abdominal and pelvic radiation therapy. Delayed bowel toxicity is difficult to manage and adversely impacts the quality of life of cancer survivors. More than 200,000 patients per year receive abdominal or pelvic radiation therapy, and the estimated number of cancer survivors with postradiation intestinal dysfunction is 1.5-2 million. Worthwhile progress towards reducing toxicity of radiation therapy has been made by dose-sculpting treatment techniques. Approaches derived from an improved understanding of the pathophysiology of bowel injury, however, will result in further advances. This article discusses the mechanisms of radiation-induced bowel toxicity and reviews current principles in diagnosis and management.

Effect of neoadjuvant chemoradiation on postoperative fecal continence and anal sphincter function in rectal cancer patients

BACKGROUND AND AIMS

Neoadjuvant chemoradiation (nCRT) followed by curative surgery has gained acceptance as the therapy of choice in locally advanced rectal cancer. This prospective study evaluates the effect of nCRT on postoperative anorectal function and continence.

PATIENTS AND METHODS

Group A consisted of 12 patients (59.8 +/- 11.9 years, male:female = 8:4) who received nCRT (5-FU, CPT-11. 45 + 5.4 Gy boost) before surgery and Group B of 27 patients (61.9 +/- 10.6 years, male:female = 16:11) who were treated by surgery alone. All patients received a questionnaire to evaluate stool continence and anorectal function before as well as after surgery. Anorectal function was further analyzed by perfusion manometry pre- and postoperatively.

RESULTS

Preoperatively, none of the patients had signs or symptoms of fecal incontinence, and preoperative measurements showed values within normal limits. Postoperatively, fecal continence was impaired in both groups, but no significant difference was found between patients with or without nCRT. Anorectal manometry revealed an impairment of anorectal function after low anterior resection regardless of the treatment regime.

CONCLUSION

nCRT does not impair anorectal function and fecal continence. The deterioration of continence and anal sphincter function after sphincter preserving surgery is solely caused by the surgical procedure.

Radiation-induced sequelae affecting the continence organ: incidence, pathogenesis, and treatment

INTRODUCTION

Incontinence is a late complication that causes symptoms years after radiation treatment and is difficult to deal with; it poses a particular challenge for care-providing physicians.

REVIEW

This review looks at our current knowledge of the incidence, symptoms, and treatment of fecal incontinence induced by radiation treatment. An approximate estimation based on retrospective data suggests an incidence of fecal incontinence of up to one-third of patients. The mechanism that causes incontinence are changes in anal resting tone, squeeze pressure, and rectal volume or rectal compliance. The other associated aspects of incontinence include such further disorders as proctitis, colitis, and other disturbances involving the lower digestive tract. The therapeutic options mainly comprise the treatment of associated aspects, such as proctitis or diarrhea.

CONCLUSION

Surgical treatment should be the absolute exception. If the creation of a stoma is being considered, a resective procedure offering freedom from symptoms seems to be the more advantageous option.

Preoperative chemoradiation for rectal cancer causes prolonged pudendal nerve terminal motor latency

PURPOSE

A worsened anorectal function after chemoradiation for high-risk rectal cancer is often attributed to radiation damage of the anorectum and pelvic floor. Its impact on pudendal nerve function is unclear. This prospective study evaluated the short-term effect of preoperative combined chemoradiation on anorectal physiologic and pudendal nerve function.

METHODS

Sixty-six patients (39 men, 27 women) with localized resectable (T3, T4, or N1) rectal cancer were included in the study. All patients received 45 Gy (1.8 Gy/day in 25 fractions) over five weeks, plus 5-fluorouracil (350 mg/m2/day) and leucovorin (20 mg/m2/day) concurrently on days 1 to 5 and 29 to 33. Patients who had rectal cancer with a distal margin within 6 cm of the anal verge had the anus included in the field of radiotherapy (Group A, n = 26). Patients who had rectal cancer with a distal margin 6 to 12 cm from the anal verge had shielding of the anus during radiotherapy (Group B, n = 40). The Wexner continence score, anorectal manometry and pudendal nerve terminal motor latency were assessed at baseline and four weeks after completion of chemoradiation.

RESULTS

The median Wexner score deteriorated significantly (P < 0.0001) from 0 to 2.5 for both Groups A (range, 0-8) and B (range, 0-14). The maximum resting anal pressures were unchanged after chemoradiation. The maximum squeeze anal pressures were reduced (mean = 166.5-157.5 mmHg) after chemoradiation. This change was similar in both Groups A and B. Eighteen patients (Group A = 7, Group B = 11) developed prolonged pudendal nerve terminal motor latency after chemoradiation. These 18 patients similarly had a worsened median Wexner continence score (range, 0-3) and maximum squeeze anal pressures (mean = 165.5-144 mmHg). The results obtained were independent of tumor response to chemoradiation.

CONCLUSIONS

Preoperative chemoradiation for rectal cancer carries a significant risk of pudendal neuropathy, which might contribute to the incidence of fecal incontinence after restorative proctectomy for rectal cancer.

Faecal incontinence: A late side-effect of pelvic radiotherapy

AIMS

Despite advances in pelvic radiotherapy, damage to normal tissue can lead to chronic gastrointestinal problems. The frequency with which this affects quality of life is controversial. Faecal incontinence is not widely perceived to be a major issue after pelvic radiotherapy. The aim of this paper is to review the frequency and mechanisms for the development of faecal incontinence after pelvic radiotherapy, and to review treatment options for faecally incontinent patients.

MATERIALS AND METHODS

A search of original literature was carried out using MEDLINE and EMBASE databases from 1966 to 2005.

RESULTS

The reliability of the published data is poor because patients frequently fail to admit to faecal incontinence, and because prospective studies are lacking that assess faecal incontinence as a specific end point using adequate, validated and reproducible methodology. The published rates of late new-onset faecal incontinence after pelvic radiation are between 3% and 53%. Patients treated for prostate rather than gynaecological, bladder, rectal or anal cancer may have a lower rate. Only 8-56% of affected patients state that faecal incontinence reduces their quality of life. Studies examining the physiological changes occurring after radiotherapy are generally not adequately controlled or powered, assessment of ano-rectal function is rarely comprehensive and loss of patients to follow-up frequently makes it difficult to extrapolate results to a wider population. Where there is agreement over the physiological changes that occur after radiotherapy, it is not clear at what threshold these changes cause symptoms. No prospective studies of any non-surgical treatment for faecal incontinence after radiotherapy have been published. Surgery other than colostomy probably carries a high risk of complications in this group of patients, but few data have been published.

CONCLUSIONS

Now that improvements in outcome from combination treatments, including radiotherapy for pelvic cancer, are being achieved, it is time that serious attention is paid to determining how frequently significant gastrointestinal toxicity arises, and how best to optimise the quality of life of long-term survivors.

Gastrointestinal symptoms after pelvic radiotherapy: role for the gastroenterologist?

PURPOSE

To analyze the cause of GI symptoms after pelvic radiotherapy (RT) in a consecutive series of patients with symptoms beginning after RT. A striking lack of evidence is available concerning the optimal treatment for the 50% of patients who develop permanent changes in bowel habits affecting their quality of life after pelvic RT. As a result, in the UK, most such patients are never referred to a gastroenterologist.

METHODS AND MATERIALS

All diagnoses were prospectively recorded from a consecutive series of patients with symptoms that started after RT and who were referred during a 32-month period to a gastroenterology clinic. Patients either underwent direct access flexible sigmoidoscopy or were investigated in a standard manner by one gastroenterologist after first being seen in the clinic.

RESULTS

A total of 265 patients referred from 15 institutions were investigated. They included 90 women (median age, 61.5 years; range, 22-84 years) and 175 men (median age, 70 years; range, 31-85 years). RT had been completed a median of 3 years (range, 0.1-34 years) before the study in the women and 2 years (range, 0-21 years) before in the men. Of the 265 patients, 171 had primary urologic, 78 gynecologic, and 16 GI tumors. The GI symptoms included rectal bleeding in 171, urgency in 82, frequency in 80, tenesmus, discomfort, or pain in 79, fecal incontinence in 79, change in bowel habit in 42, weight loss in 19, vomiting without other obstructive symptoms in 18, steatorrhea in 7, nocturnal defecation in 8, obstructive symptoms in 4, and other in 24. After investigation, significant neoplasia was found in 12%. One-third of all diagnoses were unrelated to the previous RT. More than one-half of the patients had at least two diagnoses. Many of the abnormalities diagnosed were readily treatable. The symptoms were generally unhelpful in predicting the diagnosis, with the exception of pain, which was associated with neoplasia (p < 0.001).

CONCLUSION

The results of our study have shown that radiation enteritis is not a single disease entity. More than one-half of the patients had more than one GI diagnosis contributing to their symptoms. After pelvic RT, specific GI symptoms were not a reliable measure of the underlying diagnoses, and the evaluation of new GI symptoms is worthwhile. An algorithm for this purpose is proposed.

Formalin application in the treatment of chronic radiation-induced hemorrhagic proctitis--an effective but not risk-free procedure: a prospective study of 33 patients

PURPOSE

This prospective study evaluated the efficacy and safety of local formalin application in chronic refractory radiation-induced hemorrhagic proctitis.

METHODS

All patients were treated under anesthesia by direct application of 4 percent formalin to the affected rectal areas.

RESULTS

The study included 33 patients (17 women) and was conducted between January 1994 and December 2001. There were 11 anal cancers (33 percent), 11 prostate cancers, 9 cervical or endometrial cancers, 1 bladder cancer, and 1 rectal cancer. The mean number of daily rectal bleeds was 2.7 (range, 0.5-15). Nineteen patients (58 percent) were blood transfusion dependent. Twenty-three patients had only one formalin application and 10 patients required a second application because of the persistent bleeding. The treatment was effective in 23 cases (70 percent): 13 patients had complete cessation of bleeding and 10 patients had only minor bleeding. Six anal or rectal strictures occurred: 4 patients had been treated for anal cancer (36 percent) and 2 patients had been treated for other cancers (9 percent). None of the strictures was malignant. Anal incontinence worsened in 5 patients of the 11 who had been treated for anal cancer (45 percent) and occurred in 4 of the 22 other patients (18 percent).

CONCLUSION

Formalin application is an effective treatment for chronic radiation-induced hemorrhagic proctitis. However, local morbidity is not negligible. This result may be related to the high proportion of anal cancers in the series. In our opinion, therefore, formalin application should be reserved for severe hemorrhagic proctitis refractory to medical treatment and should be thoroughly discussed in cases of anorectal radiation-induced stricture, prior anal incontinence, or treated anal cancer.

Long-term anorectal dysfunction after postoperative radiotherapy for rectal cancer

PURPOSE

Adjuvant radiotherapy in the treatment of rectal cancer has been shown to increase long-term morbidity causing severe anorectal dysfunction with physiologic changes whose interaction remains poorly understood. This study examines long-term anorectal morbidity from adjuvant postoperative radiotherapy.

METHODS

In a prospective study, patients with Dukes B or C rectal carcinoma were randomized to postoperative radiotherapy or no adjuvant treatment after anterior resection. The long-term effect of radiotherapy on anorectal function in a subset of surviving patients was assessed from a questionnaire on subjective symptoms and from physiology laboratory evaluation and flexible sigmoidoscopy.

RESULTS

Twelve of 15 patients (80 percent) treated with radiotherapy had increased bowel frequency compared with 3 of the 13 patients (23 percent) who did not have radiation therapy (P = 0.003). The former group had loose or liquid stool more often (60 vs. 23 percent, P = 0.05), had fecal incontinence more often (60 vs. 8 percent, P = 0.004), and wore pad more often (47 vs. 0 percent, P = 0.004). They also experienced fecal urgency and were unable to differentiate stool from gas more often. Endoscopy revealed a pale and atrophied mucosa and telangiectasias in the irradiated patients. Anorectal physiology showed a reduced rectal capacity (146 vs. 215 ml, P = 0.03) and maximum squeeze pressure (59 vs. 93 cm H2O, P = 0.003) in the radiotherapy group. Impedance planimetry demonstrated a reduced rectal distensibility in these patients (P < 0.0001).

CONCLUSIONS

Adjuvant postoperative radiotherapy after anterior resection causes severe long-term anorectal dysfunction, which is mainly the result of a weakened, less sensitive anal sphincter and an undistensible rectum with reduced capacity.

Topical phenylephrine in the treatment of radiation-induced faecal incontinence

AIMS

Acute bowel toxicity after pelvic radiotherapy is defined as occurring within 3 months of the start of treatment; chronic gastrointestinal toxicity may continue after the acute phase or start after a latent period. One in five patients develop chronic faecal incontinence affecting quality of life; how best to treat these patients is not known. This retrospective study aimed to determine the effects of a new agent, phenylephrine gel, in the treatment of chronic radiation-induced faecal incontinence.

MATERIALS AND METHODS

Patients prescribed phenylephrine gel for new-onset faecal incontinence after radiotherapy were identified from our database of patients treated in a specialist radiation-induced bowel damage clinic since 2000. Changes in the level of faecal incontinence were assessed using the Vaizey faecal incontinence scoring system before and after treatment.

RESULTS

Fifteen patients (nine men and six women) of mean age 70.5 years (standard deviation 8.2, age range 56-82 years) were treated with phenylephrine gel a median of 43 months after completing radiotherapy. The median Vaizey score before treatment with phenylephrine gel was 17 (interquartile range [IQR] 14-20) and after treatment was 14 (IQR 11-18) (P = 0.005). The median length of treatment with phenylephrine gel was 28 days (IQR 28-365). Scores improved in 11 out of 15 patients; four out of 15 patients showed substantial improvements of 7 or more points; and seven patients considered the gel helpful.

CONCLUSION

Topical phenylephrine gel for the treatment of radiation-induced faecal incontinence has not been previously reported. This small, retrospective study suggests that it may help most patients and, in some, the improvement may be substantial. However, larger placebo-controlled prospective studies are required.

A prospective, randomized, double-blind, placebo-controlled trial of retinol palmitate (vitamin A) for symptomatic chronic radiation proctopathy

PURPOSE

This study was designed to determine whether oral retinol palmitate (vitamin A) can reduce the symptoms of radiation proctopathy.

METHODS

A randomized, double-blind trial comparing retinol palmitate (10,000 IU by mouth for 90 days) to placebo was conducted. Eligible patients were more than six months postpelvic radiotherapy and had significant symptoms as measured with the Radiation Proctopathy System Assessments Scale. Nineteen patients were randomized in total: ten to retinol palmitate and nine to placebo. The Radiation Proctopathy System Assessments Scale scores before and every 30 days for 90 days were measured. Five placebo nonresponders were crossed over to the retinol palmitate for another 90 days. Response was defined as a reduction in two or more symptoms by at least two Radiation Proctopathy System Assessments Scale points.

RESULTS

Seven of ten retinol palmitate patients responded, whereas two of nine responded to placebo (P = 0.057). Mean pre-post-treatment change in Radiation Proctopathy System Assessments Scale (delta Radiation Proctopathy System Assessments Scale) in the retinol palmitate group was 11 +/- 5, whereas delta Radiation Proctopathy System Assessments Scale in the placebo group was 2.5 +/- 3.6 (P = 0.013, Mann-Whitney U test). Additionally, all five placebo nonresponders who were crossed over to treatment with retinal palmitate responded to treatment.

CONCLUSIONS

In our trial, retinol palmitate significantly reduced rectal symptoms of radiation proctopathy, perhaps because of wound-healing effects. The current results can serve as the foundation for future trials examining retinol palmitate in the multi-institutional setting.

How patients manage gastrointestinal symptoms after pelvic radiotherapy

BACKGROUND

Approximately 13,000 patients undergo pelvic radiotherapy annually in the UK. It is not clear how frequently patients develop a permanent change in bowel habit after pelvic radiotherapy that affects their quality of life because the measures of gastrointestinal toxicity used in trials in the past have generally been inadequate. It has been suggested that patients who are symptomatic are only rarely referred to a gastroenterologist and it is not known how patients manage their symptoms.

METHODS

Patients who had completed radiotherapy for pelvic cancer at least 1 year previously were invited to answer 30 structured questions in a face-to-face interview to determine the frequency of gastrointestinal symptoms and what orthodox, dietary and complementary therapies they used to deal with them. They were also asked to score the effectiveness of the measures they had taken.

RESULTS

One hundred and seven patients were recruited [35 males; median age, 65 years (range, 35-80 years); 72 females; median age, 67.5 years (range, 31-87 years)]. Eight had been treated for a gastrointestinal primary tumour, 34 for a urological tumour and 65 for gynaecological tumours. Eighty-seven patients (81%) described new-onset gastrointestinal problems starting after radiotherapy. These symptoms affected the quality of life in 56 patients (52%). Significant effects on the quality of life were caused by diarrhoea or constipation (n = 53), faecal leakage (n = 19), abdominal, rectal or perineal pain (n = 14) and rectal bleeding (n = 6). Fifty-nine patients had seen a doctor for their symptoms (86% found this helpful), 12 had seen a dietician or nurse (50% found this helpful) and 14 had seen alternative practitioners (88% found this helpful). Dietary manipulation generally did not improve symptoms, except in a small group of patients (14/15) who avoided raw vegetables to great benefit.

CONCLUSIONS

At least 1 year after pelvic radiotherapy, gastrointestinal symptoms which have an adverse effect on the quality of life may be more common than generally reported. Patients found that advice from doctors and alternative practitioners was equally valuable. Dietary manipulation was generally unhelpful for gastrointestinal symptoms after pelvic radiotherapy, although the role of eliminating raw vegetables may benefit from further evaluation.

Anorectal dysfunction after surgical treatment for cervical cancer

BACKGROUND

Although bowel symptoms and complaints are common after radical hysterectomy, the effects of operation on anorectal function are incompletely understood. In this prospective pilot study we evaluated the incidence of bowel symptoms, changes in anorectal physiology, and quality of life after radical hysterectomy.

STUDY DESIGN

Eleven women undergoing radical hysterectomy for early-stage cervical cancer completed bowel function symptom surveys and cancer-specific quality-of-life scales before operation and at 6 weeks and 6 months after operation. The bowel function symptom survey was also repeated at 18 months postoperation. Anorectal manometry, balloon defecation, and pudendal nerve latency tests were performed before the operation and 6 months postoperatively.

RESULTS

The mean age was 45.3 years (range 34 to 56 years), and four of the patients were postmenopausal. Resting and squeeze sphincter pressures, volume of saline infused at first leak, total volume retained, and threshold volume for maximum tolerable volume were all decreased significantly (p < 0.05) after operation. Pudendal nerve terminal motor latency increased (p < 0.05) bilaterally. There were no significant differences in sensory thresholds. At 18 months, two women reported constipation, six reported flatus incontinence, and two reported fecal incontinence. The total quality-of-life score declined at 6 weeks but then improved significantly by 6 months (p = 0.02).

CONCLUSIONS

Bowel dysfunction is common after radical hysterectomy. Many women exhibit manometric and subjective changes compatible with fecal incontinence.

Systematic review for non-surgical interventions for the management of late radiation proctitis

Chronic radiation proctitis produces a range of clinical symptoms for which there is currently no recommended standard management. The aim of this review was to identify the various non-surgical treatment options for the management of late chronic radiation proctitis and evaluate the evidence for their efficacy. Synonyms for radiation therapy and for the spectrum of lower gastrointestinal radiation toxicity were combined in an extensive search strategy and applied to a range of databases. The included studies were those that involved interventions for the non-surgical management of late radiation proctitis. Sixty-three studies were identified that met the inclusion criteria, including six randomised controlled trials that described the effects of anti-inflammatory agents in combination, rectal steroids alone, rectal sucralfate, short chain fatty acid enemas and different types of thermal therapy. However, these studies could not be compared. If the management of late radiation proctitis is to become evidence based, then, in view of its episodic and variable nature, placebo controlled studies need to be conducted to clarify which therapeutic options should be recommended. From the current data, although certain interventions look promising and may be effective, one small or modest sized study, even if well-conducted, is insufficient to implement changes in practice. In order to increase recruitment to trials, a national register of cases with established late radiation toxicity would facilitate multi-centre trials with specific entry criteria, formal baseline and therapeutic assessments providing standardised outcome data.

Anorectal irradiation in pelvic radiotherapy: an assessment using in-vivo dosimetry

The objectives of this study were to measure by in-vivo techniques the radiation doses received by the anorectum during pelvic radiotherapy and compare these with doses predicted by a GE TARGET treatment planning system. Nine patients with cancers of the prostate, bladder, cervix or uterus were planned with computed tomography (CT) using the TARGET system. A Scanditronix rectal probe containing five n-type photon-detecting diodes was placed in the anorectum during the planning CT scans. The probe position was standardized with the five diodes at 2 cm intervals from the anal verge. The probe diodes were calibrated for 10 MV photons. Doses were measured for each diode for two consecutive fractions in the first four patients and for five consecutive fractions in the remaining five. Thermoluminescent dosimeters were used initially to verify diode doses. The TARGET and diode measured doses were compared. In all patients diodes situated in the target volume were within 7% of predicted doses. This improved to 2.5% after measurement on five fractions. At the edges of the target volume, wide variability existed between measured and predicted doses (measured dose range -68% to +68% of predicted dose). Outside the target volume, considerable doses (up to 0.3 Gy per fraction) were measured in the anal canal, which were not predicted by TARGET. We conclude that TARGET planned doses are accurate within the confines of the target volume. The greatest variability was seen at the edges of the target volume, where dose can vary by 50% across a 1 cm distance in the anterior-posterior plane. TARGET does not account for scattered dose beyond the field edges and therefore underestimates the dose received by the anal canal.

Anorectal injury following pelvic radiotherapy

BACKGROUND

Current knowledge of the effects of radiation on the anorectum is based on a limited number of studies. Variability in delivery techniques, both currently and historically, combined with a paucity of prospective and randomized studies makes interpretation of the literature difficult. This review presents the existing evidence and identifies areas that require further work.

METHODS

This review is based on a literature search (Medline and PubMed) and manual cross-referencing.

RESULTS AND CONCLUSION

More than three-quarters of patients receiving pelvic radiotherapy experience acute anorectal symptoms and up to one-fifth suffer from late-phase radiation proctitis. About 5 per cent develop other chronic complications, such as fistula, stricture and disabling faecal incontinence. The risk of rectal cancer may be increased. Conservative treatment options are of limited value. Surgery may be considered if symptoms are severe, provided sphincter function is adequate and recurrent disease is excluded. Large prospective studies with accurate dosimetric data and long-term follow-up are needed to provide meaningful information on which to base new strategies to minimize the side-effects from radiotherapy.

Comparison of methods used for measurement of rectal compliance

INTRODUCTION

Compliance is defined as the change in volume or cross-sectional area divided by the change in pressure. Pressure-volume measurement during distention with a compliant balloon is the most commonly used method for computation of rectal compliance. However, intraindividual and interindividual variations are large, restricting the usefulness of the method. Other methods such as rectal distention by a large, noncompliant bag and rectal impedance planimetry for assessment of pressure-cross-sectional-area relations have been proposed as alternatives owing to the reduction of errors from elongation of the balloon within the rectal lumen. However, in vivo reproducibility of pressure-volume measurement during distention with a compliant balloon, pressure-volume measurement during rectal distention by a large, noncompliant bag, and rectal impedance planimetry have never been compared.

PURPOSE

The aim of this study was to compare in vivo reproducibility of the above-mentioned methods and to study their in vitro reproducibility and validity.

METHODS

Ten healthy volunteers (six men) aged 21-59 years were randomized to either rectal pressure-volume measurement with a compliant balloon or rectal impedance planimetry. After a one-hour rest, the other procedure was performed. After two weeks, both procedures were again performed in the same order. During rectal impedance planimetry the volume of the bag used (maximum volume 450 ml; secured at both ends to the probe) was continuously registered, measuring pressure-volume relations during rectal distention by a large, noncompliant bag. Reproducibility was tested by comparing the difference divided by the mean for each method at eight pressure steps in the range from 5 to 40 cm H2O. Furthermore, the in vitro reproducibility and validity of the three methods were studied using polyvinyl chloride tubes with known cross-sectional areas.

RESULTS

In vivo reproducibility for pressure-volume measurement with a large, noncompliant bag and rectal impedance planimetry was significantly better than for pressure-volume measurement with a compliant balloon (P = 0.005 and P = 0.019, respectively). No statistically significant difference was found between pressure-volume measurement with a large, noncompliant bag and rectal impedance planimetry (P = 0.20). In vitro reproducibility of pressure-volume measurement with a large, noncompliant bag and rectal impedance planimetry was good, but some elongation occurred, reducing the validity of pressure-volume measurement with a large, noncompliant bag. Coiling and elongation of the balloon within the lumen were major sources of error for pressure-volume measurement with a compliant balloon.

CONCLUSION

In vivo and in vitro reproducibility of methods used for measurement of rectal compliance can be improved by restricting the effects of elongation within the lumen either by using a large-volume, noncompliant bag or by rectal impedance planimetry. However, pressure-volume measurement will to some degree depend on the properties of the balloons or bags.

Surgeon influenced variables in resectional rectal cancer surgery

PURPOSE

Surgeon influenced variables in rectal cancer surgery were assessed.

METHODS

The literature was reviewed to discuss technical and educational issues that may affect the outcome of surgery for rectal cancer. Particular attention was paid to recently debated topics such as adjuvant therapy, colonic J-pouches, total mesorectal excision, and surgeons' training.

RESULTS

In some selected cases, transanal techniques with or without neoadjuvant or adjuvant therapy have improved the success of local excision. The biology of rectal cancer has begun to be understood. However, until a more complete understanding with an appreciation of therapeutic implications has been arrived at, surgeon influenced variables will continue to be of paramount importance. Multiple studies have shown tremendous surgeon variability in the outcome after rectal cancer surgery. Some of the variables that have been shown to be important include tumor-free distal and lateral margins, a total mesorectal excision, and an appropriate anastomosis. It has been well demonstrated that proctectomy with straight coloanal anastomosis compromises function as compared with preoperative levels or healthy controls. These deficiencies are further exacerbated by adjuvant therapy. Significant functional improvements, particularly in the first 12 to 24 months after surgery, have been achieved with use of colonic J-pouch.

CONCLUSION

There are many ways by which the surgeon can optimize curative resection for rectal cancer. Appropriate distal and tumor-free lateral margins with total mesorectal excision should be the goals for all tumors in the lower two-thirds of the rectum. Reconstruction should be performed, whenever technically possible, by a colonic J-pouch. Surgeons should be cognizant of their own practice patterns, volume, capabilities, and very importantly results. These results should be audited frequently and willingly shared with patients.

Morbidities of adjuvant chemotherapy and radiotherapy for resectable rectal cancer: an overview

PURPOSE

Although adjuvant chemoradiotherapy may improve outcomes after surgery for high-risk rectal cancer, its toxicities are not well documented. This is a review of complications associated with adjuvant therapy in randomized, controlled trials.

METHODS

A MEDLINE and literature search was performed for randomized, controlled trials of adjuvant therapy for rectal cancer. Modalities of adjuvant therapy evaluated included preoperative radiotherapy, preoperative chemoradiotherapy, postoperative radiotherapy, and postoperative chemoradiotherapy. All documented complications were analyzed, including any effect on pelvic floor function and quality of life.

RESULTS

Short-term (acute) complications of preoperative radiotherapy include lethargy, nausea, diarrhea, and skin erythema or desquamation. These acute effects develop to some degree in most patients during treatment but are usually self-limiting. With preoperative radiotherapy the incidence of perineal wound infection increases from 10 to 20 percent. The acute toxicities after postoperative radiotherapy for rectal cancer occur in 4 to 48 percent of cases, and serious toxicities, requiring hospitalization or surgical intervention, occur in 3 to 10 percent of cases. Postoperative radiotherapy is associated with more complications than preoperative radiotherapy. The main problems with postoperative radiotherapy are small-bowel obstruction (5-10 percent), delay in starting radiotherapy caused by delayed wound healing (6 percent) and postoperative fatigue (14 percent), and toxicities precluding completion of adjuvant therapy (49-97 percent). The morbidity and mortality of both preoperative and postoperative radiotherapy are higher in elderly patients and when two-portal rather than three-portal or four-portal radiation technique is used. Meticulous radiation technique is important, and multiple fields of irradiation are mandatory. After combined adjuvant chemotherapy and radiotherapy acute hematologic and gastrointestinal toxic effects are frequent (5-50 percent). Delayed radiation toxicities include radiation enteritis (4 percent), small-bowel obstruction (5 percent), and rectal stricture (5 percent). Pelvic floor function and quality of life have not been well evaluated in randomized, controlled trials.

CONCLUSION

Adjuvant therapy for rectal cancer has considerable adverse effects. Adverse effects on bowel and sphincter function and quality of life have not been defined.