[Radiation proctitis and chronic and refractory bleeding. Experience with 4% formaldehyde]

Diode Laser Therapy for Radiation-Induced Vascular Ectasia: Long-Term Results and Cost Analysis

BACKGROUND

Collateral damage to surrounding healthy tissues has been reported in patients who undergo radiation therapy for pelvic malignancies. This study aimed to evaluate the safety, efficacy and cost efficiency of endoscopic diode laser therapy in patients diagnosed with chronic radiation proctitis (CRP).

METHODS

The data of 24 patients (median age 78, range 67-90 years) who presented rectal bleeding and were diagnosed with CRP after undergoing high-dose radiotherapy for prostatic cancer and underwent diode laser therapy were evaluated retrospectively. Non-contact fibers were used in the patients who underwent the procedure without sedation in an outpatient setting.

RESULTS

The patients underwent a median of two sessions; overall, a mean of 1591 J of laser energy per session was used. No complications were noted during or after the procedures. Bleeding was completely resolved in 21/24 (88%) patients, and two patients showed improvement (96%). It was not necessary to suspend antiplatelet (six patients) or anticoagulant (four patients) therapy during the treatment course. The mean cost per session was EUR 473.4.

CONCLUSIONS

The study findings demonstrated that endoscopic non-contact diode laser treatment in CRP patients is safe, effective and cost efficient. For this procedure, antiplatelet and anticoagulant therapy suspension, intraprocedural sedation and hospital admission are not required.

Risk Prediction and Treatment of LE-DVT in Patients with Chronic Radiation Intestinal Injury: A Retrospective Case-Control Study

Background

Chronic radiation intestinal injury (CRII) is the most common complication after pelvic malignancy radiation. Once hemorrhagic CRII patients suffer from lower extremity deep venous thrombosis (LE-DVT), hemostasis and anticoagulation therapy will be adopted simultaneously, but the treatment strategy is a paradox, as the condition is extremely intractable and serious. The aim of this study was to investigate the prevalence of and risk factors for LE-DVT in CRII patients and explore the treatment of hemorrhagic CRII patients with LE-DVT.

Methods

This was a retrospective study, and a total of 608 hospitalized CRII patients after pelvic radiotherapy were included from November 2011 to October 2018. Univariate and multivariate analyses were conducted to investigate the potential risk factors for LE-DVT in CRII patients. Furthermore, the treatment of hemorrhagic CRII patients with LE-DVT was explored.

Results

Among the CRII patients, 94 (15.5%) were with suspicious symptoms of LE-DVT in the lower limbs, and 32 (5.3%) were diagnosed with LE-DVT. Among the patients with LE-DVT, 65.6% (21/32) had bleeding simultaneously, and 29 (90.6%) had anemia with 24 (75.0%) having moderate to severe anemia. Multivariate analysis showed that a recent surgical history (≤6 months) (OR = 5.761, 95% CI: 2.506~13.246, p < 0.001), tumor recurrence or metastasis (OR = 3.049, 95% CI: 1.398~6.648, p = 0.005) and the hemoglobin (Hb) level (OR = 0.960, 95% CI: 0.942~0.979, p < 0.001) were significantly associated with the development of LE-DVT. ROC curve analysis showed that the AUC of the merged risk score of the independent risk factors was 0.822 (95% CI: 0.789~0.852), and the optimal Hb cutoff was 82.5 g/L. After colostomy, obvious bleeding remission was rapidly found in 84.6% of hemorrhagic CRII patients with LE-DVT.

Conclusion

The prevalence of LE-DVT in hospitalized CRII patients was 5.3%. A recent surgical history, tumor recurrence or metastasis and a lower Hb level were independently associated with LE-DVT development in CRII patients. Colostomy could be a good choice for intractable hemorrhagic CRII patients with LE-DVT.

Impact of diabetes on gastrointestinal and urinary toxicity after radiotherapy for gynecologic malignancy

Objective

Although diabetes is a common co-morbidity in patients with gynecologic cancer, information about its impact on radiation toxicity in patients with gynecologic cancer treated with external pelvic irradiation is scarce. We aimed to investigate the relation of diabetes with acute toxicity in patients with gynecologic tumors who underwent pelvic +/- paraaortic radiotherapy.

Materials and Methods

One hundred twenty-nine patients with endometrium or cervix carcinoma were enrolled in the study. Demographic features, presence of diabetes, incidence and severity of upper gastrointestinal (UGIS), lower gastrointestinal (LGIS), and urinary symptoms were recorded from files. Correlation and logistic regression analysis was used to determine the impact of diabetes, age, chemotherapy, paraaortic irradiation on toxicities, and a prediction model was developed.

Results

The median age of 77 patients with endometrium cancer and 52 cervix cancer was 61 (range, 25-92) years, and 28 (21.7%) of them had diabetes. The median pelvic and tumor/tumor bed dose was 5040+247.65 cGy and 5040+222.91 cGy, respectively. Age and Gr 0 UGIS toxicity were significantly related (p=0.047). LGIS Gr 0 toxicity was found to be significantly higher in patients with diabetes (p=0.045). Gr 0 and 2 UGIS toxicities were both found to be significantly correlated with paraaortic irradiation (both p<0.001). Diabetes is also an important determinant on UGIS toxicity in patients who underwent paraaortic irradiation.

Conclusion

The correlation we found between toxicity and diabetes, concurrent chemotherapy or paraaortic radiation necessitates special care and risk stratification for patients with diabetes. Further prospective studies with long follow-up and larger patient groups are warranted.

Short and long term response to argon plasma therapy for hemorrhagic radiation proctitis

INTRODUCTION

hemorrhagic radiation proctitis appears secondary to radiotherapy. Argon plasma is an effective, safe and easy-to-use technique with a relatively low cost.

OBJECTIVES

to describe the short- and long-term response to argon plasma therapy in patients with hemorrhagic radiation proctitis.

METHOD

an observational prospective study was performed of a series of 82 patients with hemorrhagic radiation proctitis, attended at the National Center for Minimally Invasive Surgery between 2010 and 2016. Summary measurements and a comparison of means (paired Student's t-test) for the final and initial hemoglobin levels were used. In addition, the Kaplan-Meier method was used to determine the rectal bleeding recurrence free time.

RESULTS

in the present study, 54.9% of cases required 1-3 argon sessions and 86.6% required 1-5 sessions to resolve the bleeding, with a median of 3.0 sessions. In addition, 4.9% of patients had proctalgia as a complication. There was an improvement in hemoglobin of 2 g/dl. Rectal bleeding recurrence occurred in 8.5% of the patients during the nine months after therapy. Bleeding recurrence free time at three, six and nine months was 98.8%, 96.3% and 91.5%, respectively. Short-term therapy response was observed in all patients and long-term response after one year of follow-up was 91.5%.

CONCLUSION

argon plasma coagulation shows a good short- and long-term response with few therapy sessions and a low rate of complications in patients with chronic hemorrhagic radiation proctitis.

What is the impact of diabetes mellitus on radiation induced acute proctitis after radical radiotherapy for adenocarcinoma prostate? A prospective longitudinal study

Background

Long-term complications of diabetes include cardiovascular disease, retinopathy, nephropathy, and neuropathy. Diabetic patients with prostate cancer could be at a high risk of radiation-induced acute proctitis following radical radiotherapy. Our aims were to analyse the incidence, severity, and duration of radiation proctitis in diabetic patients treated by radical radiotherapy and combined androgen deprivation for prostate cancer.

Material and methods

On the bases of inclusion and exclusion criteria 716 patients with prostate cancer were retrospectively recruited. Patients were stratified into diabetic patients and non-diabetic patients. The incidence, severity, and duration of proctitis were the main outcomes. A polynomial ordered logistic regression was fitted to determine the influence of diabetes status, age, blood pressures medication, co-morbidities, Gleason score, PSA after treatment, and tumour stage on the grades of proctitis. Time to resolution per year was modelled as a negative binomial generalised linear model.

Results

The overall mean age of patients was 67.44 (SD 6.77) years with a follow-up time of 3.36 (SD 2.05) years. Data exploratory analysis suggested that the only highly significant explanatory variable was the presence or absence of diabetes. Polynomial ordered logistic regression, however, showed that the presence (or not) of diabetes remained as the only significant predictor (t = -2.74; p = 0.0059) of severity of proctitis. A negative binomial generalised linear model showed that both grade of proctitis (z = -17.178; p < 0.001), and diabetes (z = -5.92; p < 0.001), were highly significant predictors of time to resolution.

Conclusions

Diabetic patients were significantly more likely to have proctitis after radical radiation therapy for prostate cancer. Diabetes was significantly associated with an induced risk of radiation induced proctitis and also with deceleration of its resolution.

Colostomy is a simple and effective procedure for severe chronic radiation proctitis

AIM: To assess the efficacy and safety of diverting colostomy in treating severe hemorrhagic chronic radiation proctitis (CRP).

METHODS: Patients with severe hemorrhagic CRP who were admitted from 2008 to 2014 were enrolled into this study. All CRP patients were diagnosed by a combination of pelvic radiation history, clinical rectal bleeding, and endoscopic findings. Inclusion criteria were CRP patients with refractory bleeding with moderate to severe anemia with a hemoglobin level < 90 g/L. The study group included patients who were treated by diverting colostomy, while the control group included patients who received conservative treatment. The remission of bleeding was defined as complete cessation or only occasional bleeding that needed no further treatment. The primary outcome was bleeding remission at 6 mo after treatment. Quality of life before treatment and at follow-up was evaluated according to EORTC QLQ C30. Severe CRP complications were recorded during follow-up.

RESULTS: Forty-seven consecutive patients were enrolled, including 22 in the colostomy group and 27 in the conservative treatment group. When compared to conservative treatment, colostomy obtained a higher rate of bleeding remission (94% vs 12%), especially in control of transfusion-dependent bleeding (100% vs 0%), and offered a better control of refractory perianal pain (100% vs 0%), and a lower score of bleeding (P < 0.001) at 6 mo after treatment. At 1 year after treatment, colostomy achieved better remission of both moderate bleeding (100% vs 21.5%, P = 0.002) and severe bleeding (100% vs 0%, P < 0.001), obtained a lower score of bleeding (0.8 vs 2.0, P < 0.001), and achieved obvious elevated hemoglobin levels (P = 0.003), when compared to the conservative treatment group. The quality of life dramatically improved after colostomy, which included global health, function, and symptoms, but it was not improved in the control group. Pathological evaluation after colostomy found diffused chronic inflammation cells, and massive fibrosis collagen depositions under the rectal wall, which revealed potential fibrosis formation.

CONCLUSION: Diverting colostomy is a simple, effective and safe procedure for severe hemorrhagic CRP. Colostomy can improve quality of life and reduce serious complications secondary to radiotherapy.

Can Angiotensin-Converting Enzyme Inhibitors Reduce the Incidence, Severity, and Duration of Radiation Proctitis?

PURPOSE

To determine whether participants taking angiotensin-converting enzyme inhibitors (ACEIs) and treated with radical radiation therapy with neoadjuvant/adjuvant hormone therapy have less incidence, severity, and duration of radiation proctitis.

METHODS AND MATERIALS

A propensity score analysis of 817 patients who underwent radical radiation therapy with neoadjuvant or adjuvant hormone therapy as primary line management in a cohort study during 2009 to 2013 was conducted. Patients were stratified as follows: group 1, hypertensive patients taking ACEIs (as a study group); group 2, nonhypertensive patients not taking ACEIs; and group 3, hypertensive patients not taking ACEIs (both as control groups). The incidence, severity, and duration of proctitis were the main outcome. χ(2) tests, Mann-Whitney U tests, analysis of variance, risk ratio (RR), confidence interval (CI), Kaplan-Meier plots, and log-rank tests were used.

RESULTS

The mean age of the participants was 68.91 years, with a follow-up time of 3.38 years. Based on disease and age-matched comparison, there was a statistically significant difference of proctitis grading between the 3 groups: χ(2) (8, n=308) = 72.52, P<.001. The Mann-Whitney U test indicated that grades of proctitis were significantly lower in hypertensive patients taking ACEIs than in nonhypertensive patients not taking ACEIs and hypertensive patients not taking ACEIs (P<.001). The risk ratio (RR) of proctitis in hypertensive patients taking ACEIs was significantly lower than in hypertensive patients not taking ACEIs (RR 0.40, 95% CI 0.30-0.53, P<.001) and in nonhypertensive patients not taking ACEIs (RR 0.58, 95% CI 0.44-0.77, P<.001). Time to event analysis revealed that hypertensive patients taking ACEIs were significantly different from the control groups (P<.0001). Furthermore, hypertensive patients taking ACEIs had significantly faster resolution of proctitis (P<.0001).

CONCLUSION

Patients who were taking ACEIs were significantly less likely to have high-grade proctitis after radical radiation therapy with neoadjuvant or adjuvant hormone therapy (P<.001). The intake of ACEIs was significantly associated with a reduced risk of radiation-induced proctitis and also with acceleration of its resolution.