Endoscopic and histopathologic findings after formalin application for hemorrhage caused by chronic radiation-induced proctitis

Formalin irrigation for hemorrhagic chronic radiation proctitis

AIM: To assess the efficacy and safety of a modified topical formalin irrigation method in refractory hemorrhagic chronic radiation proctitis (CRP).

METHODS: Patients with CRP who did not respond to previous medical treatments and presented with grade II-III rectal bleeding according to the Common Terminology Criteria for Adverse Events were enrolled. Patients with anorectal strictures, deep ulcerations, and fistulas were excluded. All patients underwent flexible endoscopic evaluation before treatment. Patient demographics and clinical data, including primary tumor, radiotherapy and previous treatment options, were collected. Patients received topical 4% formalin irrigation in a clasp-knife position under spinal epidural anesthesia in the operating room. Remission of rectal bleeding and related complications were recorded. Defecation, remission of bleeding, and other symptoms were investigated at follow-up. Endoscopic findings in patients with rectovaginal fistulas were analyzed.

RESULTS: Twenty-four patients (19 female, 5 male) with a mean age of 61.5 ± 9.5 years were enrolled. The mean time from the end of radiotherapy to the onset of bleeding was 11.1 ± 9.0 mo (range: 2-24 mo). Six patients (25.0%) were blood transfusion dependent. The median preoperative Vienna Rectoscopy Score (VRS) was 3 points. Nineteen patients (79.2%) received only one course of topical formalin irrigation, and five (20.8%) required a second course. No side effects were observed. One month after treatment, bleeding cessation was complete in five patients and obvious in 14; the effectiveness rate was 79.1% (19/24). For long-term efficacy, 5/16, 1/9 and 0/6 patients complained of persistent bleeding at 1, 2 and 5 years after treatment, respectively. Three rectovaginal fistulas were found at 1 mo, 3 mo and 2 years after treatment. Univariate analysis showed associations of higher endoscopic VRS and ulceration score with risk of developing rectovaginal fistula.

CONCLUSION: Modified formalin irrigation is an effective and safe method for hemorrhagic CRP, but should be performed cautiously in patients with a high endoscopic VRS.

Acta Oncologica Lecture. Gastrointestinal consequences of cancer treatment and the wider context: a bad gut feeling

BACKGROUND

The percentage of people living with a diagnosis of cancer is rising globally. Between 20% and 25% of people treated for cancer experience a consequence of cancer which has an adverse impact on the quality of their life. Gastrointestinal (GI) symptoms are the most common of all consequences of cancer treatment and have the greatest impact on daily activity. PATHOPHYSIOLOGY OF LONG-TERM BOWEL DAMAGE AFTER PELVIC RADIOTHERAPY: Long-term damage to the bowel after radiotherapy is mediated by ischaemic changes and fibrosis. Each fraction of radiotherapy causes a series of repetitive injuries to the intestinal tissue resulting in an altered healing process, which affects the integrity of the repair and changes the architecture of the bowel wall. THE NATURE OF GI SYMPTOMS THAT DEVELOP: Patient-reported outcome measures show that diarrhoea, urgency, increased bowel frequency, tenesmus and flatulence are the five most prevalent GI symptoms with a moderate or severe impact on patients' daily lives after treatment with pelvic radiotherapy. Many patients also experience fatigue, urinary problems and have sexual concerns. SYSTEMATIC ASSESSMENT AND MANAGEMENT: The complex nature of those symptoms warrants systematic assessment and management. The use of a tested algorithm can assist in achieving this. The most common contributing factors to ongoing bowel problems after pelvic radiotherapy are small intestinal bacterial overgrowth, bile acid malabsorption, pancreatic insufficiency, rectal bleeding and its impact on bone health.

THE WIDER CONTEXT

Symptom burden, socio-psychosocial impact, memory and cognitive function, fatigue, urinary problems and sexual concerns need to be taken into account when thinking about consequences of cancer treatment.

CONCLUSION

As our understanding of consequences of cancer treatments continues to emerge and encompass a wide variety of specialties, a holistic, multifaceted and multidisciplinary approach is required to manage those consequences long-term.

Clinical and proctoscopic evaluation of topical formalin application in the treatment of chronic radiation proctitis

BACKGROUND AND AIMS

Chronic radiation proctitis is a disease associated with radiotherapy of cancer in the pelvic region. The main symptom is rectal bleeding. Several treatment modalities have been attempted, but few have demonstrated satisfactory effects. We present our experience with formalin applied locally to the rectal mucosa in the treatment of chronic radiation proctitis. Furthermore, we assess possible complications, the gravest suggested being cancer. Previous studies on the subject have reported good results, but often with a somewhat vaguely defined follow-up. Our evaluation of the treatment was based on both subjective symptoms and proctoscopic findings.

MATERIAL AND METHODS

A small study (N = 11) was conducted retrospectively. All patients treated for chronic radiation proctitis with formalin in our clinic were identified, and data concerning effect and complications were collected by studying the patients' records, with a questionnaire and a follow-up interview and proctoscopy.

RESULTS

The study showed a marked decrease in bleeding and objective signs of proctitis in all patients. Complete cessation of bleeding was achieved in five patients. Possible complications to the treatment detected in our study were the following: anorectal pain, tenesmus, incontinence, diarrhea, and mucous rectal discharge. No signs of neoplasia were found.

CONCLUSIONS

The formalin treatment had a very good effect on chronic radiation proctitis. Possible complications were detected. Except in the case of anorectal pain, these are all of a questionable nature and can possibly be attributed to chronic radiation proctitis itself rather than the formalin treatment. Further study is warranted to confirm long-term effects of the formalin and to exclude possible complications, especially secondary anorectal cancer.

Managing gastrointestinal symptoms after cancer treatment: a practical approach for gastroenterologists

The percentage of the population living with a diagnosis of cancer is rising. By 2030, there will be 4 million cancer survivors in the UK. One quarter of cancer survivors are left with physical symptoms, which affect their quality of life. Gastrointestinal (GI) symptoms are the most common of all chronic physical side-effects of cancer treatment and have the greatest impact on daily activity. Cancer therapies induce long-term changes in bowel function due to alterations to specific GI physiological functions. In addition, the psychological effect of a cancer diagnosis, new GI disease or pre-existing underlying conditions, may also contribute to new symptoms. Twenty-three upper GI symptoms have been identified as occurring after pelvic radiotherapy. After upper GI cancer treatment, the most troublesome symptoms include reflux, abdominal pain, indigestion, diarrhoea and fatigue. Often, several symptoms are present simultaneously and women experience more symptoms than men. The symptoms which patients rate as most difficult are urgency, wind, diarrhoea, incontinence, abdominal pain and rectal bleeding. Recent UK Guidance on managing GI symptoms suggests that these symptoms can be treated especially if gastroenterological advice is combined with dietetic and nursing input to optimise investigations and management. However, as different pathological processes can result in identical symptoms; a systematic, 'algorithmic' approach to assess and treat these symptoms is required. This paper aims to illustrate the value of such an approach to investigate and treat the most common GI symptoms that trouble patients. The algorithm allows clinicians to institute a comprehensive medical management plan.

Formalin dab, the effective way of treating haemorrhagic radiation proctitis: a randomized trial from a tertiary care hospital in South India

AIM

Chronic radiation proctitis with bleeding is a common problem encountered following radiotherapy for pelvic malignancy. Sucralfate-steroid enema and formalin dab are two common nonsurgical treatments. A randomized trial was conducted to compare the efficacy of these two methods.

METHOD

This was a prospective randomized controlled trial conducted in the Jawaharlal Institute of Postgraduate Medical Education & Research (JIPMER) from August 2005 to May 2007. One-hundred and two patients with chronic radiation proctitis, presenting as rectal bleeding after radiotherapy for carcinoma of the cervix, were recruited and randomly allocated into two treatment groups: Group 1, formalin dab; and Group 2, sucralfate-steroid retention enema. The mean age of the patients was 51.3 ± 5.1 years. The mean interval between the end of radiotherapy and the onset of bleeding was 12.3 ± 3.5 months. Symptom score and sigmoidoscopic grade were assessed before, and at 1 month after, treatment.

RESULTS

Ninety per cent of patients in Group 1 and 74.5% of patients in Group 2 responded to treatment (P = 0.038). In spite of having a higher median symptom score before treatment, patients in Group 1 demonstrated a marked decrease in symptom score after treatment compared with patients in Group 2 and the difference once again was statistically significant (P = 0.000). Similarly, the median sigmoidoscopic grade was significantly lower for patients in Group 1 compared with patients in Group 2 after treatment (P = 0.000). There were no specific treatment-related complications in either group.

CONCLUSIONS

Formalin (4%) dab is superior to sucralfate-steroid retention enema for treatment of chronic haemorrhagic radiation proctitis.

Oral vitamin A enhances the effectiveness of formalin 8% in treating chronic hemorrhagic radiation proctopathy

PURPOSE

Chronic radiation proctopathy occurs in 5 to 20% of patients receiving radiation therapy, with rectal bleeding as its most common presentation. Although formalin treatment for rectal bleeding is promising, improvement is possible. Given the success of vitamin A in other radiation-induced treatments, we studied the efficacy of combining formalin with vitamin A in controlling bleeding symptoms of chronic radiation proctopathy.

METHODS

A retrospective review (1993-2007) was performed of patients presenting with features of chronic radiation proctopathy. Formalin 8% in a buffered solution was applied to the affected mucosa with use a tip applicator, and 10,000 units of vitamin A were given orally on a daily basis. Formalin treatments were repeated at three-week to four-week intervals until symptoms resolved.

RESULTS

A comparison was made between patients who received formalin alone (n = 30) and those who received formalin in combination with vitamin A (n = 34). The 64 patients had a mean age of 79 years (range, 54-90 years). The combination group required fewer treatments (mean, 1.9) and a shorter time (11 weeks) for resolution of symptoms compared with the formalin-alone group (mean, 5.2 and 31 weeks, respectively) (P < 0.001). The overall success rate in controlling bleeding was only 64% in the formalin-alone group when compared with 94% in the combination group.

CONCLUSIONS

When vitamin A was added to the regimen, a significant reduction was observed in the number of treatments and the time needed for resolution of symptoms, and there was an increased overall success rate. This combination represents a simple, effective, and well tolerated method of controlling hemorrhagic chronic radiation proctopathy.

Radiotherapy: long-term effects on gastrointestinal function

PURPOSE OF REVIEW

Radiotherapy frequently results in persistent effects on gastrointestinal function adversely impacting on the quality of life of patients cured of their malignant disease. Long-term effects on gastrointestinal function remain prevalent despite the advent of three-dimensional techniques of radiotherapy because higher radiation doses and more combined modality treatments are prescribed to improve cure rates.

RECENT FINDINGS

Chronic elevation of cytokine levels and implication of the cyclooxygenase-2 pathway in radiation bowel injury in animals, and the involvement of the Rho/Rho kinase pathway in the fibrogenic differentiation of smooth muscle cells of patients with late radiation enteritis, suggest a role for inhibition of these pathways. The importance of limiting acute gastrointestinal toxicity by dietary, pharmacological and physical interventions and of optimizing radiotherapy techniques and prescriptions is underscored by increasing evidence that a component of the long-term effects of radiotherapy on gastrointestinal function is a consequence of acute damage.

SUMMARY

Strategies to control acute toxicity are important in reducing the impact of long-term effects of radiotherapy on gastrointestinal function. Further research into genetic profiling to characterize individual risk of radiation bowel damage and the pathways implicated in fibrogenic differentiation is needed to reduce and prevent bowel complications.

Anorectal cancer following topical formalin application for haemorrhagic radiation proctitis

OBJECTIVE

Topical formalin has been used as an effective treatment for haemorrhagic radiation proctitis. In the course of reviewing our experience with this modality, we identified two patients who developed anorectal cancer during the follow-up period.

METHOD

From 2001 to 2005, 49 patients who received pelvic radiation for treatment of prostate, rectal or endometrial cancer subsequently developed haemorrhagic radiation proctitis. Four percent formalin was applied in the office setting under direct visualization with a rigid proctoscope and without sedation. Response to treatment was then reviewed.

RESULTS

Seventy-eight per cent of patients reported a complete response to formalin application. Only 14% were refractory to formalin treatment. Two patients subsequently presented with anorectal cancer.

CONCLUSION

Topical formalin application in the outpatient setting appears to be an effective first-line treatment for haemorrhagic radiation proctitis. We report the first cases of anorectal cancer which developed subsequent to formalin application. Pelvic irradiation is known to increase the risk of developing a second malignancy, therefore it is impossible to determine what, if any, role formalin application played in the development of the second malignancies.