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Chen Y, Ding L, Zhang ZW, Wu XH, Que YT, Ma YR, Liu YY, Wen ZQ, Yang XY, Lu BL, Bao Y, Niu SQ, Yu SP. Role of dynamic contrast-enhanced MRI in predicting severe acute radiation-induced rectal injury in patients with rectal cancer. Eur Radiol 2024; 34:1471-1480. [PMID: 37665390 DOI: 10.1007/s00330-023-10194-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2022] [Revised: 05/21/2023] [Accepted: 07/07/2023] [Indexed: 09/05/2023]
Abstract
OBJECTIVES To explore the potential of dynamic contrast-enhanced MRI (DCE-MRI) quantitative parameters in predicting severe acute radiation-induced rectal injury (RRI) in rectal cancer. METHODS This retrospective study enrolled 49 patients with rectal cancer who underwent neoadjuvant chemoradiotherapy and rectal MRI including a DCE-MRI sequence from November 2014 to March 2021. Two radiologists independently measured DCE-MRI quantitative parameters, including the forward volume transfer constant (Ktrans), rate constant (kep), fractional extravascular extracellular space volume (ve), and the thickness of the rectal wall farthest away from the tumor. These parameters were compared between mild and severe acute RRI groups based on histopathological assessment. Receiver operating characteristic curve analysis was performed to analyze statistically significant parameters. RESULTS Forty-nine patients (mean age, 54 years ± 12 [standard deviation]; 37 men) were enrolled, including 25 patients with severe acute RRI. Ktrans was lower in severe acute RRI group than mild acute RRI group (0.032 min-1 vs 0.054 min-1; p = 0.008), but difference of other parameters (kep, ve and rectal wall thickness) was not significant between these two groups (all p > 0.05). The area under the receiver operating characteristic curve of Ktrans was 0.72 (95% confidence interval: 0.57, 0.84). With a Ktrans cutoff value of 0.047 min-1, the sensitivity and specificity for severe acute RRI prediction were 80% and 54%, respectively. CONCLUSION Ktrans demonstrated moderate diagnostic performance in predicting severe acute RRI. CLINICAL RELEVANCE STATEMENT Dynamic contrast-enhanced MRI can provide non-invasive and objective evidence for perioperative management and treatment strategies in rectal cancer patients with acute radiation-induced rectal injury. KEY POINTS • To our knowledge, this study is the first to evaluate the predictive value of contrast-enhanced MRI (DCE-MRI) quantitative parameters for severe acute radiation-induced rectal injury (RRI) in patients with rectal cancer. • Forward volume transfer constant (Ktrans), derived from DCE-MRI, exhibited moderate diagnostic performance (AUC = 0.72) in predicting severe acute RRI of rectal cancer, with a sensitivity of 80% and specificity of 54%. • DCE-MRI is a promising imaging marker for distinguishing the severity of acute RRI in patients with rectal cancer.
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Affiliation(s)
- Yan Chen
- Department of Radiology, The First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, 510080, China
| | - Li Ding
- Department of Pathology, The First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, 510080, China
| | - Zhi-Wen Zhang
- Department of Radiology, The First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, 510080, China
| | - Xue-Han Wu
- Department of Radiology, The First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, 510080, China
- Department of Radiology, The Seventh Affiliated Hospital, Sun Yat-Sen University, Shenzhen, 518017, China
| | - Yu-Tao Que
- Department of Radiology, The First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, 510080, China
- Department of Radiology, The Seventh Affiliated Hospital, Sun Yat-Sen University, Shenzhen, 518017, China
| | - Yu-Ru Ma
- Department of Radiology, The First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, 510080, China
| | - Yi-Yan Liu
- Department of Radiology, The First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, 510080, China
| | - Zi-Qiang Wen
- Department of Radiology, The First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, 510080, China
| | - Xin-Yue Yang
- Department of Radiology, Zhujiang Hospital, Southern Medical University, Guangzhou, 510280, China
| | - Bao-Lan Lu
- Department of Radiology, The First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, 510080, China
| | - Yong Bao
- Department of Radiotherapy, The First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, 510080, China
| | - Shao-Qing Niu
- Department of Radiotherapy, The First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, 510080, China.
| | - Shen-Ping Yu
- Department of Radiology, The First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, 510080, China.
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Deodato F, Ferro M, Bonome P, Pezzulla D, Romano C, Buwenge M, Cilla S, Morganti AG, Macchia G. Stereotactic body radiotherapy (SIB-VMAT technique) to dominant intraprostatic lesion (DIL) for localized prostate cancer: a dose-escalation trial (DESTROY-4). Strahlenther Onkol 2024; 200:239-249. [PMID: 38180492 DOI: 10.1007/s00066-023-02189-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2023] [Accepted: 12/03/2023] [Indexed: 01/06/2024]
Abstract
PURPOSE DESTROY-4 (DOSE-ESCALATION STUDY OF STEREOTACTIC BODY RADIATION THERAPY) was a Phase I trial aimed to evaluate the safety and the feasibility of escalating doses of stereotactic body radiation therapy (SBRT) on MRI-defined Dominant Intraprostatic Lesion (DIL) in low- and intermediate-risk pCa patients using a simultaneous integrated boost-volumetric arc therapy (SIB-VMAT) technique. METHODS Eligible patients included those with low- and intermediate-risk prostate carcinoma (NCCN risk classes) and an International Prostatic Symptoms Score (IPSS) ≤ 15. No restriction about DIL and prostate volumes was set. Pretreatment preparation required an enema and the placement of intraprostatic gold fiducials. SBRT was delivered in five consecutive daily fractions. For the first three patients, the DIL radiation dose was set at 8 Gy per fraction up to a total dose of 40 Gy (PTV1) and was gradually increased in succeeding cohorts to total doses of 42.5 Gy, 45.0 Gy, 47.5 Gy, and finally, 50.0 Gy, while keeping the prescription of 35 Gy/7 Gy per fraction for the entire prostate gland. Dose-limiting toxicity (DLT) was defined as grade 3 or worse gastrointestinal (GI) or genitourinary (GU) toxicity occurring within 90 days of follow-up (Common Terminology Criteria of Adverse Events scale 4.0). Patients completed quality-of-life questionnaires at defined intervals. RESULTS Twenty-four patients with a median age of 75 (range, 58-89) years were enrolled. The median follow-up was 26.3 months (8.9-84 months). 66.7% of patients were classified as intermediate-risk groups, while the others were low-risk groups, according to the NCCN guidelines. Enrolled patients were treated as follows: 8 patients (40 Gy), 5 patients (42.5 Gy), 4 patients (45 Gy), 4 patients (47.5 Gy), and 3 patients (50 Gy). No severe acute toxicities were observed. G1 and G2 acute GU toxicities occurred in 4 (16%) and 3 patients (12.5%), respectively. Two patients (8.3%) and 3 patients (12.5%) experienced G1 and G2 GI toxicities, respectively. Since no DLTs were observed, 50 Gy in five fractions was considered the MTD. The median nadir PSA was 0.20 ng/mL. A slight improvement in QoL values was registered after the treatment. CONCLUSION This trial confirms the feasibility and safety of a total SIB-VMAT dose of 35 Gy on the whole gland and 50 Gy on DIL in 5 fractions daily administered in a well-selected low- and intermediate-risk prostate carcinoma population. A phase II study is ongoing to confirm the tolerability of the schedule and assess the efficacy.
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Affiliation(s)
- Francesco Deodato
- Radiation Oncology Unit, Responsible Research Hospital, Campobasso, Italy
- Istituto di Radiologia, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Milena Ferro
- Radiation Oncology Unit, Responsible Research Hospital, Campobasso, Italy.
| | - Paolo Bonome
- Radiation Oncology Unit, Responsible Research Hospital, Campobasso, Italy
| | - Donato Pezzulla
- Radiation Oncology Unit, Responsible Research Hospital, Campobasso, Italy
| | - Carmela Romano
- Medical Physics Unit, Responsible Research Hospital, Campobasso, Italy
| | - Milly Buwenge
- Radiation Oncology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Savino Cilla
- Medical Physics Unit, Responsible Research Hospital, Campobasso, Italy
| | - Alessio Giuseppe Morganti
- Radiation Oncology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
- Department of Experimental, Diagnostic, and Specialty Medicine - DIMES, Alma Mater Studiorum, Bologna University, Bologna, Italy
| | - Gabriella Macchia
- Radiation Oncology Unit, Responsible Research Hospital, Campobasso, Italy
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Bae BK, Kim JE, Pyo H, Hong SN, Park W. Long-term findings of rectal endoscopy and rectal bleeding after moderately hypofractionated, intensity-modulated radiotherapy for prostate cancer. Sci Rep 2023; 13:22099. [PMID: 38092835 PMCID: PMC10719280 DOI: 10.1038/s41598-023-43202-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2022] [Accepted: 09/21/2023] [Indexed: 12/17/2023] Open
Abstract
To present rectal endoscopic findings and toxicity after definitive moderately hypofractionated, intensity-modulated radiotherapy (IMRT) for prostate cancer. We retrospectively reviewed patients who underwent IMRT for prostate cancer and underwent post-radiotherapy endoscopies between 2008 and 2018. Endoscopic findings were reviewed and graded using Vienna Rectoscopy Score (VRS). We have analyzed the association between endoscopic findings and rectal bleeding, and investigated risk factors for rectal bleeding. Total 162 patients met the inclusion criteria of this study. There was a trend of VRS worsening during the initial 3 years after radiotherapy followed by recovery. Rectal bleeding was highest at 1 year after radiotherapy and improved thereafter. The 5-year cumulative incidence of grade ≥ 2 rectal bleeding was 14.8%. In the multivariable Cox regression analysis, cardiovascular disease (hazard ratio [HR] 2.732, P = 0.037), rectal wall V65 (HR 1.158, P = 0.027), and VRS ≥ 3 in first post-radiotherapy endoscopy (HR 2.573, P = 0.031) were significant risk factors for rectal bleeding. After IMRT for prostate cancer, VRS and rectal bleeding worsened over 1-3 years after radiotherapy and recovered. Cardiovascular disease, rectal wall V65, and VRS ≥ 3 in first post-radiotherapy endoscopy were significant risk factors for rectal bleeding.
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Affiliation(s)
- Bong Kyung Bae
- Department of Radiation Oncology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
- Department of Radiation Oncology, Kyungpook National University Chilgok Hospital, Daegu, Republic of Korea
| | - Ji Eun Kim
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Hongryull Pyo
- Department of Radiation Oncology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Sung Noh Hong
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Won Park
- Department of Radiation Oncology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea.
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Pasquier D, Lacornerie T, Supiot S, Pommier P, Quivrin M, Simon JM, Loos G, Meyer E, Calais G, Peiffert D, Vandendorpe B, Aymes E, Leguillette C, Brihoum M, Nenan S, Cormier L, Le Deley MC, Lartigau EF. The Safety and Efficacy of Salvage Stereotactic Radiation Therapy in Patients with Intraprostatic Tumor Recurrence After Previous External Radiation Therapy: Phase 1 Results from the GETUG-AFU 31 Study. Eur Urol Oncol 2023; 6:399-405. [PMID: 36754722 DOI: 10.1016/j.euo.2023.01.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2022] [Revised: 12/11/2022] [Accepted: 01/12/2023] [Indexed: 02/09/2023]
Abstract
BACKGROUND There is no consensus on the best local salvage treatment for prostate cancer recurrence after primary external beam radiotherapy. Prospective data on stereotactic body radiation therapy (SBRT) are very scarce. OBJECTIVE To determine the optimal dose regimen for salvage SBRT. DESIGN, SETTING, AND PARTICIPANTS The present report concerns the phase 1 part of the GETUG-AFU 31 multicenter open-label study. The main inclusion criteria were histologically proven biochemical recurrence, clinical stage T1-T2 upon relapse, multiparametric magnetic resonance imaging data, prostate-specific antigen (PSA) level ≤10 ng/ml prior to salvage SBRT, PSA doubling time >10 mo, and an International Prostate Symptom Score of ≤12. INTERVENTION Five or six fractions of 6 Gy were delivered using focal SBRT. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS Dose-limiting toxicity (DLT) was defined as grade ≥3 gastrointestinal or genitourinary tract toxicity, or any grade 4 toxicity (according to the National Cancer Institute Common Terminology Criteria for Adverse Events version 4.03) occurring in the first 18 wk following treatment initiation. A time-to-event continual reassessment method was used to select the dose regimen. RESULTS AND LIMITATIONS Twenty-one patients were treated (median [interquartile range] age: 76.8 yr [72.2-80.8]), including 12 at 6 × 6 dose level. No DLT was observed. The acute grade 2 genitourinary tract toxicity rate was 19%. With a median follow-up of 12.3 mo, the estimated cumulative incidence of late grade 2 genitourinary toxicity was 41.2% (95% confidence interval: 18.1-63.1%). No grade >2 genitourinary toxicity and no grade ≥2 gastrointestinal toxicity were reported. All treated patients were alive and relapse free at the last follow-up. CONCLUSIONS A 6 × 6 Gy dose regimen was selected for our phase 2 study of salvage SBRT. With a short follow-up period, the level of toxicity appears to be acceptable. PATIENT SUMMARY There is no consensus on the best local treatment for patients with local relapse after radiotherapy for prostate cancer. Prospective data are very scarce. Our early phase trial allowed us to recommend six fractions of 6 Gy using high-precision radiotherapy for further studies.
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Affiliation(s)
- David Pasquier
- Academic Department of Radiation Oncology, Centre Oscar Lambret, Lille, France; CRIStAL UMR CNRS 9189, Lille University, Lille, France.
| | - Thomas Lacornerie
- Département de Physique Médicale, Centre Oscar Lambret, Lille, France
| | - Stéphane Supiot
- Département de Radiothérapie, Institut de Cancérologie de l'Ouest-Site René Gauducheau, Saint-Herblain, France
| | - Pascal Pommier
- Département de Radiothérapie, Centre Léon Bérard, Lyon, France
| | - Magali Quivrin
- Département de Radiothérapie, Centre Georges François Leclerc, Dijon, France
| | - Jean-Marc Simon
- Service d'Oncologie Radiothérapie, Assistance Publique-Hôpitaux de Paris (APHP), Hôpital Pitié-Salpêtrière, Sorbonne Université, Paris, France
| | - Geneviève Loos
- Département de Radiothérapie, Centre Jean Perrin, Clermont-Ferrand, France
| | - Emmanuel Meyer
- Département de Radiothérapie, Centre François Baclesse, Caen, France
| | - Gilles Calais
- Département d'Oncologie et de Radiothérapie, CHRU Tours, France
| | - Didier Peiffert
- Département de Radiothérapie, Institut de Cancérologie de Lorraine, Vandœuvre-lès-Nancy, France
| | | | - Estelle Aymes
- Département de Biostatistiques, Centre Oscar Lambret, Lille, France
| | | | | | - Soazig Nenan
- Unicancer, Recherche et Développement, Paris, France
| | | | | | - Eric F Lartigau
- Academic Department of Radiation Oncology, Centre Oscar Lambret, Lille, France; CRIStAL UMR CNRS 9189, Lille University, Lille, France
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The Lymphatic Endothelium in the Context of Radioimmuno-Oncology. Cancers (Basel) 2022; 15:cancers15010021. [PMID: 36612017 PMCID: PMC9817924 DOI: 10.3390/cancers15010021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2022] [Revised: 12/11/2022] [Accepted: 12/16/2022] [Indexed: 12/24/2022] Open
Abstract
The study of lymphatic tumor vasculature has been gaining interest in the context of cancer immunotherapy. These vessels constitute conduits for immune cells' transit toward the lymph nodes, and they endow tumors with routes to metastasize to the lymph nodes and, from them, toward distant sites. In addition, this vasculature participates in the modulation of the immune response directly through the interaction with tumor-infiltrating leukocytes and indirectly through the secretion of cytokines and chemokines that attract leukocytes and tumor cells. Radiotherapy constitutes the therapeutic option for more than 50% of solid tumors. Besides impacting transformed cells, RT affects stromal cells such as endothelial and immune cells. Mature lymphatic endothelial cells are resistant to RT, but we do not know to what extent RT may affect tumor-aberrant lymphatics. RT compromises lymphatic integrity and functionality, and it is a risk factor to the onset of lymphedema, a condition characterized by deficient lymphatic drainage and compromised tissue homeostasis. This review aims to provide evidence of RT's effects on tumor vessels, particularly on lymphatic endothelial cell physiology and immune properties. We will also explore the therapeutic options available so far to modulate signaling through lymphatic endothelial cell receptors and their repercussions on tumor immune cells in the context of cancer. There is a need for careful consideration of the RT dosage to come to terms with the participation of the lymphatic vasculature in anti-tumor response. Here, we provide new approaches to enhance the contribution of the lymphatic endothelium to radioimmuno-oncology.
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Deng J, Su M, Hu J, Lin D, Li J, Liu W, Zhang J, Zhong Q, Guo X. A nomogram to predict risk factors of frequent defecation early after ileostomy reversal for rectal cancer patients. ANNALS OF TRANSLATIONAL MEDICINE 2021; 9:1595. [PMID: 34790801 PMCID: PMC8576722 DOI: 10.21037/atm-21-4660] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/17/2021] [Accepted: 10/09/2021] [Indexed: 11/30/2022]
Abstract
Background Defecation disorders after ileostomy reversal are among the most common complications for rectal cancer patients, and significantly diminish their quality of life. The aim of this study was to identify the risk factors associated with frequent defecation early after ileostomy reversal for rectal cancer patients. Methods We retrospectively collected the data of rectal cancer patients who underwent ileostomy reversal from January 2018 to December 2019 at the Sixth Affiliated Hospital of Sun Yat-sen University. We divided patients into two groups: a no frequent defecation group (≤7 times/day) and a frequent defecation group (>7 times/day). Results Of the 264 included patients, 59 patients (22.35%) had frequent defecation within 1 month after ileostomy closure and were defined as the frequent defecation group. There were no significant differences between the two groups in terms of gender, age, hypertension, and diabetes. Univariate and multivariate analyses showed that proctitis (P=0.04) and anastomotic stenosis (P=0.02) were independent risk factors for frequent defecation. Four factors, including proctitis, anastomotic stenosis, hypertension, and age were included to construct the nomogram. The consistency index of the nomogram was 0.949 and the area under the curve value was 0.623. Conclusions For rectal cancer patients, proctitis and anastomotic stenosis were correlated with frequent defecation within 1 month after ileostomy closure. Surgeons should pay attention to the rectal examination before ileostomy reversal surgery.
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Affiliation(s)
- Jiaxin Deng
- Department of Endoscopic Surgery, the Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, China.,Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, the Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Mingli Su
- Department of Endoscopic Surgery, the Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, China.,Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, the Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Jiancong Hu
- Department of Endoscopic Surgery, the Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, China.,Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, the Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Dezheng Lin
- Department of Endoscopic Surgery, the Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, China.,Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, the Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Juan Li
- Department of Endoscopic Surgery, the Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, China.,Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, the Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Wei Liu
- Department of Endoscopic Surgery, the Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, China.,Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, the Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Jiawei Zhang
- Department of Endoscopic Surgery, the Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, China.,Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, the Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Qinghua Zhong
- Department of Endoscopic Surgery, the Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, China.,Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, the Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Xuefeng Guo
- Department of Endoscopic Surgery, the Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, China.,Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, the Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
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Alpuim Costa D, Amaro CE, Nunes A, Cardoso JS, Daniel PM, Rosa I, Branco JV. Hyperbaric oxygen therapy as a complementary treatment for radiation proctitis: Useless or useful? - A literature review. World J Gastroenterol 2021; 27:4413-4428. [PMID: 34366613 PMCID: PMC8316904 DOI: 10.3748/wjg.v27.i27.4413] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2021] [Revised: 05/02/2021] [Accepted: 06/22/2021] [Indexed: 02/06/2023] Open
Abstract
Radiotherapy (RT) is the backbone of multimodality treatment of more than half of cancer cases. Despite new modern RT techniques, late complications may occur such as radiation proctitis (RP). The natural history of RP is unpredictable. Minor symptoms may resolve spontaneously or require conservative treatment. On the other hand, for similar and uncomplicated clinical contexts, symptoms may persist and can even be refractory to the progressive increase in treatment measures. Over the last decades, an enormous therapeutic armamentarium has been considered in RP, including hyperbaric oxygen therapy (HBOT). Currently, the evidence regarding the impact of HBOT on RP and its benefits is conflicting. Additional prospective and randomised studies are necessary to validate HBOT's effectiveness in the 'real world' clinical practice. This article reviewed the relevant literature on pathophysiology, clinical presentation, different classifications and discuss RP management including a proposal for a therapeutic algorithm with a focus on HBOT.
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Affiliation(s)
- Diogo Alpuim Costa
- Department of Haematology and Oncology, CUF Oncologia, Lisboa 1998-018, Portugal
- Centro de Medicina Subaquática e Hiperbárica (CMSH), Portuguese Navy, Lisboa 1649-020, Portugal
- Centro de Investigação Naval (CINAV), Portuguese Navy, Base Naval do Alfeite, Almada 2810-001, Portugal
- NOVA Medical School, Faculdade de Ciências Médicas, Lisboa 1169-056, Portugal
| | - Carla Espiney Amaro
- Centro de Investigação Naval (CINAV), Portuguese Navy, Base Naval do Alfeite, Almada 2810-001, Portugal
- Department of Otorhinolaryngology, Hospital das Forças Armadas (HFAR), Lisboa 1649-020, Portugal
| | - Ana Nunes
- Department of Gastroenterology, Hospital das Forças Armadas (HFAR), Lisboa 1649-020, Portugal
| | - Joana Santos Cardoso
- Centro de Medicina Subaquática e Hiperbárica (CMSH), Portuguese Navy, Lisboa 1649-020, Portugal
- Department of Vascular Surgery, Centro Hospitalar Universitário de Lisboa Central, Hospital de Santa Marta, Lisboa 1169-024, Portugal
| | - Pedro Modas Daniel
- Centro de Medicina Subaquática e Hiperbárica (CMSH), Portuguese Navy, Lisboa 1649-020, Portugal
- Centro de Investigação Naval (CINAV), Portuguese Navy, Base Naval do Alfeite, Almada 2810-001, Portugal
- Department of Intensive Care Unit, Hospital das Forças Armadas (HFAR), Lisboa 1649-020, Portugal
| | - Isabel Rosa
- Centro de Medicina Subaquática e Hiperbárica (CMSH), Portuguese Navy, Lisboa 1649-020, Portugal
- Centro de Investigação Naval (CINAV), Portuguese Navy, Base Naval do Alfeite, Almada 2810-001, Portugal
- Department of General Surgery, Hospital das Forças Armadas (HFAR), Lisboa 1649-020, Portugal
| | - João Vieira Branco
- Centro de Medicina Subaquática e Hiperbárica (CMSH), Portuguese Navy, Lisboa 1649-020, Portugal
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Wang X, Zhang B, He Q, Kong Y, Dai Z, Meng H, Huang F, Zhang S, Zhu Y, Tan X, Zhen X. Rectum Protection by Rectal Gel Injection in Cervical Cancer Brachytherapy: A Dosimetric Study via Deformable Surface Dose Accumulation and Machine-Learning-Based Discriminative Modeling. Front Oncol 2021; 11:657208. [PMID: 33937068 PMCID: PMC8085420 DOI: 10.3389/fonc.2021.657208] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2021] [Accepted: 03/29/2021] [Indexed: 11/13/2022] Open
Abstract
PURPOSE This retrospective study aimed to evaluate the dosimetric effects of a rectal insertion of Kushen Ningjiao on rectal protection using deformable dose accumulation and machine learning-based discriminative modelling. MATERIALS AND METHODS Sixty-two patients with cervical cancer enrolled in a clinical trial, who received a Kushen Ningjiao injection of 20 g into their rectum for rectal protection via high-dose rate brachytherapy (HDR-BT, 6 Gy/f), were studied. The cumulative equivalent 2-Gy fractional rectal surface dose was deformably summed using an in-house-developed topography-preserved point-matching deformable image registration method. The cumulative three-dimensional (3D) dose was flattened and mapped to a two-dimensional (2D) plane to obtain the rectal surface dose map (RSDM). For analysis, the rectal dose (RD) was further subdivided as follows: whole, anterior, and posterior 3D-RD and 2D-RSDM. The dose-volume parameters (DVPs) were extracted from the 3D-RD, while the dose geometric parameters (DGPs) and textures were extracted from the 2D-RSDM. These features were fed into 192 classification models (built with 8 classifiers and 24 feature selection methods) for discriminating the dose distributions between pre-Kushen Ningjiao and pro-Kushen Ningjiao. RESULTS The rectal insertion of Kushen Ningjiao dialated the rectum in the ambilateral direction, with the rectal column increased from pre-KN 15 cm3 to post-KN 18 cm3 (P < 0.001). The characteristics of DGPs accounted for the largest portions of the top-ranked features. The top-ranked dosimetric features extracted from the posterior rectum were more reliable indicators of the dosimetric effects/changes introduced by the rectal insertion of Kushen Ningjiao. A significant dosimetric impact was found on the dose-volume parameters D1.0cc-D2.5cc extracted on the posterior rectal wall. CONCLUSIONS The rectal insertion of Kushen Ningjiao incurs significant dosimetric changes on the posterior rectal wall. Whether this effect is eventually translated into clinical gains requires further long-term follow-up and more clinical data for confirmation.
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Affiliation(s)
- Xuetao Wang
- Radiation Oncology Department, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Bailin Zhang
- Radiation Oncology Department, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Qiang He
- Radiation Oncology Department, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Yilin Kong
- Radiation Oncology Department, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Zhenhui Dai
- Radiation Oncology Department, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Haoyu Meng
- Radiation Oncology Department, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Fangjun Huang
- School of Biomedical Engineering, Southern Medical University, Guangzhou, China
| | - Shengfeng Zhang
- Radiation Oncology Department, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Yuanhu Zhu
- Radiation Oncology Department, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Xiang Tan
- Radiation Oncology Department, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Xin Zhen
- School of Biomedical Engineering, Southern Medical University, Guangzhou, China
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9
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Mahmood S, Bollipo S, Steele S, Bristow RG, Choudhury A, Oakland K, Martin J. It's All the RAVE: Time to Give up on the "Chronic Radiation Proctitis" Misnomer. Gastroenterology 2021; 160:635-638. [PMID: 33096102 DOI: 10.1053/j.gastro.2020.09.054] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2020] [Revised: 09/17/2020] [Accepted: 09/21/2020] [Indexed: 01/16/2023]
Affiliation(s)
- Sultan Mahmood
- Department of Medicine, University at Buffalo, Buffalo, New York
| | - Steven Bollipo
- School of Medicine and Public Health, University of Newcastle and, Department of Gastroenterology, John Hunter Hospital, Newcastle, New South Wales, Australia
| | - Scott Steele
- Department of Colorectal Surgery, Cleveland Clinic, Cleveland, Ohio
| | | | | | - Kathryn Oakland
- Department of Digestive Diseases, HCA Healthcare UK, London, UK
| | - Jarad Martin
- School of Medicine and Public Health, University of Newcastle, Newcastle, New South Wales, Australia
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10
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White K, Henson CC. Endoscopically delivered Purastat for the treatment of severe haemorrhagic radiation proctopathy: a service evaluation of a new endoscopic treatment for a challenging condition. Frontline Gastroenterol 2021; 12:608-613. [PMID: 34925747 PMCID: PMC8640411 DOI: 10.1136/flgastro-2020-101735] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2020] [Revised: 12/29/2020] [Accepted: 01/07/2021] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND A total of 30 000 people are treated with pelvic radiotherapy annually in the UK. Rectal bleeding is common following pelvic radiotherapy and one of the main causes is radiation proctopathy (RP). Six per cent develop severe bleeding from RP, leading to anaemia requiring iron +/- blood transfusion. There are very few safe, effective, evidence-based treatments. Purastat is a haemostatic agent licensed for gastrointestinal bleeding. It is a self-assembling peptide that forms a molecular mesh in contact with blood, thereby sealing blood vessels. There are numerous studies showing its efficacy and safety in various surgical/endoscopic settings. This service evaluation reports the first experience of the use of Purastat in RP. METHODS Consecutive patients attending pelvic radiation disease clinic with severe refractory RP were offered treatment with Purastat. This was defined as rectal bleeding into the pan±anaemia with no response to rectal sucralfate. Purastat was applied endoscopically at four weekly intervals up to three times, with more as required. Bleeding severity, endoscopic grade and haemoglobin were recorded. RESULTS Twenty-one patients were treated (18 men, median age 76 years) with a median of three treatments. Ten were on antithrombotics, 1 had thrombocytopenia and 13 had anaemia at baseline. Median episodes of bleeding reduced from 4.5 (0-27) to 2 (0-16) in the 7 days prior to the first and third treatment, respectively. Endoscopic grade was improved. Mean haemoglobin increased from 116.0 to 122.7. There were no complications. CONCLUSION Even in this cohort of severe refractory RP, there was an improvement in bleeding and endoscopic grade with Purastat. A randomised controlled trial is planned.
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11
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In reply to Afkhami Ardekani M et al. Strahlenther Onkol 2020; 197:355-357. [PMID: 33296002 DOI: 10.1007/s00066-020-01720-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2020] [Accepted: 11/16/2020] [Indexed: 10/22/2022]
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12
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Pui WC, Chieng TH, Siow SL, Nik Abdullah NA, Sagap I. A Randomized Controlled Trial of Novel Treatment for Hemorrhagic Radiation Proctitis. Asian Pac J Cancer Prev 2020; 21:2927-2934. [PMID: 33112550 PMCID: PMC7798148 DOI: 10.31557/apjcp.2020.21.10.2927] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2020] [Indexed: 12/30/2022] Open
Abstract
Background: Various methods have been used for treatment of hemorrhagic radiation proctitis (HRP) with variable results. Currently, the preferred treatment is formalin application or endoscopic therapy with argon plasma coagulation. Recently, a novel therapy with colonic water irrigation and oral antibiotics showed promising results and more effective compared to 4% formalin application for HRP. The study objective is to compare the effect of water irrigation and oral antibiotics versus 4% formalin application in improving per rectal bleeding due to HRP and related symptoms such as diarrhoea, tenesmus, stool frequency, stool urgency and endoscopic findings. Methods: We conducted a study on 34 patients with HRP and randomly assigned the patients to two treatment arm groups (n=17). The formalin group underwent 4% formalin dab and another session 4 weeks later. The irrigation group self-administered daily rectal irrigation at home for 8 weeks and consumed oral metronidazole and ciprofloxacin during the first one week. We measured the patients’ symptoms and endoscopic findings before and after total of 8 weeks of treatment in both groups. Results: Our study showed that HRP patients had reduced per rectal bleeding (p = 0.003) in formalin group, whereas irrigation group showed reduced diarrhoea (p=0.018) and tenesmus (p=0.024) symptoms. The comparison between the two treatment arms showed that irrigation technique was better than formalin technique for tenesmus (p=0.043) symptom only. Conclusion: This novel treatment showed benefit in treating HRP. It could be a new treatment option which is safe and conveniently self-administered at home or used as a combination with other therapies to improve the treatment outcome for HRP.
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Affiliation(s)
- Wei Chieng Pui
- Department of Surgery, Sibu Hospital, Sarawak, Malaysia.,Department of Surgery, Sarawak General Hospital(SGH), Sarawak, Malaysia
| | - Tiong How Chieng
- Department of Surgery, Sibu Hospital, Sarawak, Malaysia.,Department of Surgery, Sarawak General Hospital(SGH), Sarawak, Malaysia
| | - Sze Li Siow
- Department of Surgery, Sarawak General Hospital(SGH), Sarawak, Malaysia
| | | | - Ismail Sagap
- Colorectal Unit, Department of Surgery, Universiti Kebangsaan Malaysia(UKM), Kuala Lumpur, Malaysia
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13
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Akpolat M, Oz ZS, Gulle K, Hamamcioglu AC, Bakkal BH, Kececi M. X irradiation induced colonic mucosal injury and the detection of apoptosis through PARP-1/p53 regulatory pathway. Biomed Pharmacother 2020; 127:110134. [PMID: 32361637 DOI: 10.1016/j.biopha.2020.110134] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2019] [Revised: 03/25/2020] [Accepted: 03/27/2020] [Indexed: 12/13/2022] Open
Abstract
This study aimed to explore whether PARP-1 regulatory pathway mediated X irradiation induced cell cycle arrest and apoptosis or not. In this regard, colonic mucosal injury caused by whole-body X-irradiation induced apoptosis through PARP-1, caspase 3 and p53 regulatory pathway were evaluated in experimental rat models. Eighteen Wistar albino rats were divided into three groups. Two radiation groups received 8.3 Gy dose of whole-body X-irradiation as a single dose and the control group received physiological saline intraperitoneally. Radiation groups were sacrificed after 6 h and 4 days of irradiation. PARP-1 and caspase 3 expression in the nuclei of colonic crypt cells significantly increased 6 h after irradiation, and declined 4 days after irradiation. In conflict with other studies that reported p53 as not being expressed widely in colonic mucosa, in our study the expressions of p53 were elevated both in the cytoplasm and in the nucleus of the crypt cells, especially 6 h after irradiation. In the radiation groups, colonic mucosal injury score was significantly elevated compared with that of the control group. Our data demonstrated that PARP-1, caspase-3 and p53 expression increased in colonic mucosa 6 h after irradiation.
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Affiliation(s)
- Meryem Akpolat
- Zonguldak Bulent Ecevit University, Faculty of Medicine, Department of Histology and Embryology, Zonguldak, Turkey.
| | - Zehra Safi Oz
- Zonguldak Bulent Ecevit University Faculty of Medicine, Department of Medical Biology, Zonguldak, Turkey.
| | - Kanat Gulle
- Suleyman Demirel University, Faculty of Medicine, Department of Histology and Embryology, Isparta, Turkey.
| | - Ayse C Hamamcioglu
- Zonguldak Bulent Ecevit University, Faculty of Pharmacy, Department of Biochemistry, Zonguldak, Turkey.
| | - Bekir H Bakkal
- Zonguldak Bulent Ecevit University, Faculty of Medicine, Department of Radiation Oncology, Zonguldak, Turkey.
| | - Mete Kececi
- Zonguldak Bulent Ecevit University, Faculty of Medicine, Department of Histology and Embryology, Zonguldak, Turkey
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14
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Campostrini F, Remo A, Astati L, Zorzi M, Capodaglio G, Buffoli A, Moretti G, Della Monica B, Zanella C, Verlato G. Association between acute histopathological changes of rectal walls and late radiation proctitis following radiotherapy for prostate cancer. Strahlenther Onkol 2020; 196:617-627. [PMID: 32166451 DOI: 10.1007/s00066-020-01590-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2019] [Accepted: 01/28/2020] [Indexed: 10/24/2022]
Abstract
PURPOSE The impact of acute histopathological changes (HC) of the rectum on development of late clinical proctitis (LCP) after external radiotherapy (RT) for prostate cancer is poorly explored and was the primary end point of this prospective study. METHODS In 70 patients, 15 HC of early rectal biopsies after RT were identified, whereby RT was conventional 2D RT in 41 cases and conformational 3D RT in 29. Associations of HC in anterior and posterior rectal walls (ARW, PRW) with LCP, acute endoscopic (AEP) and acute clinical proctitis (ACP) were statistically evaluated considering as explicative variables the patient general characteristics and the HC. RESULTS The mean patients' follow-up was 123.5 months (24-209). The median prostatic dose was 72 Gy (2 Gy/fraction). For the 41 and 29 patients the ARW and PRW doses were 64 and 49 Gy vs. 63 and 50 Gy, respectively. The incidence of LCP ≥ grade 2 at 10 years was 12.9%. The univariate (p = 0.02) and Kaplan-Meyer methods (p = 0.007) showed that the gland (or crypts) loss in the ARW was significantly associated with LCP. AEP and ACP occurred in 14.3 and 55.7% of cases. At multivariate level AEP significantly correlated with hemorrhoids (p = 0.014) and neutrophilia in ARW (p = 0.042). CONCLUSIONS Early after RT, substantial gland loss in ARW is predictive of LCP. To reduce this complication with conventional fractionation, we suggest keeping the mean dose to ARW ≤48-52 Gy.
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Affiliation(s)
- Franco Campostrini
- Department of Radiation Oncology, "Mater Salutis" Hospital, Legnago, Italy.
| | - Andrea Remo
- Department of Pathology, "Mater Salutis" Hospital, Via Gianella 1, 37045, Legnago, Italy.
| | - Laura Astati
- Department of Pathology, "Mater Salutis" Hospital, Via Gianella 1, 37045, Legnago, Italy
| | - Manuel Zorzi
- Veneto Tumour Registry, Azienda Zero, Padova, Italy
| | | | - Alberto Buffoli
- Radiotherapy Department, Istituto Clinico S. Anna, Brescia, Italy
| | - Gaia Moretti
- Radiotherapy Department, Istituto Clinico S. Anna, Brescia, Italy
| | | | - Caterina Zanella
- Department of Pathology, "Mater Salutis" Hospital, Via Gianella 1, 37045, Legnago, Italy
| | - Giuseppe Verlato
- Unit of Epidemiology and Medical Statistics, University of Verona, Verona, Italy
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15
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Ozkan EE, Ozseven A, Cerkesli ZAK. Evaluating the predictive value of quantec rectum tolerance dose suggestions on acute rectal toxicity in prostate carcinoma patients treated with IMRT. Rep Pract Oncol Radiother 2019; 25:50-54. [PMID: 31889921 DOI: 10.1016/j.rpor.2019.12.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2019] [Revised: 09/23/2019] [Accepted: 12/04/2019] [Indexed: 12/01/2022] Open
Abstract
Aim To investigate the predictive value of convenience of rectum dosimetry with Quantitative Analysis of Normal Tissue Effects in the Clinic (QUANTEC) dose limits, maximum rectum dose (Dmax), total rectal volume (TVrectum), rectal volume included in PTV (VrectumPTV) on Grade 2-3 acute rectal toxicity for utilization in clinical practice. Background Numerous previous data have reported frequent acute proctitis after external-beam RT of prostate cancer. Predicting toxicity limited with dose information is inadequate in clinical practice due to comorbidities and medications used. Materials and Method Sixty-four non-metastatic prostate cancer patients treated with IMRT were enrolled. Patients were treated to a total dose of 70-76 Gy. Rectal dose volume histograms (DVH) of all patients were evaluated retrospectively, and a QUANTEC Score between 0 and 5 was calculated for each patient. The correlation between the rectal DVH data, QUANTEC score, TVrectum, VrectumPTV, rectum Dmax and Grade 2-3 rectal toxicity was investigated. Results In the whole group grade 1, 2 and 3 acute rectal toxicities were 25%, 18.8% and 3.1%, respectively. In the DVH data, rectum doses of all patients were under RTOG dose limits. Statistically significant correlation was found between grade 2-3 rectal toxicity and TVrectum (p = 0,043); however. It was not correlated with QUANTEC score, VrectumPTV and Dmax. Conclusion Our results were not able to show any significant correlation between increasing convenience with QUANTEC limits and lower rectal toxicity. Conclusively, new dosimetric definitions are warranted to predict acute rectal toxicity more accurately in prostate cancer patients during IMRT treatment.
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Affiliation(s)
- E Elif Ozkan
- Suleyman Demirel University, Department of Radiation Oncology, Isparta, Turkey
| | - Alper Ozseven
- Suleyman Demirel University, Department of Radiation Oncology, Isparta, Turkey
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16
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Li X, Xiao C, Kong Y, Guo W, Zhan W, Li G, Wang X, Zhang B, Gao L. Rectal wall dose-volume effect of pre- or post KUSHEN Ningjiaos relationship with 3D brachytherapy in cervical cancer patients. Radiat Oncol 2019; 14:149. [PMID: 31429773 PMCID: PMC6700783 DOI: 10.1186/s13014-019-1354-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2019] [Accepted: 08/05/2019] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND The present prospective study evaluated the safety and efficacy of the rectum following KUSHEN Ningjiaos in cervical cancer. We compared rectal wall changes during brachytherapy with or without KUSHEN Ningjiaos in cervical cancer patients and analyzed the difference in spatial dose distribution, including whole rectum-wall (R-w), anterior rectum-wall (R-a) and posterior rectum-wall (R-p). METHODS AND MATERIALS One hundred cervical cancer patients with and without KUSHEN Ningjiaos were treated with brachytherapy (600 cGy). The whole R-w was divided into two areas of R-a and R-p, and R-w dose surface map were constructed. The volume of each R-w was compared in patients pre- and post-KUSHEN Ningjiaos. RESULTS When the pre- vs. post-KUSHEN groups were compared the volume of R-w increased. In the post-KUSHEN group, a significantly higher proportion of the D2cc of VR-w and VR-a compared with the pre-KUSHEN group showed that the D2ccmean increased from 532.45 cGy to 564.7 cGy and 533.51 cGy to 565.26 cGy, respectively; however, results demonstrated a decrease in the D2ccmean of R-p from 260.5 cGy to 240.0868 cGy (P < 0.05). The insertion of KUSHEN Ningjiaos resulted in a reduction of the relative volume of R-p exposed to high doses, and regressive analysis showed that the DR-p-max correlated most strongly with VR-w and D2ccR-p (P < 0.01 and P < 0.05, respectively). CONCLUSION The insertion of KUSHEN Ningjiaos can protect the rectum. KUSHEN Ningjiaos appears to be safe and well tolerated; therefore, we believe that there will be fewer adverse events after brachytherapy for patients. TRIAL REGISTRATION A multi-center, prospective clinical trial for KUSHEN Ningjiaos was inserted into rectum to reduce the rate of radiation proctitis in three-dimensional brachytherapy of cervical cancer. ChiCTR1900021631 . 2 Mar 2019-Retrospectively registered.
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Affiliation(s)
- Xiaojuan Li
- Graduate student of grade 2016, Guangzhou University of Chinese Medicine, No.232, Waihuandong Road, University Town, Panyu District, Guangzhou, Guangdong, China
| | - Cheng Xiao
- Graduate student of grade 2016, Guangzhou University of Chinese Medicine, No.232, Waihuandong Road, University Town, Panyu District, Guangzhou, Guangdong, China
| | - Yilin Kong
- Radiation Oncology Department, Guangzhou University of Chinese Medicine Second Affiliated Hospital (Guangdong Provincial Hosiptal of Chinese Medicine), No. 55, Neihuanxi Road, University Town, Panyu District, Guangzhou, Guangdong, China
| | - Weiwei Guo
- Radiation Oncology Department, Guangzhou University of Chinese Medicine Second Affiliated Hospital (Guangdong Provincial Hosiptal of Chinese Medicine), No. 55, Neihuanxi Road, University Town, Panyu District, Guangzhou, Guangdong, China
| | - Wenting Zhan
- Radiation Oncology Department, Guangzhou University of Chinese Medicine Second Affiliated Hospital (Guangdong Provincial Hosiptal of Chinese Medicine), No. 55, Neihuanxi Road, University Town, Panyu District, Guangzhou, Guangdong, China
| | - Gong Li
- Radiation Oncology Department, Guangzhou University of Chinese Medicine Second Affiliated Hospital (Guangdong Provincial Hosiptal of Chinese Medicine), No. 55, Neihuanxi Road, University Town, Panyu District, Guangzhou, Guangdong, China
| | - Xuetao Wang
- Radiation Therapy Department, Guangzhou University of Chinese Medicine Second Affiliated Hospital (Guangdong Provincial Hosiptal of Chinese Medicine), No.55, Neihuanxi Road, University Town, Panyu District, Guangzhou, Guangdong, China
| | - Bailin Zhang
- Radiation Therapy Department, Guangzhou University of Chinese Medicine Second Affiliated Hospital (Guangdong Provincial Hosiptal of Chinese Medicine), No.55, Neihuanxi Road, University Town, Panyu District, Guangzhou, Guangdong, China
| | - Lei Gao
- Radiation Oncology Department, Guangzhou University of Chinese Medicine Second Affiliated Hospital (Guangdong Provincial Hosiptal of Chinese Medicine), No. 55, Neihuanxi Road, University Town, Panyu District, Guangzhou, Guangdong, China.
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17
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Pasquier D, Le Deley MC, Tresch E, Cormier L, Duterque M, Nenan S, Lartigau E. GETUG-AFU 31: a phase I/II multicentre study evaluating the safety and efficacy of salvage stereotactic radiation in patients with intraprostatic tumour recurrence after external radiation therapy-study protocol. BMJ Open 2019; 9:e026666. [PMID: 31377694 PMCID: PMC6686998 DOI: 10.1136/bmjopen-2018-026666] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
INTRODUCTION Prostate cancer is the third most important cancer in terms of mortality in men. No standard local treatment exists for patients with an intraprostatic recurrence after radiotherapy. Stereotatic body radiotherapy (SBRT) could be a curative treatment for local recurrence. The phase I/II primary objective is the selection of the recommended dose for salvage-SBRT and to estimate the efficacy. METHODS AND ANALYSIS We plan to perform a multicentre prospective phase I/II study including at least 47 patients. Eligible patients are patients with biochemical recurrence occurring at least 2 years after external radiotherapy for prostatic adenocarcinoma by the Phoenix definition (prostate-specific antigen (PSA) nadir +2 ng/mL) and histologically proven intraprostatic recurrence only (stage T1-T2 on relapse, PSA level ≤10 ng/mL, PSA doubling time >10 months, absence of pelvic or metastatic recurrence proven by choline or PSMA positron emission tomography scan, and pelvic and prostatic assessment by multiparametric MRI). The phase I primary objective is the selection of the recommended dose for salvage-SBRT (5×6, 6×6 or 5×5 Gy) based on dose-limiting toxicity (DLT). The dose of salvage-SBRT will be selected using a time-to-event continual reassessment method based on DLT defined as grade ≥3 gastrointestinal or urinary toxicity or any other grade 4 adverse event. The phase II primary outcome is to estimate the efficacy of the salvage-SBRT in terms of biochemical relapse-free survival rate (Phoenix definition: increase in serum total PSA ≥2 ng/mL above the nadir). Phase II secondary outcomes are acute and late toxicities, quality of life, clinical progression-free survival defined as the time interval between the date of registration and the date of clinical progression or death irrespective of the cause. ETHICS AND DISSEMINATION The study has received ethical approval from the Ethics committee 'Ile-de-France III'. Academic dissemination will occur through publication and conference presentations. TRIAL REGISTRATION NUMBER NCT03438552.
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Affiliation(s)
- David Pasquier
- Academic Department of Radiation Oncology, Centre Oscar Lambret, Lille, France
- CRIStAL UMR CNRS 9189, Lille University, Villeneuve-d'Ascq, France
| | | | - Emmanuelle Tresch
- Methodology and Biostatistic Unit, Centre Oscar Lambret, Lille, France
| | - Luc Cormier
- Department of Urology, Centre Hospitalier Universitaire de Dijon, Dijon, France
| | | | | | - Eric Lartigau
- Academic Department of Radiation Oncology, Centre Oscar Lambret, Lille, France
- CRIStAL UMR CNRS 9189, Lille University, Villeneuve-d'Ascq, France
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18
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Lee J, Han HJ, Min BS, Hong SP, Shin SJ, Yoon HI, Park SJ, Koom WS. The role of endoscopic evaluation for radiation proctitis in patients receiving intermediate-dose postoperative radiotherapy for rectal cancer. Jpn J Clin Oncol 2018; 48:988-994. [PMID: 30239826 DOI: 10.1093/jjco/hyy126] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2018] [Accepted: 09/08/2018] [Indexed: 11/13/2022] Open
Abstract
Objectives High-dose pelvic radiotherapy (RT) is known to be associated with chronic radiation proctitis (RP). However, the effects of intermediate radiation doses are unknown. We assessed the incidence of late clinical RP among patients with rectal cancer receiving intermediate-dose postoperative RT, as well as the role of early endoscopic abnormalities in predicting RP development. Methods We retrospectively reviewed 153 patients with rectal cancer who received postoperative RT at a median dose of 54 Gy between 2005 and 2009 and who underwent endoscopic examination within 12 months thereafter. Endoscopic RP was assessed using the Vienna rectoscopy score (VRS). Late clinical RP toxicity was evaluated, as was its correlation with endoscopic RP. Results All patients underwent an endoscopic examination at a median of 9 months after postoperative pelvic RT. Endoscopic RP was detected in 45 patients (29.4%); the predominant patterns were telangiectasia and congested mucosa. During the median 88-month follow-up period, 29 patients (19.0%) experienced late clinical RP; only 3 (2.0%) had Grade 3 or above. The VRS predicted the development of late clinical RP as well as its cumulative incidence (P < 0.001). Endoscopic evidence of telangiectasia was significantly associated with the development of late clinical RP (P < 0.001). Conclusions Early endoscopic findings using VRS are useful for predicting the possibility of late clinical RP, although the incidences of severe cases were low. Patients with endoscopic abnormalities should be followed closely owing to their susceptibility to clinical RP.
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Affiliation(s)
- Jeongshim Lee
- Department of Radiation Oncology, Yonsei University College of Medicine, Seoul.,Department of Radiation Oncology, Inha University Hospital, Incheon
| | - Hee Ji Han
- Department of Radiation Oncology, Yonsei University College of Medicine, Seoul
| | - Byung So Min
- Department of Surgery, Yonsei University College of Medicine
| | - Sung Pil Hong
- Division of Gastroenterology, Department of Internal Medicine, Yonsei University College of Medicine
| | - Sang Joon Shin
- Division of Medical Oncology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Hong In Yoon
- Department of Radiation Oncology, Yonsei University College of Medicine, Seoul
| | - Soo Jung Park
- Division of Gastroenterology, Department of Internal Medicine, Yonsei University College of Medicine
| | - Woong Sub Koom
- Department of Radiation Oncology, Yonsei University College of Medicine, Seoul
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19
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Ohno T, Noda SE, Murata K, Yoshimoto Y, Okonogi N, Ando K, Tamaki T, Kato S, Hirakawa T, Kanuma T, Minegishi T, Nakano T. Phase I Study of Carbon Ion Radiotherapy and Image-Guided Brachytherapy for Locally Advanced Cervical Cancer. Cancers (Basel) 2018; 10:cancers10090338. [PMID: 30231543 PMCID: PMC6162662 DOI: 10.3390/cancers10090338] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2018] [Revised: 09/12/2018] [Accepted: 09/13/2018] [Indexed: 01/05/2023] Open
Abstract
A phase I study was performed to determine the recommended dose of carbon ion radiotherapy and 3D image-guided brachytherapy for histologically confirmed stage II (≥4 cm), III, or IVA cervical cancer. Dose-limiting toxicities (treatment-related toxicities occurring within three months from the start of carbon ion radiotherapy) included Grade 3 non-hematological toxicity, Grade 4 hematological toxicity, or interruption of treatment for more than two weeks due to treatment-related toxicities. Carbon ion radiotherapy consisted of whole-pelvic irradiation with 36.0 Gy (relative biological effectiveness) in 12 fractions and local boost with 19.2 Gy in four fractions for the primary site, and for positive lymph nodes. Three sessions of three-dimensional (3D) image-guided brachytherapy were administered after completion of carbon ion radiotherapy. Weekly cisplatin at a dose of 40 mg/m2 was given concurrently. At a dose level of one, a total rectosigmoid D2cc dose between 67.2 Gy and 71.3 Gy at a biological equivalent dose of 2 Gy per fraction from carbon ion radiotherapy and 3D image-guided brachytherapy was prescribed. Six patients were enrolled into this dose level. No patients developed the pre-defined dose-limiting toxicities. For late toxicities, however, one patient developed Grade 3 rectal hemorrhage requiring transfusion at 10 months after treatment. The median survival time was 50.0 months for the five surviving patients. No further dose escalation was performed, and we determined the dose of level one as the recommended rectosigmoid dose. Although our results are preliminary, the study regimen encourages further investigation (registration: UMIN000013340).
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Affiliation(s)
- Tatsuya Ohno
- Gunma University Heavy Ion Medical Center, Gunma University, 3-39-22 Showa, Maebashi, Gunma 371-8511, Japan.
| | - Shin-Ei Noda
- Gunma University Heavy Ion Medical Center, Gunma University, 3-39-22 Showa, Maebashi, Gunma 371-8511, Japan.
| | - Kazutoshi Murata
- Gunma University Heavy Ion Medical Center, Gunma University, 3-39-22 Showa, Maebashi, Gunma 371-8511, Japan.
| | - Yuya Yoshimoto
- Gunma University Heavy Ion Medical Center, Gunma University, 3-39-22 Showa, Maebashi, Gunma 371-8511, Japan.
| | - Noriyuki Okonogi
- Gunma University Heavy Ion Medical Center, Gunma University, 3-39-22 Showa, Maebashi, Gunma 371-8511, Japan.
| | - Ken Ando
- Gunma University Heavy Ion Medical Center, Gunma University, 3-39-22 Showa, Maebashi, Gunma 371-8511, Japan.
| | - Tomoaki Tamaki
- Gunma University Heavy Ion Medical Center, Gunma University, 3-39-22 Showa, Maebashi, Gunma 371-8511, Japan.
| | - Shingo Kato
- Department of Radiation Oncology, Saitama Medical University International Medical Center, 1397-1 Yamane, Hidaka, Saitama 350-1298, Japan.
| | - Takashi Hirakawa
- Department of Obstetrics and Gynecology, Gunma University Graduate School of Medicine, 3-39-22 Showa, Maebashi, Gunma 371-8511, Japan.
| | - Tatsuya Kanuma
- Division of Gynecology, Gunma Prefectural Cancer Center, 617-1 Takahayashi-nishi, Ota, Gunma 373-0828, Japan.
| | - Takashi Minegishi
- Department of Obstetrics and Gynecology, Gunma University Graduate School of Medicine, 3-39-22 Showa, Maebashi, Gunma 371-8511, Japan.
| | - Takashi Nakano
- Gunma University Heavy Ion Medical Center, Gunma University, 3-39-22 Showa, Maebashi, Gunma 371-8511, Japan.
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Ippolito E, Guido A, Macchia G, Deodato F, Giaccherini L, Farioli A, Arcelli A, Cuicchi D, Frazzoni L, Cilla S, Buwenge M, Mantini G, Alitto AR, Nuzzo M, Valentini V, Ingrosso M, Morganti AG, Fuccio L. Predictive Factors of Late-onset Rectal Mucosal Changes After Radiotherapy of Prostate Cancer. ACTA ACUST UNITED AC 2018; 31:961-966. [PMID: 28882966 DOI: 10.21873/invivo.11154] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2017] [Revised: 07/03/2017] [Accepted: 07/06/2017] [Indexed: 12/19/2022]
Abstract
BACKGROUND/AIM The Vienna Rectoscopy Score (VRS; from 0, absence of rectal mucosal changes, to 5) assessed 1 year after radiotherapy is a surrogate end-point of late rectal toxicity. The aim of this study was to investigate the association between treatment-related factors and 1-year VRS. PATIENTS AND METHODS We performed a retrospective analysis of prospectively collected data. Patients with prostate adenocarcinoma treated with definitive or postoperative radiotherapy (RT) underwent endoscopy 1 year after RT. Relationships between VRS of 2 or more and treatment parameters were investigated by univariate and multivariate logistic analyses. RESULTS One hundred and ninety-five patients (mean age=69 years; range=43-81 years) were considered eligible for the study. At univariate analysis, patients treated with hypofractionation plus radiosurgery boost (p<0.001) and an equivalent dose in 2 Gy per fraction (EQD2) (α/β=3) ≥75 Gy (p<0.001) was associated with a significantly higher incidence of VRS ≥2 after 1 year of follow-up. At multivariate analysis, radiosurgery boost was an independent risk factor for developing rectal mucosal lesions (VRS ≥2), yielding an odds ratio (OR) of 4.14 (95% confidence interval (CI)=1.2-13.8), while pelvic surgery was inversely associated with VRS ≥2 (OR=0.39; 95% CI=0.17-0.94). CONCLUSION Hypofractionation followed by radiosurgery boost significantly increased the risk of developing late-onset rectal mucosal changes. Therefore, special care and preventative treatment strategies are needed when using radiosurgery boost after hypofractionated RT.
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Affiliation(s)
- Edy Ippolito
- Radiotherapy Unit, Campus Bio-Medico University, Rome, Italy
| | - Alessandra Guido
- Radiation Oncology Center, Department of Experimental, Diagnostic and Specialty Medicine DIMES, University of Bologna, Bologna, Italy
| | - Gabriella Macchia
- Radiotherapy Unit, Giovanni Paolo II Research and Care Foundation, Campobasso, Italy
| | - Francesco Deodato
- Radiotherapy Unit, Giovanni Paolo II Research and Care Foundation, Campobasso, Italy
| | - Lucia Giaccherini
- Radiation Oncology Center, Department of Experimental, Diagnostic and Specialty Medicine DIMES, University of Bologna, Bologna, Italy
| | - Andrea Farioli
- Department of Medical and Surgical Sciences (DIMEC), University of Bologna, Bologna, Italy
| | - Alessandra Arcelli
- Radiation Oncology Center, Department of Experimental, Diagnostic and Specialty Medicine DIMES, University of Bologna, Bologna, Italy
| | - Dajana Cuicchi
- Department of Medical and Surgical Sciences (DIMEC), University of Bologna, Bologna, Italy
| | - Leonardo Frazzoni
- Department of Medical and Surgical Sciences (DIMEC), University of Bologna, Bologna, Italy
| | - Savino Cilla
- Medical Physics Unit, Giovanni Paolo II Research and Care Foundation, Campobasso, Italy
| | - Milly Buwenge
- Radiation Oncology Center, Department of Experimental, Diagnostic and Specialty Medicine DIMES, University of Bologna, Bologna, Italy
| | - Giovanna Mantini
- Department of Radiotherapy, A. Gemelli Hospital, Sacred Heart Catholic University, Rome, Italy
| | - Anna R Alitto
- Department of Radiotherapy, A. Gemelli Hospital, Sacred Heart Catholic University, Rome, Italy
| | - Marianna Nuzzo
- Radiotherapy Unit, Giovanni Paolo II Research and Care Foundation, Campobasso, Italy
| | - Vincenzo Valentini
- Department of Radiotherapy, A. Gemelli Hospital, Sacred Heart Catholic University, Rome, Italy
| | - Marcello Ingrosso
- Endoscopy Unit, Giovanni Paolo II Research and Care Foundation, Campobasso, Italy
| | - Alessio G Morganti
- Radiation Oncology Center, Department of Experimental, Diagnostic and Specialty Medicine DIMES, University of Bologna, Bologna, Italy
| | - Lorenzo Fuccio
- Department of Medical and Surgical Sciences (DIMEC), University of Bologna, Bologna, Italy
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21
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Trzcinski R, Dziki A, Brys M, Moszynska-Zielinska M, Chalubinska-Fendler J, Mik M, Kujawski R, Dziki L. Expression of vascular endothelial growth factor and its correlation with clinical symptoms and endoscopic findings in patients with chronic radiation proctitis. Colorectal Dis 2018; 20:321-330. [PMID: 28963746 DOI: 10.1111/codi.13902] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2017] [Accepted: 09/04/2017] [Indexed: 12/12/2022]
Abstract
AIM The aim of this study was to assess the expression of vascular endothelial growth factor (VEGF) as a key proangiogenic factor and determine whether there is any correlation between its expression and clinical symptoms or endoscopic changes in patients with chronic radiation proctitis (ChRP). METHOD Fifty patients who had all undergone radiotherapy for prostate, cervical or uterine cancer were included in the study (37 women, 13 men). There was a control group of 20 patients (9 women, 11 men). The Radiation Therapy Oncology Group/European Organization for Research and Treatment of Cancer (RTOG/EORTC) scoring system was used for grading the severity of the proctitis. Endoscopic scoring of late rectal mucosal damage was performed using Gilinsky's classification. Serum levels of VEGF were analysed by the enzyme-linked immunosorbent assay method. RESULTS Most patients presented with Grade 1 symptoms. Endoscopic assessment showed that most patients had Grade 1 late rectal mucosal damage. The predominant endoscopic finding was the presence of telangiectasia. Assessment of VEGF correlation between the control group and the degrees of endoscopic changes showed statistically significant differences for all three degrees (P < 0.0001, P = 0.0251 and P = 0.0005, respectively). Due to the small numbers of patients with Grades 2 and 3 symptoms using the RTOG/EORTC scoring system, they were grouped with Grades 1 and 4 respectively forming two groups for statistical purposes. VEGF expression differed significantly between controls and group I and between controls and group II (P = 0.0001, P = 0.0009, respectively). CONCLUSION A significant increase in VEGF expression was found to correlate with clinical symptoms and endoscopic rectal mucosa changes in patients with ChRP, suggesting that it may play an important role in pathological angiogenesis.
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Affiliation(s)
- R Trzcinski
- Department of General and Colorectal Surgery, Medical University of Lodz, Lodz, Poland
| | - A Dziki
- Department of General and Colorectal Surgery, Medical University of Lodz, Lodz, Poland
| | - M Brys
- Department of Cytobiochemistry, University of Lodz, Lodz, Poland
| | - M Moszynska-Zielinska
- Department of Radiotherapy, Copernicus Memorial Hospital, Regional Cancer Center, Lodz, Poland
| | | | - M Mik
- Department of General and Colorectal Surgery, Medical University of Lodz, Lodz, Poland
| | - R Kujawski
- Department of General and Colorectal Surgery, Medical University of Lodz, Lodz, Poland
| | - L Dziki
- Department of General and Colorectal Surgery, Medical University of Lodz, Lodz, Poland
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Rijkmans E, van Triest B, Nout R, Kerkhof E, Buijsen J, Rozema T, Franssen J, Velema L, Laman M, Cats A, Marijnen C. Evaluation of clinical and endoscopic toxicity after external beam radiotherapy and endorectal brachytherapy in elderly patients with rectal cancer treated in the HERBERT study. Radiother Oncol 2018; 126:417-423. [DOI: 10.1016/j.radonc.2017.12.023] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2017] [Revised: 12/15/2017] [Accepted: 12/27/2017] [Indexed: 01/30/2023]
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23
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Ren Y, Ye J, Wang Y, Xiong W, Xu J, He Y, Cai S, Tan M, Yuan Y. The Optimal Application of Transrectal Ultrasound in Staging of Rectal Cancer Following Neoadjuvant Therapy: A Pragmatic Study for Accuracy Investigation. J Cancer 2018; 9:784-791. [PMID: 29581756 PMCID: PMC5868142 DOI: 10.7150/jca.22661] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2017] [Accepted: 12/29/2017] [Indexed: 12/12/2022] Open
Abstract
Background: Transrectal ultrasound (TRUS) is a cost-effective test for preoperative assessment of rectal cancer. However, whether the accuracy of TRUS staging is correlated with tumor location remains obscured. This study is designed to explore their relationship and confirm an optimal application of TRUS in rectal cancer restaging. Methods: From 2005 to 2011, rectal cancer patients with TRUS data were retrospectively reviewed. Patients were divided into five groups according to tumor-involved rectal segment (SEG) above the anal verge: SEG I 1-3cm, II 3-6cm, III 6-9cm, IV 9-12cm, and V 12-16cm. The accuracy and long-term outcomes of tumor staging were compared between ultrasonographic and pathological stages. Results: 219 patients were included, with 55 (25.1%) in SEG I, 123 (56.2%) in SEG II, 32 (14.6%) in SEG III, 4 (1.8%) in SEG IV and 5 (2.3%) in SEG V. The overall accuracy of TRUS staging was remarkably superior to clinical staging by CT (64.8% vs. 34.7%, P<0.001), with 70.3% and 82.2% for ultrasonographic T and N stages respectively. The accuracy of TRUS reached its peak value when tumors were located in SEG II. The 5-year overall survival had no significant difference between TRUS and pathology staging for all stages. A cox regression analysis indicated that high levels of CEA and tumor location were risk factors of inaccurate staging. Conclusions: TRUS is still a valuable examination for restaging of rectal cancer after neoadjuvant therapy. The application of TRUS would be optimal for rectal cancer located 3-6cm above the anal verge.
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Affiliation(s)
- Yufeng Ren
- Department of Radiation Oncology, The First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, P.R. China
| | - Jinning Ye
- Center of Gastrointestinal Surgery, The First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, P.R. China
| | - Yan Wang
- Department of Medical Ultrasonics, Institute of Diagnostic and Interventional Ultrasound, The First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, P.R. China
| | - Weixin Xiong
- Center of Gastrointestinal Surgery, The First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, P.R. China
| | - Jianbo Xu
- Center of Gastrointestinal Surgery, The First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, P.R. China.,Center of Gastric cancer, Sun Yat-Sen University, Guangzhou, P.R. China
| | - Yulong He
- Center of Gastrointestinal Surgery, The First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, P.R. China.,Center of Gastric cancer, Sun Yat-Sen University, Guangzhou, P.R. China
| | - Shirong Cai
- Center of Gastrointestinal Surgery, The First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, P.R. China.,Center of Gastric cancer, Sun Yat-Sen University, Guangzhou, P.R. China
| | - Min Tan
- Center of Gastrointestinal Surgery, The First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, P.R. China.,Center of Gastric cancer, Sun Yat-Sen University, Guangzhou, P.R. China
| | - Yujie Yuan
- Center of Gastrointestinal Surgery, The First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, P.R. China.,Center of Gastric cancer, Sun Yat-Sen University, Guangzhou, P.R. China
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Lawrie TA, Green JT, Beresford M, Wedlake L, Burden S, Davidson SE, Lal S, Henson CC, Andreyev HJN. Interventions to reduce acute and late adverse gastrointestinal effects of pelvic radiotherapy for primary pelvic cancers. Cochrane Database Syst Rev 2018; 1:CD012529. [PMID: 29360138 PMCID: PMC6491191 DOI: 10.1002/14651858.cd012529.pub2] [Citation(s) in RCA: 44] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND An increasing number of people survive cancer but a significant proportion have gastrointestinal side effects as a result of radiotherapy (RT), which impairs their quality of life (QoL). OBJECTIVES To determine which prophylactic interventions reduce the incidence, severity or both of adverse gastrointestinal effects among adults receiving radiotherapy to treat primary pelvic cancers. SEARCH METHODS We conducted searches of CENTRAL, MEDLINE, and Embase in September 2016 and updated them on 2 November 2017. We also searched clinical trial registries. SELECTION CRITERIA We included randomised controlled trials (RCTs) of interventions to prevent adverse gastrointestinal effects of pelvic radiotherapy among adults receiving radiotherapy to treat primary pelvic cancers, including radiotherapy techniques, other aspects of radiotherapy delivery, pharmacological interventions and non-pharmacological interventions. Studies needed a sample size of 20 or more participants and needed to evaluate gastrointestinal toxicity outcomes. We excluded studies that evaluated dosimetric parameters only. We also excluded trials of interventions to treat acute gastrointestinal symptoms, trials of altered fractionation and dose escalation schedules, and trials of pre- versus postoperative radiotherapy regimens, to restrict the vast scope of the review. DATA COLLECTION AND ANALYSIS We used standard Cochrane methodology. We used the random-effects statistical model for all meta-analyses, and the GRADE system to rate the certainty of the evidence. MAIN RESULTS We included 92 RCTs involving more than 10,000 men and women undergoing pelvic radiotherapy. Trials involved 44 different interventions, including radiotherapy techniques (11 trials, 4 interventions/comparisons), other aspects of radiotherapy delivery (14 trials, 10 interventions), pharmacological interventions (38 trials, 16 interventions), and non-pharmacological interventions (29 trials, 13 interventions). Most studies (79/92) had design limitations. Thirteen studies had a low risk of bias, 50 studies had an unclear risk of bias and 29 studies had a high risk of bias. Main findings include the following:Radiotherapy techniques: Intensity-modulated radiotherapy (IMRT) versus 3D conformal RT (3DCRT) may reduce acute (risk ratio (RR) 0.48, 95% confidence interval (CI) 0.26 to 0.88; participants = 444; studies = 4; I2 = 77%; low-certainty evidence) and late gastrointestinal (GI) toxicity grade 2+ (RR 0.37, 95% CI 0.21 to 0.65; participants = 332; studies = 2; I2 = 0%; low-certainty evidence). Conformal RT (3DCRT or IMRT) versus conventional RT reduces acute GI toxicity grade 2+ (RR 0.57, 95% CI 0.40 to 0.82; participants = 307; studies = 2; I2 = 0%; high-certainty evidence) and probably leads to less late GI toxicity grade 2+ (RR 0.49, 95% CI 0.22 to 1.09; participants = 517; studies = 3; I2 = 44%; moderate-certainty evidence). When brachytherapy (BT) is used instead of external beam radiotherapy (EBRT) in early endometrial cancer, evidence indicates that it reduces acute GI toxicity (grade 2+) (RR 0.02, 95% CI 0.00 to 0.18; participants = 423; studies = 1; high-certainty evidence).Other aspects of radiotherapy delivery: There is probably little or no difference in acute GI toxicity grade 2+ with reduced radiation dose volume (RR 1.21, 95% CI 0.81 to 1.81; participants = 211; studies = 1; moderate-certainty evidence) and maybe no difference in late GI toxicity grade 2+ (RR 1.02, 95% CI 0.15 to 6.97; participants = 107; studies = 1; low-certainty evidence). Evening delivery of RT may reduce acute GI toxicity (diarrhoea) grade 2+ during RT compared with morning delivery of RT (RR 0.51, 95% CI 0.34 to 0.76; participants = 294; studies = 2; I2 = 0%; low-certainty evidence). There may be no difference in acute (RR 2.22, 95% CI 0.62 to 7.93, participants = 110; studies = 1) and late GI toxicity grade 2+ (RR 0.44, 95% CI 0.12 to 1.65; participants = 81; studies = 1) between a bladder volume preparation of 1080 mls and that of 540 mls (low-certainty evidence). Low-certainty evidence on balloon and hydrogel spacers suggests that these interventions for prostate cancer RT may make little or no difference to GI outcomes.Pharmacological interventions: Evidence for any beneficial effects of aminosalicylates, sucralfate, amifostine, corticosteroid enemas, bile acid sequestrants, famotidine and selenium is of a low or very low certainty. However, evidence on certain aminosalicylates (mesalazine, olsalazine), misoprostol suppositories, oral magnesium oxide and octreotide injections suggests that these agents may worsen GI symptoms, such as diarrhoea or rectal bleeding.Non-pharmacological interventions: Low-certainty evidence suggests that protein supplements (RR 0.23, 95% CI 0.07 to 0.74; participants = 74; studies = 1), dietary counselling (RR 0.04, 95% CI 0.00 to 0.60; participants = 74; studies = 1) and probiotics (RR 0.43, 95% CI 0.22 to 0.82; participants = 923; studies = 5; I2 = 91%) may reduce acute RT-related diarrhoea (grade 2+). Dietary counselling may also reduce diarrhoeal symptoms in the long term (at five years, RR 0.05, 95% CI 0.00 to 0.78; participants = 61; studies = 1). Low-certainty evidence from one study (108 participants) suggests that a high-fibre diet may have a beneficial effect on GI symptoms (mean difference (MD) 6.10, 95% CI 1.71 to 10.49) and quality of life (MD 20.50, 95% CI 9.97 to 31.03) at one year. High-certainty evidence indicates that glutamine supplements do not prevent RT-induced diarrhoea. Evidence on various other non-pharmacological interventions, such as green tea tablets, is lacking.Quality of life was rarely and inconsistently reported across included studies, and the available data were seldom adequate for meta-analysis. AUTHORS' CONCLUSIONS Conformal radiotherapy techniques are an improvement on older radiotherapy techniques. IMRT may be better than 3DCRT in terms of GI toxicity, but the evidence to support this is uncertain. There is no high-quality evidence to support the use of any other prophylactic intervention evaluated. However, evidence on some potential interventions shows that they probably have no role to play in reducing RT-related GI toxicity. More RCTs are needed for interventions with limited evidence suggesting potential benefits.
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Affiliation(s)
- Theresa A Lawrie
- Cochrane Gynaecological, Neuro-oncology and Orphan Cancer Group, 1st Floor Education Centre, Royal United Hospital, Combe Park, Bath, UK, BA1 3NG
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Schack LMH, Petersen SE, Nielsen S, Lundby L, Høyer M, Bentzen L, Overgaard J, Andreassen CN, Alsner J. Validation of genetic predictors of late radiation-induced morbidity in prostate cancer patients. Acta Oncol 2017; 56:1514-1521. [PMID: 28844157 DOI: 10.1080/0284186x.2017.1348626] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
INTRODUCTION Normal tissue morbidity sets the dose limit for radiotherapy (RT) in cancer treatment and has importance for quality of life for cancer survivors. A previous study of prostate cancer patients treated with RT generated clinical data for radiation-induced morbidity measured by anorectal physiological methods and validated questionnaires. Other studies have identified genetic predictors associated with late radiation-induced morbidity outcome. We have expanded biobank material aiming to validate single nucleotide polymorphisms (SNPs) and a gene expression classifier with endpoints on patient-reported outcomes and biomechanical properties of the anorectum from our cohort matching originally published endpoints. MATERIALS AND METHODS The present cohort of prostate cancer patients was treated with RT curative intent in 1999-2007. Nine SNPs associated with late radiation-induced morbidity were tested in 96 patients (rs2788612, rs1800629, rs264663, rs2682585, rs2268363, rs1801516, rs13035033, rs7120482 and rs17779457). A validated gene expression profile predictive of resistance to radiation-induced skin fibrosis was tested in 42 patients. An RT-induced anorectal dysfunction score (RT-ARD) served as a fibrosis-surrogate and a measure of overall radiation-induced morbidity. RESULTS The lowest p-value found in the genotype analyses was for SNP rs2682585 minor allele (A) in the FSHR gene and the RT-ARD score with odds ratios (OR) = 1.76; 95% CI (0.98-3.17) p = .06, which was out of concordance with original data showing a protective effect of the minor allele. The gene expression profile in patients classified as fibrosis-resistant was associated with high RT-ARD scores OR 4.18; 95% CI (1.1-16.6), p = .04 conflicting with the hypothesis that fibrosis-resistant patients would experience lower RT-ARD scores. CONCLUSIONS We aimed to validate nine SNPs and a gene expression classifier in a cohort of prostate cancer patients with unique scoring of radiation-induced morbidity. One significant association was found, pointing to the opposite direction of originally published data. We conclude that the material was not able to validate previously published genetic predictors of radiation-induced morbidity.
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Affiliation(s)
- Line M. H. Schack
- Department of Experimental Clinical Oncology, Aarhus University Hospital, Aarhus, Denmark
| | | | - Steffen Nielsen
- Department of Experimental Clinical Oncology, Aarhus University Hospital, Aarhus, Denmark
| | - Lilly Lundby
- Department of Surgery, Aarhus University Hospital, Aarhus, Denmark
| | - Morten Høyer
- Danish Centre for Particle Therapy, Aarhus University Hospital, Aarhus, Denmark
| | - Lise Bentzen
- Department of Oncology, Aarhus University Hospital, Aarhus, Denmark
| | - Jens Overgaard
- Department of Experimental Clinical Oncology, Aarhus University Hospital, Aarhus, Denmark
| | - Christian N. Andreassen
- Department of Experimental Clinical Oncology, Aarhus University Hospital, Aarhus, Denmark
- Department of Oncology, Aarhus University Hospital, Aarhus, Denmark
| | - Jan Alsner
- Department of Experimental Clinical Oncology, Aarhus University Hospital, Aarhus, Denmark
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Cao F, Ma TH, Liu GJ, Wen YL, Wang HM, Kuang YY, Qin S, Liu XY, Huang BJ, Wang L. Correlation between Disease Activity and Endorectal Ultrasound Findings of Chronic Radiation Proctitis. ULTRASOUND IN MEDICINE & BIOLOGY 2017; 43:2182-2191. [PMID: 28755790 DOI: 10.1016/j.ultrasmedbio.2017.06.025] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/24/2017] [Revised: 06/03/2017] [Accepted: 06/21/2017] [Indexed: 06/07/2023]
Abstract
The aim of this study was to summarize the imaging features of chronic radiation proctitis (CRP) on endorectal ultrasound (ERUS) and investigate the value of ERUS in the evaluation of disease activity. 40 CRP patients and 30 control patients were investigated by ERUS. Rectal wall thickness and layers, ulcers and rectovaginal fistulas were evaluated by B-mode ultrasound. Power Doppler imaging was used to evaluate the vascularity of the rectal wall using a semiquantitative score. Disease activity was calculated according to the National Cancer Institute Common Terminology Criteria for Adverse Events 4.0 (CTCAE 4.0). Imaging findings for patients with mild and severe CRP were compared. For 30 patients in the control group, the average maximum thickness of the rectal wall was 3.07 ± 0.73 mm, with all exhibiting typical wall stratification and level 0 vascularity. For the 40 CRP patients, there was marked thickening of the rectal wall (average thickness = 9.42 ± 1.94 mm), which was significantly thicker than in the control group (p < 0.05). The rectal walls of the mild group were significantly thinner than those of the severe group (8.71 ± 1.67 mm vs. 10.00 ± 2.00 mm, p < 0.05). Among the 22 severe cases, 19 cases (19/22, 86.4%) exhibited hyper-vascularity (level IV) or blurred wall stratification (including hypo-echoic submucosa, ulcer and fistula); 12 of the 18 mild cases (166.7%) exhibited a vascularity of level III and typical wall stratification. A significant association (p < 0.05) was observed between stratification and vascularity of the rectal wall and CRP activity. When ERUS findings of blurred rectal wall stratification or increasing vascularity (level IV) were used to evaluate CRP activity, the sensitivity was 86.4% (95% confidence interval: 64.0-96.4) and the specificity was 66.7% (95% confidence interval: 41.2-85.6). Thickening of the rectal wall, blurred wall stratification and increased vascularity are characteristic ERUS findings of CRP. ERUS is helpful in the comprehensive evaluation of disease activity and may provide objective evidence during treatment planning and follow-up.
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Affiliation(s)
- Fei Cao
- Department of Medical Ultrasonics, the Sixth Affiliated Hospital of Sun Yat-Sen University, Guangzhou, Guangdong, China
| | - Teng-Hui Ma
- 1 Department of gastroenterological surgery, the Sixth Affiliated Hospital, 2 Guangdong Institute of Gastroenterology, 3 Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, Sun Yat-sen University, Guangzhou, Guangdong, China
| | - Guang-Jian Liu
- Department of Medical Ultrasonics, the Sixth Affiliated Hospital of Sun Yat-Sen University, Guangzhou, Guangdong, China
| | - Yan-Ling Wen
- Department of Medical Ultrasonics, the Sixth Affiliated Hospital of Sun Yat-Sen University, Guangzhou, Guangdong, China
| | - Huai-Ming Wang
- 1 Department of gastroenterological surgery, the Sixth Affiliated Hospital, 2 Guangdong Institute of Gastroenterology, 3 Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, Sun Yat-sen University, Guangzhou, Guangdong, China
| | - Ying-Yi Kuang
- 1 Department of gastroenterological surgery, the Sixth Affiliated Hospital, 2 Guangdong Institute of Gastroenterology, 3 Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, Sun Yat-sen University, Guangzhou, Guangdong, China
| | - Si Qin
- Department of Medical Ultrasonics, the Sixth Affiliated Hospital of Sun Yat-Sen University, Guangzhou, Guangdong, China
| | - Xiao-Yin Liu
- Department of Medical Ultrasonics, the Sixth Affiliated Hospital of Sun Yat-Sen University, Guangzhou, Guangdong, China
| | - Bin-Jie Huang
- 1 Department of gastroenterological surgery, the Sixth Affiliated Hospital, 2 Guangdong Institute of Gastroenterology, 3 Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, Sun Yat-sen University, Guangzhou, Guangdong, China
| | - Lei Wang
- 1 Department of gastroenterological surgery, the Sixth Affiliated Hospital, 2 Guangdong Institute of Gastroenterology, 3 Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, Sun Yat-sen University, Guangzhou, Guangdong, China.
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Delobel JB, Gnep K, Ospina JD, Beckendorf V, Chira C, Zhu J, Bossi A, Messai T, Acosta O, Castelli J, de Crevoisier R. Nomogram to predict rectal toxicity following prostate cancer radiotherapy. PLoS One 2017. [PMID: 28640871 PMCID: PMC5480987 DOI: 10.1371/journal.pone.0179845] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND To identify predictors of acute and late rectal toxicity following prostate cancer radiotherapy (RT), while integrating the potential impact of RT technique, dose escalation, and moderate hypofractionation, thus enabling us to generate a nomogram for individual prediction. METHODS In total, 972 patients underwent RT for localized prostate cancer, to a total dose of 70 Gy or 80 Gy, using two different fractionations (2 Gy or 2.5 Gy/day), by means of several RT techniques (3D conformal RT [3DCRT], intensity-modulated RT [IMRT], or image-guided RT [IGRT]). Multivariate analyses were performed to identify predictors of acute and late rectal toxicity. A nomogram was generated based on the logistic regression model used to predict the 3-year rectal toxicity risk, with its accuracy assessed by dividing the cohort into training and validation subgroups. RESULTS Mean follow-up for the entire cohort was 62 months, ranging from 6 to 235. The rate of acute Grade ≥2 rectal toxicity was 22.2%, decreasing when combining IMRT and IGRT, compared to 3DCRT (RR = 0.4, 95%CI: 0.3-0.6, p<0.01). The 5-year Grade ≥2 risks for rectal bleeding, urgency/tenesmus, diarrhea, and fecal incontinence were 9.9%, 4.5%, 2.8%, and 0.4%, respectively. The 3-year Grade ≥2 risk for overall rectal toxicity increased with total dose (p<0.01, RR = 1.1, 95%CI: 1.0-1.1) and dose per fraction (2Gy vs. 2.5Gy) (p = 0.03, RR = 3.3, 95%CI: 1.1-10.0), and decreased when combining IMRT and IGRT (RR = 0.50, 95% CI: 0.3-0.8, p<0.01). Based on these three parameters, a nomogram was generated. CONCLUSIONS Dose escalation and moderate hypofractionation increase late rectal toxicity. IMRT combined with IGRT markedly decreases acute and late rectal toxicity. Performing combined IMRT and IGRT can thus be envisaged for dose escalation and moderate hypofractionation. Our nomogram predicts the 3-year rectal toxicity risk by integrating total dose, fraction dose, and RT technique.
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Affiliation(s)
- Jean-Bernard Delobel
- Dept. of Gastroenterology, Centre Hospitalier Universitaire Pontchaillou, Rennes, France
| | - Khemara Gnep
- LTSI, Inserm U1099, Université de Rennes 1, Rennes, France
- Centre Eugene Marquis, Rennes, France
- * E-mail:
| | - Juan David Ospina
- LTSI, Inserm U1099, Université de Rennes 1, Rennes, France
- Escuela de Estadística, Universidad Nacional de Colombia, Medellin, Colombia
| | | | | | - Jian Zhu
- LTSI, Inserm U1099, Université de Rennes 1, Rennes, France
- Laboratory of Image Science and Technology, Southeast University, Nanjing, PR China
- Centre de Recherche en Information Biomédicale Sino-Français (CRIBs), Rennes, France
| | | | | | - Oscar Acosta
- LTSI, Inserm U1099, Université de Rennes 1, Rennes, France
| | - Joël Castelli
- LTSI, Inserm U1099, Université de Rennes 1, Rennes, France
- Centre Eugene Marquis, Rennes, France
| | - Renaud de Crevoisier
- LTSI, Inserm U1099, Université de Rennes 1, Rennes, France
- Centre Eugene Marquis, Rennes, France
- Centre de Recherche en Information Biomédicale Sino-Français (CRIBs), Rennes, France
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Moulton CR, House MJ, Lye V, Tang CI, Krawiec M, Joseph DJ, Denham JW, Ebert MA. Spatial features of dose-surface maps from deformably-registered plans correlate with late gastrointestinal complications. Phys Med Biol 2017; 62:4118-4139. [PMID: 28445167 DOI: 10.1088/1361-6560/aa663d] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
This study investigates the associations between spatial distribution of dose to the rectal surface and observed gastrointestinal toxicities after deformably registering each phase of a combined external beam radiotherapy (EBRT)/high-dose-rate brachytherapy (HDRBT) prostate cancer treatment. The study contains data for 118 patients where the HDRBT CT was deformably-registered to the EBRT CT. The EBRT and registered HDRBT TG43 dose distributions in a reference 2 Gy/fraction were 3D-summed. Rectum dose-surface maps (DSMs) were obtained by virtually unfolding the rectum surface slice-by-slice. Associations with late peak gastrointestinal toxicities were investigated using voxel-wise DSM analysis as well as parameterised spatial patterns. The latter were obtained by thresholding DSMs from 1-80 Gy (increment = 1) and extracting inferior-superior extent, left-right extent, area, perimeter, compactness, circularity and ellipse fit parameters. Logistic regressions and Mann-Whitney U-tests were used to correlate features with toxicities. Rectal bleeding, stool frequency, diarrhoea and urgency/tenesmus were associated with greater lateral and/or longitudinal spread of the high doses near the anterior rectal surface. Rectal bleeding and stool frequency were also influenced by greater low-intermediate doses to the most inferior 20% of the rectum and greater low-intermediate-high doses to 40-80% of the rectum length respectively. Greater low-intermediate doses to the superior 20% and inferior 20% of the rectum length were associated with anorectal pain and urgency/tenesmus respectively. Diarrhoea, completeness of evacuation and proctitis were also related to greater low doses to the posterior side of the rectum. Spatial features for the intermediate-high dose regions such as area, perimeter, compactness, circularity, ellipse eccentricity and confinement to ellipse fits were strongly associated with toxicities other than anorectal pain. Consequently, toxicity is related to the shape of isodoses as well as dose coverage. The findings indicate spatial constraints on doses to certain sections of the rectum may be important for reducing toxicities and optimising dose.
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Affiliation(s)
- Calyn R Moulton
- School of Physics, University of Western Australia, Crawley, Western Australia, Australia
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Paydar I, Pepin A, Cyr RA, King J, Yung TM, Bullock EG, Lei S, Satinsky A, Harter KW, Suy S, Dritschilo A, Lynch JH, Kole TP, Collins SP. Intensity-Modulated Radiation Therapy with Stereotactic Body Radiation Therapy Boost for Unfavorable Prostate Cancer: A Report on 3-Year Toxicity. Front Oncol 2017; 7:5. [PMID: 28224113 PMCID: PMC5293802 DOI: 10.3389/fonc.2017.00005] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2016] [Accepted: 01/05/2017] [Indexed: 12/16/2022] Open
Abstract
Background Recent data suggest that intensity-modulated radiation therapy (IMRT) plus brachytherapy boost for unfavorable prostate cancer provides improved biochemical relapse-free survival over IMRT alone. Stereotactic body radiation therapy (SBRT) may be a less invasive alternative to brachytherapy boost. Here, we report the 3-year gastrointestinal (GI) and genitourinary (GU) toxicities of IMRT plus SBRT boost. Materials and methods Between March 2008 and September 2012, patients with prostate cancer were treated with robotic SBRT (19.5 Gy in three fractions) followed by fiducial-guided IMRT (45–50.4 Gy) on an institutional protocol. Toxicity was prospectively graded using the common terminology criteria for adverse events version 4.0 (CTCAEv.4) at the start of and at 1- to 6-month intervals after therapy. Rectal telangiectasias were graded using the Vienna Rectoscopy Score (VRS). Results At a median follow-up of 4.2 years (2.4–7.5), 108 patients (4 low-, 45 intermediate-, and 59 high-risk) with a median age of 74 years (55–92) were treated with SBRT plus IMRT, with 8% on anticoagulation and an additional 48% on antiplatelet therapy at the start of therapy. The cumulative incidence of late ≥grade 2 GI toxicity was 12%. Of these, 7% were due to late rectal bleeding, with six patients requiring up to two coagulation procedures. One patient with rectal telangiectasias was treated with hyperbaric oxygen (grade 3 toxicity). No rectal fistulas or stenoses were observed. Ten patients had multiple non-confluent telangiectasias (VRS grade 2), and three patients had multiple confluent telangiectasias (VRS grade 3). The cumulative incidence of late grade 3 GU toxicity was 6%. Most late toxicities were due to hematuria requiring bladder fulguration. There were no late ≥grade 4 GU toxicities. Conclusion Rates of clinically significant GI and GU toxicities are modest following IMRT plus SBRT boost. Future studies should compare cancer control, quality of life, and toxicity with other treatment modalities for patients with high-risk prostate cancer.
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Affiliation(s)
- Ima Paydar
- Department of Radiation Medicine, Georgetown University Hospital , Washington, DC , USA
| | | | - Robyn A Cyr
- Department of Radiation Medicine, Georgetown University Hospital , Washington, DC , USA
| | - Joseph King
- University of South Carolina School of Medicine , Columbia, SC , USA
| | - Thomas M Yung
- Department of Radiation Medicine, Georgetown University Hospital , Washington, DC , USA
| | - Elizabeth G Bullock
- Department of Radiation Medicine, Georgetown University Hospital , Washington, DC , USA
| | - Siyuan Lei
- Department of Radiation Medicine, Georgetown University Hospital , Washington, DC , USA
| | - Andrew Satinsky
- Department of Radiation Medicine, Georgetown University Hospital , Washington, DC , USA
| | - K William Harter
- Department of Radiation Medicine, Georgetown University Hospital , Washington, DC , USA
| | - Simeng Suy
- Department of Radiation Medicine, Georgetown University Hospital , Washington, DC , USA
| | - Anatoly Dritschilo
- Department of Radiation Medicine, Georgetown University Hospital , Washington, DC , USA
| | - John H Lynch
- Department of Urology, Georgetown University Hospital , Washington, DC , USA
| | - Thomas P Kole
- Department of Radiation Oncology, The Valley Hospital , Ridgewood, NJ , USA
| | - Sean P Collins
- Department of Radiation Medicine, Georgetown University Hospital , Washington, DC , USA
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Yuan ZX, Ma TH, Zhong QH, Wang HM, Yu XH, Qin QY, Chu LL, Wang L, Wang JP. Novel and Effective Almagate Enema for Hemorrhagic Chronic Radiation Proctitis and Risk Factors for Fistula Development. Asian Pac J Cancer Prev 2017; 17:631-8. [PMID: 26925655 DOI: 10.7314/apjcp.2016.17.2.631] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
Radiation proctitis is a common complication after radiotherapy for pelvic malignant tumors. This study was conducted to assess the efficacy of novel almagate enemas in hemorrhagic chronic radiation proctitis (CRP) and evaluate risk factors related to rectal deep ulcer or fistula secondary to CRP. All patients underwent a colonoscopy to confirm the diagnosis of CRP and symptoms were graded. Typical endoscopic and pathological images, risk factors, and quality of life were also recorded. A total of 59 patients were enrolled. Gynecological cancers composed 93.1% of the primary malignancies. Complete or obvious reduction of bleeding was observed in 90% (53/59) patients after almagate enema. The mean score of bleeding improved from 2.17 to 0.83 (P<0.001) after the enemas. The mean response time was 12 days. No adverse effects were found. Moreover, long-term successful rate in controlling bleeding was 69% and the quality of life was dramatically improved (P=0.001). The efficacy was equivalent to rectal sucralfate, but the almagate with its antacid properties acted more rapidly than sucralfate. Furthermore, we firstly found that moderate to severe anemia was the risk factor of CRP patients who developed rectal deep ulcer or fistulas (P= 0.015). We also found abnormal hyaline-like thick wall vessels, which revealed endarteritis obliterans and the fibrosis underlying this disease. These findings indicate that almagate enema is a novel effective, rapid and well-tolerated method for hemorrhagic CRP. Moderate to severe anemia is a risk factor for deep ulceration or fistula.
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Affiliation(s)
- Zi-Xu Yuan
- Department of Colorectal Surgery, the Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, China E-mail : , wangl9@mail. sysu.edu.cn,
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Long-Term Endoscopic Follow-Up of Patients with Chronic Radiation Proctopathy after Brachytherapy for Prostate Cancer. DIAGNOSTIC AND THERAPEUTIC ENDOSCOPY 2016; 2016:1414090. [PMID: 27378828 PMCID: PMC4917689 DOI: 10.1155/2016/1414090] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/04/2016] [Accepted: 05/16/2016] [Indexed: 02/07/2023]
Abstract
Background. Chronic radiation proctopathy (CRP) is late toxicity and associated with morbidity. Aim. To investigate the predictors of prognosis in patients with CRP after brachytherapy (BT). Methods. One hundred four patients with prostate cancer were treated with BT or BT followed by external-beam radiotherapy (BT + EBRT). We retrospectively investigated the 5-year incidence of rectal bleeding and endoscopic findings of CRP using the Vienna Rectoscopy Score (VRS). Twenty patients with VRS ≥ 1 were divided into the improved VRS group without treatment, unchanged VRS group, and treated group. The parameters associated with alteration of VRS were analyzed. Results. The incidence of rectal bleeding was 24%. The risk of rectal bleeding was higher in patients treated with BT + EBRT compared to those treated with BT (p < 0.0001). The incidence of superficial microulceration was higher in the improved VRS group than in the unchanged VRS group (p < 0.05). The incidence of multiple confluent telangiectasia or superficial ulcers > 1 cm2 was higher in the treated group than in both the improved and unchanged VRS groups (p < 0.05). Conclusions. Patients treated with BT + EBRT have a high risk of CRP. Endoscopic findings were useful for prognostic prediction of CRP.
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Yuan ZX, Ma TH, Wang HM, Zhong QH, Yu XH, Qin QY, Wang JP, Wang L. Colostomy is a simple and effective procedure for severe chronic radiation proctitis. World J Gastroenterol 2016; 22:5598-5608. [PMID: 27350738 PMCID: PMC4917620 DOI: 10.3748/wjg.v22.i24.5598] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2016] [Revised: 04/05/2016] [Accepted: 05/04/2016] [Indexed: 02/06/2023] Open
Abstract
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.
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Eton DT, Lai JS, Cella D, Reeve BB, Talcott JA, Clark JA, McPherson CP, Litwin MS, Moinpour CM. Data Pooling and Analysis to Build a Preliminary Item Bank. Eval Health Prof 2016; 28:142-59. [PMID: 15851770 DOI: 10.1177/0163278705275338] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Assessing bowel function (BF) in prostate cancer can help determine therapeutic trade-offs. We determined the components of BF commonly assessed in prostate cancer studies as an initial step in creating an item bank for clinical and research application. We analyzed six archived data sets representing 4,246 men with prostate cancer. Thirty-one items from validated instruments were available for analysis. Items were classified into domains (diarrhea, rectal urgency, pain, bleeding, bother/distress, and other) then subjected to conventional psychometric and item response theory (IRT) analyses. Items fit the IRT model if the ratio between observed and expected item variance was between 0.60 and 1.40. Four of 31 items had inadequate fit in at least one analysis. Poorly fitting items included bleeding (2), rectal urgency (1), and bother/distress (1). A fifth item assessing hemorrhoids was poorly correlated with other items. Our analyses supported four related components of BF: diarrhea, rectal urgency, pain, and bother/distress.
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Affiliation(s)
- David T Eton
- Northwestern University School of Medicine, Evanston, IL 60201, USA.
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Dréan G, Acosta O, Ospina JD, Fargeas A, Lafond C, Corrégé G, Lagrange JL, Créhange G, Simon A, Haigron P, de Crevoisier R. Identification of a rectal subregion highly predictive of rectal bleeding in prostate cancer IMRT. Radiother Oncol 2016; 119:388-97. [PMID: 27173457 DOI: 10.1016/j.radonc.2016.04.023] [Citation(s) in RCA: 42] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2015] [Revised: 03/14/2016] [Accepted: 04/16/2016] [Indexed: 12/23/2022]
Abstract
BACKGROUND AND PURPOSE To identify rectal subregions at risks (SRR) highly predictive of 3-year rectal bleeding (RB) in prostate cancer IMRT. MATERIALS AND METHODS Overall, 173 prostate cancer patients treated with IMRT/IGRT were prospectively analyzed, divided into "training" (n=118) and "validation" cohorts (n=53). Dose-volume histograms (DVHs) were calculated in three types of rectal subregions: "geometric", intuitively defined (hemi-rectum,…); "personalized", obtained by non-rigid registration followed by voxel-wise statistical analysis (SRRp); "generic", mapped from SRRps, located within 8×8 rectal subsections (SRRg). DVHs from patients with and without RB were compared and used for toxicity prediction. RESULTS Training cohort SRRps were primarily within the inferior anterior hemi-rectum and upper anal canal, with 3.8Gy mean dose increase for Grade⩾1 RB patients. The SRRg, representing 15% of the absolute rectal volume, was located in 10 inferior-anterior rectal subsections. V18-V70 for SRRps and V58-V65 for SRRg were significantly higher for RB patients than non-RB. Maximum areas under the curve (AUCs) for SRRp and SRRg RB prediction were 71% and 64%, respectively. The validation cohort confirmed the predictive value of SRRg for Grade⩾1 RB. The total cohort confirmed the predictive value of SRRg for Grade⩾2 RB. Geometrical subregions were not RB predictors. CONCLUSION The inferior-anterior hemi anorectum was highly predictive of RB.
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Affiliation(s)
- Gaël Dréan
- INSERM 1099, Rennes, France; LTSI, Université de Rennes 1, Rennes, France
| | - Oscar Acosta
- INSERM 1099, Rennes, France; LTSI, Université de Rennes 1, Rennes, France
| | - Juan D Ospina
- INSERM 1099, Rennes, France; LTSI, Université de Rennes 1, Rennes, France
| | - Auréline Fargeas
- INSERM 1099, Rennes, France; LTSI, Université de Rennes 1, Rennes, France
| | - Caroline Lafond
- INSERM 1099, Rennes, France; LTSI, Université de Rennes 1, Rennes, France; Département de radiothérapie, Centre Eugène Marquis, Rennes, France
| | | | - Jean-L Lagrange
- Hôpital Henri Mondor, France; UPEC, Université Paris Est Créteil, France
| | | | - Antoine Simon
- INSERM 1099, Rennes, France; LTSI, Université de Rennes 1, Rennes, France
| | - Pascal Haigron
- INSERM 1099, Rennes, France; LTSI, Université de Rennes 1, Rennes, France
| | - Renaud de Crevoisier
- INSERM 1099, Rennes, France; LTSI, Université de Rennes 1, Rennes, France; Département de radiothérapie, Centre Eugène Marquis, Rennes, France.
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Vanneste BGL, Van De Voorde L, de Ridder RJ, Van Limbergen EJ, Lambin P, van Lin EN. Chronic radiation proctitis: tricks to prevent and treat. Int J Colorectal Dis 2015; 30:1293-303. [PMID: 26198994 PMCID: PMC4575375 DOI: 10.1007/s00384-015-2289-4] [Citation(s) in RCA: 66] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/13/2015] [Indexed: 02/04/2023]
Abstract
OBJECTIVE The purpose of this study was to give an overview of the measures used to prevent chronic radiation proctitis (CRP) and to provide an algorithm for the treatment of CRP. METHODS Medical literature databases including PubMed and Medline were screened and critically analyzed for relevance in the scope of our purpose. RESULTS CRP is a relatively frequent late side effect (5-20%) and mainly dependent on the dose and volume of irradiated rectum. Radiation treatment (RT) techniques to prevent CRP are constantly improving thanks to image-guided RT and intensity-modulated RT. Also, newer techniques like protons and new devices such as rectum spacers and balloons have been developed to spare rectal structures. Biopsies do not contribute to diagnosing CRP and should be avoided because of the risk of severe rectal wall damage, such as necrosis and fistulas. There is no consensus on the optimal treatment of CRP. A variety of possibilities is available and includes topical and oral agents, hyperbaric oxygen therapy, and endoscopic interventions. CONCLUSIONS CRP has a natural history of improving over time, even without treatment. This is important to take into account when considering these treatments: first be conservative (topical and oral agents) and be aware that invasive treatments can be very toxic.
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Affiliation(s)
- Ben G L Vanneste
- Department of Radiation Oncology (MAASTRO Clinic), GROW-School for Oncology and Developmental Biology, Maastricht University Medical Center, P.O. Box 3035, 6202 NA, Maastricht, The Netherlands.
| | - Lien Van De Voorde
- Department of Radiation Oncology (MAASTRO Clinic), GROW-School for Oncology and Developmental Biology, Maastricht University Medical Center, P.O. Box 3035, 6202 NA, Maastricht, The Netherlands
| | - Rogier J de Ridder
- Department of Gastroenterology, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Evert J Van Limbergen
- Department of Radiation Oncology (MAASTRO Clinic), GROW-School for Oncology and Developmental Biology, Maastricht University Medical Center, P.O. Box 3035, 6202 NA, Maastricht, The Netherlands
| | - Philippe Lambin
- Department of Radiation Oncology (MAASTRO Clinic), GROW-School for Oncology and Developmental Biology, Maastricht University Medical Center, P.O. Box 3035, 6202 NA, Maastricht, The Netherlands
| | - Emile N van Lin
- Department of Radiation Oncology (MAASTRO Clinic), GROW-School for Oncology and Developmental Biology, Maastricht University Medical Center, P.O. Box 3035, 6202 NA, Maastricht, The Netherlands
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Russell NS, Floot B, van Werkhoven E, Schriemer M, de Jong-Korlaar R, Woerdeman LA, Stewart FA, Scharpfenecker M. Blood and lymphatic microvessel damage in irradiated human skin: The role of TGF-β, endoglin and macrophages. Radiother Oncol 2015; 116:455-61. [DOI: 10.1016/j.radonc.2015.08.024] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2015] [Revised: 08/18/2015] [Accepted: 08/20/2015] [Indexed: 02/01/2023]
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Abstract
Radiation therapy is a widely utilized treatment modality for pelvic malignancies, including prostate cancer, rectal cancer, and cervical cancer. Given its fixed position in the pelvis, the rectum is at a high risk for injury secondary to ionizing radiation. Despite advances made in radiation science, up to 75% of the patients will suffer from acute radiation proctitis and up to 20% may experience chronic symptoms. Symptoms can be variable and include diarrhea, bleeding, incontinence, and fistulization. A multitude of treatment options exist. This article summarizes the latest knowledge relating to radiation proctopathy focusing on the vast array of treatment options.
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Affiliation(s)
- Marc B. Grodsky
- Section of Colon and Rectal Surgery, MedStar Washington Hospital Center, Washington, District of Columbia
| | - Shafik M. Sidani
- Department of Colorectal Surgery, Virginia Hospital Center Physician Group, Arlington, Virginia
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Reggiani Bonetti L, Domati F, Farinetti A, Migaldi M, Manenti A. Radiotherapy-induced mesorectum alterations: histological evaluation of 90 consecutive cases. Scand J Gastroenterol 2015; 50:197-203. [PMID: 25515346 DOI: 10.3109/00365521.2014.983153] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVE In order to identify the radiotherapy-induced histological modifications in the mesorectum, we reviewed the surgical specimens of 90 rectal resections comprehensive of the total mesorectal excision (23 cases radiologically classified as cT2N0M0 and 67 as cT3N0M0). All patients were preoperative treated with radiotherapy: 20 with 50 Gy, 20 with 20 Gy and 50 Gy irradiation associated to FOLFOX scheme chemotherapy. MATERIAL AND METHODS Routine hematoxylin and eosin stained serial slides at 5 mm of intervals were obtained from surgical specimens and included the tumor site and the adjacent irradiated mucosa, the submucosa and the muscular layers of the rectal wall and the mesorectal adipose tissue, completely removed until to the mesorectal fascia. Ten subjects (eight cT2N0M0 and two cT3N0M0), who did not received preoperative oncological treatments were adopted as controls. RESULTS Histologically, examination revealed fibrosis of the adipose tissue in 86 cases (95%), vascular damage including vasculities and fibrotic thickening wall of arteries and veins in 46 cases (51%), sclero-hyalinosis of lymph nodes with pericapsular fibrosis in 22 cases (23%) and perineural deposition of fibrosis in 12 (13%). These findings were ubiquitously observed in the whole mesorectum. Fibrosis of the adipose tissue and vasculitis were mainly associated to the combination of 50 Gy radiations plus chemotherapy (p < 0.05). CONCLUSION The detection of histopathological alterations in the mesorectum can give reason of the well-known postoperative complications and long-term sequels.
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Affiliation(s)
- Luca Reggiani Bonetti
- Department of Forensic Medicine, Laboratory and Pathologic Anatomy, University of Modena and Reggio Emilia , Modena , Italy
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Late rectal toxicity after low-dose-rate brachytherapy: incidence, predictors, and management of side effects. Brachytherapy 2014; 14:148-59. [PMID: 25516492 DOI: 10.1016/j.brachy.2014.11.005] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2014] [Revised: 11/05/2014] [Accepted: 11/06/2014] [Indexed: 12/20/2022]
Abstract
As clinical outcomes for patients with clinically localized prostate cancer continue to improve, patients and physicians are increasing making treatment decisions based on concerns regarding long-term morbidity. A primary concern is late radiation proctitis, a clinical entity embodied by various signs and symptoms, ranging from diarrhea to rectal fistulas. Here, we present a comprehensive literature review examining the clinical manifestations and pathophysiology of late radiation proctitis after low-dose-rate brachytherapy (BT), as well as its incidence and predictors. The long-term risks of rectal bleeding after BT are on the order of 5-7%, whereas the risks of severe ulceration or fistula are on the order of 0.6%. The most robust predictor appears to be the volume of rectum receiving the prescription dose. In certain situations (e.g., salvage setting, for patients with increased radiosensitivity, and following aggressive biopsy after BT), the risk of these severe toxicities may be increased by up to 10-fold. A variety of excellent management options exist for rectal bleeding, with endoscopic methods being the most commonly used.
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Joh DY, Chen LN, Porter G, Bhagat A, Sood S, Kim JS, Moures R, Yung T, Lei S, Collins BT, Ju AW, Suy S, Carroll J, Lynch JH, Dritschilo A, Collins SP. Proctitis following stereotactic body radiation therapy for prostate cancer. Radiat Oncol 2014; 9:277. [PMID: 25497602 PMCID: PMC4272823 DOI: 10.1186/s13014-014-0277-4] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2014] [Accepted: 11/26/2014] [Indexed: 11/26/2022] Open
Abstract
Background Proctitis after radiation therapy for prostate cancer remains an ongoing clinical challenge and critical quality of life issue. SBRT could minimize rectal toxicity by reducing the volume of rectum receiving high radiation doses and offers the potential radiobiologic benefits of hypofractionation. This study sought to evaluate the incidence and severity of proctitis following SBRT for prostate cancer. Methods Between February 2008 and July 2011, 269 men with clinically localized prostate cancer were treated definitively with SBRT monotherapy at Georgetown University Hospital. All patients were treated to 35-36.25Gy in 5 fractions delivered with the CyberKnife Radiosurgical System (Accuray). Rectal bleeding was recorded and scored using the CTCAE v.4. Telangiectasias were graded using the Vienna Rectoscopy Score (VRS). Proctitis was assessed via the Bowel domain of the Expanded Prostate Index Composite (EPIC)-26 at baseline and at 1, 3, 6, 9, 12, 18 and 24 months post-SBRT. Results The median age was 69 years with a median prostate volume of 39 cc. The median follow-up was 3.9 years with a minimum follow-up of two years. The 2-year actuarial incidence of late rectal bleeding ≥ grade 2 was 1.5%. Endoscopy revealed VRS Grade 2 rectal telangiectasias in 11% of patients. All proctitis symptoms increased at one month post-SBRT but returned to near-baseline with longer follow-up. The most bothersome symptoms were bowel urgency and frequency. At one month post-SBRT, 11.2% and 8.5% of patients reported a moderate to big problem with bowel urgency and frequency, respectively. The EPIC bowel summary scores declined transiently at 1 month and experienced a second, more protracted decline between 6 months and 18 months before returning to near-baseline at two years post-SBRT. Prior to treatment, 4.1% of men felt their bowel function was a moderate to big problem which increased to 11.5% one month post-SBRT but returned to near-baseline at two years post-SBRT. Conclusions In this single institution cohort, the rate and severity of proctitis observed following SBRT is low. QOL decreased on follow-up; however, our results compare favorably to those reported for patients treated with alternative radiation modalities. Future prospective randomized studies are needed to confirm these observations.
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Affiliation(s)
- Daniel Y Joh
- Department of Radiation Medicine, Georgetown University Medical Center, 3800 Reservoir Road, N.W, Washington, DC, 20007, USA.
| | - Leonard N Chen
- Department of Radiation Medicine, Georgetown University Medical Center, 3800 Reservoir Road, N.W, Washington, DC, 20007, USA.
| | - Gerald Porter
- Department of Radiation Medicine, Georgetown University Medical Center, 3800 Reservoir Road, N.W, Washington, DC, 20007, USA.
| | - Aditi Bhagat
- Department of Radiation Medicine, Georgetown University Medical Center, 3800 Reservoir Road, N.W, Washington, DC, 20007, USA.
| | - Sumit Sood
- Department of Radiation Medicine, Georgetown University Medical Center, 3800 Reservoir Road, N.W, Washington, DC, 20007, USA.
| | - Joy S Kim
- Department of Radiation Medicine, Georgetown University Medical Center, 3800 Reservoir Road, N.W, Washington, DC, 20007, USA.
| | - Rudy Moures
- Department of Radiation Medicine, Georgetown University Medical Center, 3800 Reservoir Road, N.W, Washington, DC, 20007, USA.
| | - Thomas Yung
- Department of Radiation Medicine, Georgetown University Medical Center, 3800 Reservoir Road, N.W, Washington, DC, 20007, USA.
| | - Siyuan Lei
- Department of Radiation Medicine, Georgetown University Medical Center, 3800 Reservoir Road, N.W, Washington, DC, 20007, USA.
| | - Brian T Collins
- Department of Radiation Medicine, Georgetown University Medical Center, 3800 Reservoir Road, N.W, Washington, DC, 20007, USA.
| | - Andrew W Ju
- Department of Radiation Oncology, East Carolina University, Greenville, NC, 27834, USA.
| | - Simeng Suy
- Department of Radiation Medicine, Georgetown University Medical Center, 3800 Reservoir Road, N.W, Washington, DC, 20007, USA.
| | - John Carroll
- Department of Gastroenterology, Georgetown University Hospital, Washington, DC, 20007, USA.
| | - John H Lynch
- Department of Urology, Georgetown University Hospital, Washington, DC, 20007, USA.
| | - Anatoly Dritschilo
- Department of Radiation Medicine, Georgetown University Medical Center, 3800 Reservoir Road, N.W, Washington, DC, 20007, USA.
| | - Sean P Collins
- Department of Radiation Medicine, Georgetown University Medical Center, 3800 Reservoir Road, N.W, Washington, DC, 20007, USA.
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Mok G, Benz E, Vallee JP, Miralbell R, Zilli T. Optimization of radiation therapy techniques for prostate cancer with prostate-rectum spacers: a systematic review. Int J Radiat Oncol Biol Phys 2014; 90:278-88. [PMID: 25304788 DOI: 10.1016/j.ijrobp.2014.06.044] [Citation(s) in RCA: 54] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2014] [Revised: 05/12/2014] [Accepted: 06/18/2014] [Indexed: 10/24/2022]
Abstract
Dose-escalated radiation therapy for localized prostate cancer improves disease control but is also associated with worse rectal toxicity. A spacer placed between the prostate and rectum can be used to displace the anterior rectal wall outside of the high-dose radiation regions and potentially minimize radiation-induced rectal toxicity. This systematic review focuses on the published data regarding the different types of commercially available prostate-rectum spacers. Dosimetric results and preliminary clinical data using prostate-rectum spacers in patients with localized prostate cancer treated by curative radiation therapy are compared and discussed.
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Affiliation(s)
- Gary Mok
- Department of Radiation Oncology, Geneva University Hospital, Geneva, Switzerland; Department of Radiation Oncology, Centre Intégré de Cancérologie de Laval, Centre de Santé et de Services Sociaux de Laval, Laval, Québec, Canada; Department of Radiology, Radiation Oncology, and Nuclear Medicine, Centre Hospitalier Universitaire de Montréal, Montréal, Québec, Canada
| | - Eileen Benz
- Department of Radiation Oncology, Geneva University Hospital, Geneva, Switzerland
| | - Jean-Paul Vallee
- Department of Radiology, Geneva University Hospital, Geneva, Switzerland
| | - Raymond Miralbell
- Department of Radiation Oncology, Geneva University Hospital, Geneva, Switzerland
| | - Thomas Zilli
- Department of Radiation Oncology, Geneva University Hospital, Geneva, Switzerland.
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Petersen SE, Bregendahl S, Langschwager M, Laurberg S, Brock C, Drewes AM, Krogh K, Høyer M, Lundby L. Pathophysiology of late anorectal dysfunction following external beam radiotherapy for prostate cancer. Acta Oncol 2014; 53:1398-404. [PMID: 24960583 DOI: 10.3109/0284186x.2014.926029] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
BACKGROUND Patients treated with external beam radiotherapy (EBRT) may suffer from long-term anorectal adverse effects. The purpose of the present study was to assess long-term functional and structural anorectal changes in patients previously treated with EBRT for prostate cancer and to suggest the mechanism behind the development of the adverse effects. MATERIAL AND METHODS Our previously proposed RT-induced anorectal dysfunction (RT-ARD) score, developed with the intention to survey anorectal dysfunction was used to identify patients with and without anorectal symptoms. Among 309 patients surveyed with the questionnaire, we chose 23 patients with the highest RT-ARD score and 19 patients with the lowest RT-ARD score. They were investigated by multimodal rectal sensory stimulation, standard anal physiological tests. Changes of the rectal mucosa were assessed by flexible sigmoidoscopy and graded by the Vienna Rectoscopy Score (VRS). RESULTS The mean follow-up time was 3.8 (range, 2.8; 8.6) years in patients with high RT-ARD and 3.8 (range, 2.6; 5.9) in patients with low RT-ARD. Endoscopic evaluation revealed higher VRS scores in patients with high RT-ARD compared to patients with low RT-ARD (p = 0.002). Patients with high RT-ARD had increased rectal sensory response to distension manifested both as volume (p = 0.006) and cross-sectional area (p = 0.04), and they had reduced maximum anal resting pressure assessed by anal manometri (p = 0.02). CONCLUSIONS Long-term anorectal symptoms correlate to changes in anorectal biomechanical properties and rectal mucosal injury. Our data suggests that RT-induced long-term anorectal dysfunction is multifactorial caused by injury of the rectal mucosa and the internal anal sphincter combined with increased rectal sensitivity and reduced rectal functional capacity.
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Guo GH, Yu FY, Wang XJ, Lu F. A randomized controlled clinical trial of formalin for treatment of chronic hemorrhagic radiation proctopathy in cervical carcinoma patients. Support Care Cancer 2014; 23:441-6. [PMID: 25128068 DOI: 10.1007/s00520-014-2401-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2014] [Accepted: 08/11/2014] [Indexed: 12/22/2022]
Abstract
PURPOSE Chronic hemorrhagic radiation proctopathy is not uncommon after radiotherapy for cervical carcinoma. The outcomes of several treatments have been variable. Many studies demonstrate that topical treatment with 4 % formalin is effective and safe. However, a nonrandomized control study showed a high response rate and good tolerance in chronic radiation proctopathy patients treated with 10 % formalin. The optimal concentration of formalin therefore remains unclear. METHODS To compare the effectiveness and safety of 4 and 10 % formalin for the treatment of chronic hemorrhagic radiation proctopathy, a prospective trial was conducted at the Department of Gynecology of the Affiliated Hospital of Binzhou Medical College from January 2009 to December 2012. One hundred and twenty patients with chronic hemorrhagic radiation proctopathy following radiotherapy for cervical carcinoma were recruited and randomized to receive 4 or 10 % formalin. A standard protocol was followed for formalin application. Symptom and rectoscopy scores were evaluated before and at 12 weeks after treatment. RESULTS In the 4 % formalin group, 49 (86.0 %) and 53 (91.4 %) patients showed an improvement in symptom score and rectoscopy score, respectively (P = 0.36). Symptom and rectoscopy scores decreased significantly after treatment in both the 4 % formalin group and the 10 % formalin group (P < 0.001). Symptom score was correlated with rectoscopy score (P < 0.001). More patients in the 10 % group suffered treatment-related complications than did those in the 4 % group (P = 0.03). CONCLUSIONS For the treatment of chronic hemorrhagic radiation proctopathy, 4 % should be the preferred formalin concentration.
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Affiliation(s)
- Guang-Hong Guo
- Department of Gynecology, Affiliated Hospital of Binzhou Medical College, No. 661, Yellow-River Second Street, Binzhou, 256600, China,
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Tharavichtikul E, Meungwong P, Chitapanarux T, Chakrabandhu S, Klunklin P, Onchan W, Wanwilairat S, Traisathit P, Galalae R, Chitapanarux I. The association of rectal equivalent dose in 2 Gy fractions (EQD2) to late rectal toxicity in locally advanced cervical cancer patients who were evaluated by rectosigmoidoscopy in Faculty of Medicine, Chiang Mai University. Radiat Oncol J 2014; 32:57-62. [PMID: 25061573 PMCID: PMC4104220 DOI: 10.3857/roj.2014.32.2.57] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2014] [Revised: 04/04/2014] [Accepted: 05/22/2014] [Indexed: 11/17/2022] Open
Abstract
Purpose To evaluate association between equivalent dose in 2 Gy (EQD2) to rectal point dose and gastrointestinal toxicity from whole pelvic radiotherapy (WPRT) and intracavitary brachytherapy (ICBT) in cervical cancer patients who were evaluated by rectosigmoidoscopy in Faculty of Medicine, Chiang Mai University. Materials and Methods Retrospective study was designed for the patients with locally advanced cervical cancer, treated by radical radiotherapy from 2004 to 2009 and were evaluated by rectosigmoidoscopy. The cumulative doses of WPRT and ICBT to the maximally rectal point were calculated to the EQD2 and evaluated the association of toxicities. Results Thirty-nine patients were evaluated for late rectal toxicity. The mean cumulative dose in term of EQD2 to rectum was 64.2 Gy. Grade 1 toxicities were the most common findings. According to endoscopic exam, the most common toxicities were congested mucosa (36 patients) and telangiectasia (32 patients). In evaluation between rectal dose in EQD2 and toxicities, no association of cumulative rectal dose to rectal toxicity, except the association of cumulative rectal dose in EQD2 >65 Gy to late effects of normal tissue (LENT-SOMA) scale ≥ grade 2 (p = 0.022; odds ratio, 5.312; 95% confidence interval, 1.269-22.244). Conclusion The cumulative rectal dose in EQD2 >65 Gy have association with ≥ grade 2 LENT-SOMA scale.
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Affiliation(s)
- Ekkasit Tharavichtikul
- Division of Therapeutic Radiology and Oncology, Department of Radiology, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | | | - Taned Chitapanarux
- Department of Medicine, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Somvilai Chakrabandhu
- Division of Therapeutic Radiology and Oncology, Department of Radiology, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Pitchayaponne Klunklin
- Division of Therapeutic Radiology and Oncology, Department of Radiology, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Wimrak Onchan
- Division of Therapeutic Radiology and Oncology, Department of Radiology, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Somsak Wanwilairat
- Division of Therapeutic Radiology and Oncology, Department of Radiology, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Patrinee Traisathit
- Biostatistics and Applied Statistics Laboratory, Department of Statistics, Faculty of Science, Chiang Mai University, Chiang Mai, Thailand
| | - Razvan Galalae
- Faculty of Medicine, Christian-Albrechts University at Kiel, Kiel, Germany
| | - Imjai Chitapanarux
- Division of Therapeutic Radiology and Oncology, Department of Radiology, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
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Uhl M, Herfarth K, Eble MJ, Pinkawa M, van Triest B, Kalisvaart R, Weber DC, Miralbell R, Song DY, DeWeese TL. Absorbable hydrogel spacer use in men undergoing prostate cancer radiotherapy: 12 month toxicity and proctoscopy results of a prospective multicenter phase II trial. Radiat Oncol 2014; 9:96. [PMID: 24758224 PMCID: PMC4016630 DOI: 10.1186/1748-717x-9-96] [Citation(s) in RCA: 57] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2013] [Accepted: 04/15/2014] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Radiation therapy is one of the recommended treatment options for localized prostate cancer. In randomized trials, dose escalation was correlated with better biochemical control but also with higher rectal toxicity. A prospective multicenter phase II study was carried out to evaluate the safety, clinical and dosimetric effects of the hydrogel prostate-rectum spacer. Here we present the 12 months toxicity results of this trial. METHODS Fifty two patients with localized prostate cancer received a transperineal PEG hydrogel injection between the prostate and rectum, and then received IMRT to a dose of 78 Gy. Gastrointestinal and genitourinary toxicity were recorded during treatment and at 3, 6 and 12 months following irradiation by using the RTOG/EORTC criteria. Additionally, proctoscopy was performed 12 months after treatment and the results were scored using the Vienna Rectoscopy Scale (VRS). RESULTS Of the patients treated 39.6% and 12.5% experienced acute Grade 1 and Grade 2 GI toxicity, respectively. There was no Grade 3 or Grade 4 acute GI toxicity experienced in the study. Only 4.3% showed late Grade 1 GI toxicity, and there was no late Grade 2 or greater GI toxicity experienced in the study. A total of 41.7%, 35.4% and 2.1% of the men experienced acute Grade 1, Grade 2 and Grade 3 GU toxicity, respectively. There was no Grade 4 acute GU toxicity experienced in the study. Late Grade 1 and Grade 2 GU toxicity was experienced in 17.0% and 2.1% of the patients, respectively. There was no late Grade 3 or greater GU toxicity experienced in the study. Seventy one percent of the patients had a VRS score of 0, and one patient (2%) had Grade 3 teleangiectasia. There was no evidence of ulceration, stricture or necrosis at 12 months. CONCLUSION The use of PEG spacer gel is a safe and effective method to spare the rectum from higher dose and toxicity.
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Affiliation(s)
- Matthias Uhl
- Department of Radiation Oncology, University of Heidelberg, Im Neuenheimer Feld 400, 69120 Heidelberg, Germany.
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Krol R, Smeenk RJ, van Lin ENJT, Yeoh EEK, Hopman WPM. Systematic review: anal and rectal changes after radiotherapy for prostate cancer. Int J Colorectal Dis 2014; 29:273-83. [PMID: 24150230 DOI: 10.1007/s00384-013-1784-8] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/04/2013] [Indexed: 02/04/2023]
Abstract
PURPOSE Pelvic radiotherapy may lead to changes of anorectal function resulting in incontinence-related complaints. The aim of this study was to systematically review objective findings of late anorectal physiology and mucosal appearance after irradiation for prostate cancer. METHODS MEDLINE, EMBASE, and the Cochrane library were searched. Original articles in which anal function, rectal function, or rectal mucosa were examined ≥3 months after EBRT for prostate cancer were included. RESULTS Twenty-one studies were included with low to moderate quality. Anal resting pressures significantly decreased in 6 of the 9 studies including 277 patients. Changes of squeeze pressure and rectoanal inhibitory reflex were less uniform. Rectal distensibility was significantly impaired after EBRT in 7 of 9 studies (277 patients). In 4 of 9 studies on anal and in 5 of 9 on rectal function, disturbances were associated with urgency, frequent bowel movements or fecal incontinence. Mucosal changes as assessed by the Vienna Rectoscopy Score revealed telangiectasias in 73 %, congestion in 33 %, and ulceration in 4 % of patients in 8 studies including 346 patients, but no strictures or necrosis. Three studies reported mucosal improvement during follow-up. Telangiectasias, particularly multiple, were associated with rectal bleeding. Not all bowel complaints (30 %) were related to radiotherapy. CONCLUSIONS Low to moderate quality evidence indicates that EBRT reduces anal resting pressure, decreases rectal distensibility, and frequently induces telangiectasias of rectal mucosa. Objective changes may be associated with fecal incontinence, urgency, frequent bowel movements, and rectal bleeding, but these symptoms are not always related to radiation damage.
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Affiliation(s)
- Robin Krol
- 455 Department of Gastroenterology and Hepatology, Radboud University Medical Centre, PO Box 9101, 6500 HB, Nijmegen, The Netherlands
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Rao N, Shridhar R, Hoffe SE. Late effects of pelvic radiation for rectal cancer and implications for survivorship. SEMINARS IN COLON AND RECTAL SURGERY 2014. [DOI: 10.1053/j.scrs.2013.09.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
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Is “pelvic radiation disease” always the cause of bowel symptoms following prostate cancer intensity-modulated radiotherapy? Radiother Oncol 2014; 110:278-83. [DOI: 10.1016/j.radonc.2013.11.012] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2012] [Revised: 10/25/2013] [Accepted: 11/09/2013] [Indexed: 01/03/2023]
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Linard C, Busson E, Holler V, Strup-Perrot C, Lacave-Lapalun JV, Lhomme B, Prat M, Devauchelle P, Sabourin JC, Simon JM, Bonneau M, Lataillade JJ, Benderitter M. Repeated autologous bone marrow-derived mesenchymal stem cell injections improve radiation-induced proctitis in pigs. Stem Cells Transl Med 2013; 2:916-27. [PMID: 24068742 DOI: 10.5966/sctm.2013-0030] [Citation(s) in RCA: 70] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
The management of proctitis in patients who have undergone very-high-dose conformal radiotherapy is extremely challenging. The fibrosis-necrosis, fistulae, and hemorrhage induced by pelvic overirradiation have an impact on morbidity. Augmenting tissue repair by the use of mesenchymal stem cells (MSCs) may be an important advance in treating radiation-induced toxicity. Using a preclinical pig model, we investigated the effect of autologous bone marrow-derived MSCs on high-dose radiation-induced proctitis. Irradiated pigs received repeated intravenous administrations of autologous bone marrow-derived MSCs. Immunostaining and real-time polymerase chain reaction analysis were used to assess the MSCs' effect on inflammation, extracellular matrix remodeling, and angiogenesis, in radiation-induced anorectal and colon damages. In humans, as in pigs, rectal overexposure induces mucosal damage (crypt depletion, macrophage infiltration, and fibrosis). In a pig model, repeated administrations of MSCs controlled systemic inflammation, reduced in situ both expression of inflammatory cytokines and macrophage recruitment, and augmented interleukin-10 expression in rectal mucosa. MSC injections limited radiation-induced fibrosis by reducing collagen deposition and expression of col1a2/col3a1 and transforming growth factor-β/connective tissue growth factor, and by modifying the matrix metalloproteinase/TIMP balance. In a pig model of proctitis, repeated injections of MSCs effectively reduced inflammation and fibrosis. This treatment represents a promising therapy for radiation-induced severe rectal damage.
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Affiliation(s)
- Christine Linard
- Institute of Radiological Protection and Nuclear Safety, Fontenay-aux-Roses, France
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Sood S, Ju AW, Wang H, Lei S, Uhm S, Zhang G, Suy S, Carroll J, Lynch J, Dritschilo A, Collins SP. Rectal endoscopy findings following stereotactic body radiation therapy for clinically localized prostate cancer. Radiat Oncol 2013; 8:197. [PMID: 23937800 PMCID: PMC3751769 DOI: 10.1186/1748-717x-8-197] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2013] [Accepted: 08/02/2013] [Indexed: 11/12/2022] Open
Abstract
Background Treating prostate cancer with SBRT could potentially minimize radiation proctitis by reducing high-dose rectal irradiation. In addition, it offers the potential radiobiologic benefits of hypofractionation. This study reports the endoscopic changes and the associated clinical rectal toxicity in these patients. Methods We reviewed the records of patients treated from 2008–2011 for localized prostate cancer who had rectal endoscopy following SBRT. SBRT was delivered either as primary treatment in 5 fractions of 7–7.25 Gy, or as an initial boost in 3 fractions of 6.5 Gy followed by conventionally fractionated radiotherapy to 45–50.4 Gy. Endoscopic changes were graded using the Vienna Rectoscopy Score (VRS). Rectal toxicity was graded via CTCAEv.4. Rectal quality of life (QOL) was assessed via the bowel domain of the EPIC-26 questionnaire. Results Fifty-one patients with a median 23 months follow-up were analyzed. Thirty-five patients completed SBRT monotherapy and 16 patients received SBRT as a boost to conventionally fractionated IMRT. The median interval from SBRT to rectal endoscopy was 13 months. Endoscopy revealed VRS Grade 1–2 telangiectasias for 10 patients and VRS Grade 1–2 mucosal edema for 12 patients. No rectal ulcerations, strictures or necrosis were observed. Grade 1–2 late rectal bleeding occurred in 10 patients. There were no CTCAEv.4 Grade ≥3 toxicities. Mean EPIC bowel scores decreased from a baseline value of 96.9 to 82.3 at 1-month, but subsequently increased to 91.0 at 24 months. Conclusions In this cohort that is skewed towards patients with rectal complaints, the rate and severity of endoscopic changes following SBRT is low. Rectal toxicity and QOL were comparable to patients treated with other radiation modalities. Prospective trials examining the endoscopic outcomes following SBRT for prostate cancer are needed for confirmation of the findings of this study. Trial registration The Georgetown Institutional Review Board has approved this retrospective study (IRB 2009–510).
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