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Ching L, Bourne M, Kearney T, Choudhury K, Zwart AL, Danner MT, Suy S, Esposito G, Collins S. Distinguishing Physiological Ureter Uptake From an Involved Lymph Node in Staging Prostate-Specific Membrane Antigen (PSMA) Scans: Implications for Radiation Planning. Cureus 2024; 16:e63105. [PMID: 39055460 PMCID: PMC11271162 DOI: 10.7759/cureus.63105] [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] [Accepted: 06/24/2024] [Indexed: 07/27/2024] Open
Abstract
Prostate-specific membrane antigen (PSMA) imaging has become a mainstay diagnostic tool in staging unfavorable primary prostate cancer (PC) and identifying sites of recurrence in previously treated PC. One of the biggest pitfalls of PSMA imaging is rapid radionucleotide excretion in the urine via the kidneys, ureters, and bladder. The positron-emission tomography (PET) images obtained show increased radiotracer activity in these structures, which can occlude or even mimic true malignant disease. We describe the diagnostic challenges encountered in differentiating benign versus malignant disease with PSMA scans. A 78-year-old male presented to our outpatient radiation oncology office with high-risk prostate cancer. His medical history was significant for ulcerative colitis (UC). Magnetic resonance imaging (MRI) revealed an enlarged prostate and a Prostate Imaging Reporting and Data System (PI-RADS) class 4 lesion. A subsequent transperineal biopsy confirmed unilateral Gleason 8 adenocarcinoma. A PSMA PET scan was read as increased uptake in the right prostate and a left external iliac node. The patient, having been initially informed of a positive lymph node metastasis, sought a second opinion,resulting in a CT urogram that revealed physiologic ureteral uptake. We were thus able to avoid lymph node radiation and morbidity to the surrounding bowel, already chronically inflamed with ulcerative colitis. This study demonstrates the potential for misinterpretation of PSMA uptake in the ureter as lymph node metastases. We discuss how peri-uretic activity can hinder accurate visualization of pelvic lymph node metastases. This study highlights the need for careful image interpretation of PSMA uptake patterns in order to avoid diagnostic errors and unnecessary radiation to at-risk organs in prostate cancer management.
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Affiliation(s)
- Lauren Ching
- Radiation Oncology, MedStar Georgetown University Hospital, Washington, DC, USA
| | - Matthew Bourne
- Radiology, MedStar Georgetown University Hospital, Washington, DC, USA
| | - Tim Kearney
- Radiation Oncology, MedStar Georgetown University Hospital, Washington, DC, USA
| | - Karbi Choudhury
- Radiation Oncology, MedStar Georgetown University Hospital, Washington, DC, USA
| | - Alan L Zwart
- Radiation Oncology, MedStar Georgetown University Hospital, Washington, DC, USA
| | - Malika T Danner
- Radiation Oncology, MedStar Georgetown University Hospital, Washington, DC, USA
| | - Simeng Suy
- Radiation Oncology, MedStar Georgetown University Hospital, Washington, DC, USA
| | - Giuseppe Esposito
- Nuclear Medicine, MedStar Georgetown University Hospital, Washington, DC, USA
| | - Sean Collins
- Radiation Oncology, MedStar Georgetown University Hospital, Washington, DC, USA
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Isabelle Choi J, Wojcieszynski A, Amos RA, Giap H, Apisarnthanarax S, Ashman JB, Anand A, Perles LA, Williamson T, Ramkumar S, Molitoris J, Simone CB, Chuong MD. PTCOG Gastrointestinal Subcommittee Lower Gastrointestinal Tract Malignancies Consensus Statement. Int J Part Ther 2024; 11:100019. [PMID: 38757077 PMCID: PMC11095104 DOI: 10.1016/j.ijpt.2024.100019] [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: 12/29/2023] [Accepted: 01/02/2024] [Indexed: 05/18/2024] Open
Abstract
Purpose Radiotherapy delivery in the definitive management of lower gastrointestinal (LGI) tract malignancies is associated with substantial risk of acute and late gastrointestinal (GI), genitourinary, dermatologic, and hematologic toxicities. Advanced radiation therapy techniques such as proton beam therapy (PBT) offer optimal dosimetric sparing of critical organs at risk, achieving a more favorable therapeutic ratio compared with photon therapy. Materials and Methods The international Particle Therapy Cooperative Group GI Subcommittee conducted a systematic literature review, from which consensus recommendations were developed on the application of PBT for LGI malignancies. Results Eleven recommendations on clinical indications for which PBT should be considered are presented with supporting literature, and each recommendation was assessed for level of evidence and strength of recommendation. Detailed technical guidelines pertaining to simulation, treatment planning and delivery, and image guidance are also provided. Conclusion PBT may be of significant value in select patients with LGI malignancies. Additional clinical data are needed to further elucidate the potential benefits of PBT for patients with anal cancer and rectal cancer.
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Affiliation(s)
- J. Isabelle Choi
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York, USA
- New York Proton Center, New York, New York, USA
| | | | - Richard A. Amos
- Department of Medical Physics & Biomedical Engineering, University College London, London, UK
| | - Huan Giap
- Medical University of South Carolina, Charleston, South Carolina, USA
| | - Smith Apisarnthanarax
- Department of Radiation Oncology, University of Washington, Seattle, Washington, USA
| | | | - Aman Anand
- Department of Radiation Oncology, Mayo Clinic, Scottsdale, Arizona, USA
| | - Luis A. Perles
- Department of Radiation Physics, UT MD Anderson Cancer Center, Houston, Texas, USA
| | - Tyler Williamson
- Department of Radiation Physics, UT MD Anderson Cancer Center, Houston, Texas, USA
| | | | - Jason Molitoris
- Department of Radiation Oncology, University of Maryland Medical Center, Baltimore, Maryland, USA
| | - Charles B. Simone
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York, USA
- New York Proton Center, New York, New York, USA
| | - Michael D. Chuong
- Department of Radiation Oncology, Miami Cancer Institute, Miami, Florida, USA
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Lynn PB, Cronin C, Rangarajan S, Widmar M. Rectal Cancer and Radiation in Colitis. Clin Colon Rectal Surg 2024; 37:30-36. [PMID: 38188064 PMCID: PMC10769583 DOI: 10.1055/s-0043-1762561] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2024]
Abstract
Inflammatory bowel disease (IBD) is associated with an increased risk of colorectal cancer. When IBD patients develop a rectal cancer, this should be treated with the same oncological principles and guidelines as the general population. Rectal cancer treatment includes surgery, chemotherapy, and radiation therapy (RT). Many IBD patients will require a total proctocolectomy with an ileal-pouch anal anastomosis (IPAA) and others, restoration of intestinal continuity may not be feasible or advisable. The literature is scarce regarding outcomes of IPAA after RT. In the present review, we will summarize the evidence regarding RT toxicity in IBD patients and review surgical strategies and outcomes of IPAA after RT.
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Affiliation(s)
- Patricio B. Lynn
- Division of Colorectal Surgery, Department of General Surgery, New York Presbyterian – Weill-Cornell, New York, New York
| | - Catherine Cronin
- Colorectal Surgery Service, Department of Surgical Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Sriram Rangarajan
- Colorectal Surgery Service, Department of Surgical Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Maria Widmar
- Colorectal Surgery Service, Department of Surgical Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
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Trotta M, Patel KR, Singh S, Verma V, Ryckman J. Safety of Radiation Therapy in Patients With Prostate Cancer and Inflammatory Bowel Disease: A Systematic Review. Pract Radiat Oncol 2023; 13:454-465. [PMID: 37100389 PMCID: PMC10527639 DOI: 10.1016/j.prro.2023.04.006] [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: 02/07/2023] [Revised: 04/11/2023] [Accepted: 04/13/2023] [Indexed: 04/28/2023]
Abstract
PURPOSE Inflammatory bowel disease (IBD) has historically been considered a relative contraindication for pelvic radiation therapy (RT). To date, no systematic review has summarized the toxicity profile of RT for patients with prostate cancer and comorbid IBD. METHODS AND MATERIALS A PRISMA-guided systematic search was conducted on PubMed/Embase for original investigations that reported gastrointestinal (GI; rectal/bowel) toxicity in patients with IBD undergoing RT for prostate cancer. The substantial heterogeneity in patient population, follow-up, and toxicity reporting practices precluded a formal meta-analysis; however, a summary of the individual study-level data and crude pooled rates was described. RESULTS Twelve retrospective studies with 194 patients were included: 5 examined predominantly low-dose-rate brachytherapy (BT) monotherapy, 1 predominantly high-dose-rate BT monotherapy, 3 mixed external beam RT (3-dimensional conformal or intensity modulated RT [IMRT]) + low-dose-rate BT, 1 IMRT + high-dose-rate BT, and 2 stereotactic RT. Among these studies, patients with active IBD, patients receiving pelvic RT, and patients with prior abdominopelvic surgery were underrepresented. In all but 1 publication, the rate of late grade 3+ GI toxicities was <5%. The crude pooled rate of acute and late grade 2+ GI events was 15.3% (n = 27/177 evaluable patients; range, 0%-100%) and 11.3% (n = 20/177 evaluable patients; range, 0%-38.5%), respectively. Crude rates of acute and late grade 3+ GI events were 3.4% (6 cases; range, 0%-23%) and 2.3% (4 cases; range, 0%-15%). CONCLUSIONS Prostate RT in patients with comorbid IBD appears to be associated with low rates of grade 3+ GI toxicity; however, patients must be counseled regarding the possibility for lower-grade toxicities. These data cannot be generalized to the underrepresented subpopulations mentioned above, and individualize decision-making is recommended for those high-risk cases. Several strategies should be considered to minimize the probability of toxicity in this susceptible population, including careful patient selection, minimizing elective (nodal) treatment volumes, using rectal sparing techniques, and employing contemporary RT advancements to minimize exposure to GI organs at risk (eg, IMRT, magnetic resonance imaging-based target delineation, and high-quality daily image guidance).
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Affiliation(s)
- Matthew Trotta
- Department of Radiation Oncology, West Virginia University Cancer Institute, Morgantown, West Virginia
| | - Krishnan R Patel
- Radiation Oncology Branch, National Cancer Institute, National Institutes of Health, Bethesda, Maryland
| | - Sarah Singh
- Department of Radiation Oncology, West Virginia University Cancer Institute, Morgantown, West Virginia
| | - Vivek Verma
- Department of Radiation Oncology, West Virginia University Cancer Institute, Morgantown, West Virginia
| | - Jeffrey Ryckman
- Department of Radiation Oncology, West Virginia University Cancer Institute, Parkersburg, West Virginia.
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Vitamin D Receptor Protects against Radiation-Induced Intestinal Injury in Mice via Inhibition of Intestinal Crypt Stem/Progenitor Cell Apoptosis. Nutrients 2021; 13:nu13092910. [PMID: 34578802 PMCID: PMC8466099 DOI: 10.3390/nu13092910] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2021] [Revised: 08/13/2021] [Accepted: 08/20/2021] [Indexed: 12/13/2022] Open
Abstract
It is urgent to seek new potential targets for the prevention or relief of gastrointestinal syndrome in clinical radiation therapy for cancers. Vitamin D, mediated through the vitamin D receptor (VDR), has been identified as a protective nutrient against ionizing radiation (IR)-induced damage. This study investigated whether VDR could inhibit IR-induced intestinal injury and explored underlying mechanism. We first found that vitamin D induced VDR expression and inhibited IR-induced DNA damage and apoptosis in vitro. VDR was highly expressed in intestinal crypts and was critical for crypt stem/progenitor cell proliferation under physiological conditions. Next, VDR-deficient mice exposed to IR significantly increased DNA damage and crypt stem/progenitor cell apoptosis, leading to impaired intestinal regeneration as well as shorter survival time. Furthermore, VDR deficiency activated the Pmaip1-mediated apoptotic pathway of intestinal crypt stem/progenitor cells in IR-treated mice, whereas inhibition of Pmaip1 expression by siRNA transfection protected against IR-induced cell apoptosis. Therefore, VDR protects against IR-induced intestinal injury through inhibition of crypt stem/progenitor cell apoptosis via the Pmaip1-mediated pathway. Our results reveal the importance of VDR level in clinical radiation therapy, and targeting VDR may be a useful strategy for treatment of gastrointestinal syndrome.
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Lischalk JW, Blacksburg S, Mendez C, Repka M, Sanchez A, Carpenter T, Witten M, Garbus JE, Evans A, Collins SP, Katz A, Haas J. Stereotactic body radiation therapy for the treatment of localized prostate cancer in men with underlying inflammatory bowel disease. Radiat Oncol 2021; 16:126. [PMID: 34243797 PMCID: PMC8267228 DOI: 10.1186/s13014-021-01850-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2021] [Accepted: 06/24/2021] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Historically, IBD has been thought to increase the underlying risk of radiation related toxicity in the treatment of prostate cancer. In the modern era, contemporary radiation planning and delivery may mitigate radiation-related toxicity in this theoretically high-risk cohort. This is the first manuscript to report clinical outcomes for men diagnosed with prostate cancer and underlying IBD curatively treated with stereotactic body radiation therapy (SBRT). METHODS A large institutional database of patients (n = 4245) treated with SBRT for adenocarcinoma of the prostate was interrogated to identify patients who were diagnosed with underlying IBD prior to treatment. All patients were treated with SBRT over five treatment fractions using a robotic radiosurgical platform and fiducial tracking. Baseline IBD characteristics including IBD subtype, pre-SBRT IBD medications, and EPIC bowel questionnaires were reviewed for the IBD cohort. Acute and late toxicity was evaluated using the CTCAE version 5.0. RESULTS A total of 31 patients were identified who had underlying IBD prior to SBRT for the curative treatment of prostate cancer. The majority (n = 18) were diagnosed with ulcerative colitis and were being treated with local steroid suppositories for IBD. No biochemical relapses were observed in the IBD cohort with early follow up. High-grade acute and late toxicities were rare (n = 1, grade 3 proctitis) with a median time to any GI toxicity of 22 months. Hemorrhoidal flare was the most common low-grade toxicity observed (n = 3). CONCLUSION To date, this is one of the largest groups of patients with IBD treated safely and effectively with radiation for prostate cancer and the only review of patients treated with SBRT. Caution is warranted when delivering therapeutic radiation to patients with IBD, however modern radiation techniques appear to have mitigated the risk of GI side effects.
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Affiliation(s)
- Jonathan W Lischalk
- Department of Radiation Oncology, NYCyberKnife at Perlmutter Cancer Center - Manhattan, Perlmutter Cancer Center at New York University Langone Hospital - Long Island, 150 Amsterdam Ave, New York, NY, 11501, USA.
| | - Seth Blacksburg
- Department of Radiation Medicine, Lenox Hill Hospital - Northwell Health, New York, NY, 10075, USA
| | - Christopher Mendez
- Department of Radiation Oncology, NYCyberKnife at Perlmutter Cancer Center - Manhattan, Perlmutter Cancer Center at New York University Langone Hospital - Long Island, 150 Amsterdam Ave, New York, NY, 11501, USA
| | - Michael Repka
- Department of Radiation Oncology, NYCyberKnife at Perlmutter Cancer Center - Manhattan, Perlmutter Cancer Center at New York University Langone Hospital - Long Island, 150 Amsterdam Ave, New York, NY, 11501, USA
| | - Astrid Sanchez
- Department of Radiation Oncology, NYCyberKnife at Perlmutter Cancer Center - Manhattan, Perlmutter Cancer Center at New York University Langone Hospital - Long Island, 150 Amsterdam Ave, New York, NY, 11501, USA
| | - Todd Carpenter
- Department of Radiation Oncology, NYCyberKnife at Perlmutter Cancer Center - Manhattan, Perlmutter Cancer Center at New York University Langone Hospital - Long Island, 150 Amsterdam Ave, New York, NY, 11501, USA
| | - Matthew Witten
- Department of Radiation Oncology, NYCyberKnife at Perlmutter Cancer Center - Manhattan, Perlmutter Cancer Center at New York University Langone Hospital - Long Island, 150 Amsterdam Ave, New York, NY, 11501, USA
| | - Jules E Garbus
- Department of Surgery, New York University Long Island School of Medicine, Mineola, NY, 11501, USA
| | - Andrew Evans
- Department of Radiation Oncology, New York University School of Medicine, New York, NY, USA
| | - Sean P Collins
- Department of Radiation Medicine, Medstar Georgetown University Hospital, Washington, DC, 20007, USA
| | - Aaron Katz
- Department of Urology, New York University Long Island School of Medicine, Mineola, NY, 11501, USA
| | - Jonathan Haas
- Department of Radiation Oncology, NYCyberKnife at Perlmutter Cancer Center - Manhattan, Perlmutter Cancer Center at New York University Langone Hospital - Long Island, 150 Amsterdam Ave, New York, NY, 11501, USA
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Sensi B, Bagaglini G, Bellato V, Cerbo D, Guida AM, Khan J, Panis Y, Savino L, Siragusa L, Sica GS. Management of Low Rectal Cancer Complicating Ulcerative Colitis: Proposal of a Treatment Algorithm. Cancers (Basel) 2021; 13:cancers13102350. [PMID: 34068058 PMCID: PMC8152518 DOI: 10.3390/cancers13102350] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2021] [Revised: 04/29/2021] [Accepted: 05/05/2021] [Indexed: 01/04/2023] Open
Abstract
Simple Summary This article expresses the viewpoint of the authors’ management of low rectal cancer in ulcerative colitis (UC). This subject suffers from a paucity of literature and therefore management decision is very difficult to take. The aim of this paper is to provide a structured approach to a challenging situation. It is subdivided into two parts: a first part where the existing literature is reviewed critically, and a second part in which, on the basis of the literature review and their extensive clinical experience, a management algorithm is proposed by the authors to offer guidance to surgical and oncological practices. This text adds to the literature a useful guide for the treatment of these complex clinical scenarios. Abstract Low rectal Carcinoma arising at the background of Ulcerative Colitis poses significant management challenges to the clinicians. The complex decision-making requires discussion at the multidisciplinary team meeting. The published literature is scarce, and there are significant variations in the management of such patients. We reviewed treatment protocols and operative strategies; with the aim of providing a practical framework for the management of low rectal cancer complicating UC. A practical treatment algorithm is proposed.
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Affiliation(s)
- Bruno Sensi
- Minimally Invasive Surgery, Department of Surgery, Policlinico Tor Vergata, 00133 Rome, Italy; (G.B.); (V.B.); (D.C.); (A.M.G.); (L.S.); (G.S.S.)
- Correspondence: ; Tel.: +39-338-535-2902
| | - Giulia Bagaglini
- Minimally Invasive Surgery, Department of Surgery, Policlinico Tor Vergata, 00133 Rome, Italy; (G.B.); (V.B.); (D.C.); (A.M.G.); (L.S.); (G.S.S.)
| | - Vittoria Bellato
- Minimally Invasive Surgery, Department of Surgery, Policlinico Tor Vergata, 00133 Rome, Italy; (G.B.); (V.B.); (D.C.); (A.M.G.); (L.S.); (G.S.S.)
| | - Daniele Cerbo
- Minimally Invasive Surgery, Department of Surgery, Policlinico Tor Vergata, 00133 Rome, Italy; (G.B.); (V.B.); (D.C.); (A.M.G.); (L.S.); (G.S.S.)
| | - Andrea Martina Guida
- Minimally Invasive Surgery, Department of Surgery, Policlinico Tor Vergata, 00133 Rome, Italy; (G.B.); (V.B.); (D.C.); (A.M.G.); (L.S.); (G.S.S.)
| | - Jim Khan
- Colorectal Surgery Department, Queen Alexandra Hospital, Portsmouth NHS Trust, Portsmouth PO6 3LY, UK;
| | - Yves Panis
- Service de Chirurgie Colorectale, Pôle des Maladies de L’appareil Digestif (PMAD), Université Denis-Diderot (Paris VII), Hôpital Beaujon, Assistance Publique-Hôpitaux de Paris (AP-HP), 100, Boulevard du Général-Leclerc, 92110 Clichy, France;
| | - Luca Savino
- Pathology, Department of Biomedicine and Prevention, Policlinico Tor Vergata, 00133 Rome, Italy;
| | - Leandro Siragusa
- Minimally Invasive Surgery, Department of Surgery, Policlinico Tor Vergata, 00133 Rome, Italy; (G.B.); (V.B.); (D.C.); (A.M.G.); (L.S.); (G.S.S.)
| | - Giuseppe S. Sica
- Minimally Invasive Surgery, Department of Surgery, Policlinico Tor Vergata, 00133 Rome, Italy; (G.B.); (V.B.); (D.C.); (A.M.G.); (L.S.); (G.S.S.)
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Babar M, Katz A, Ciatto M. Dosimetric and clinical outcomes of SpaceOAR in men undergoing external beam radiation therapy for localized prostate cancer: A systematic review. J Med Imaging Radiat Oncol 2021; 65:384-397. [PMID: 33855816 DOI: 10.1111/1754-9485.13179] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2020] [Revised: 03/08/2021] [Accepted: 03/11/2021] [Indexed: 12/30/2022]
Abstract
SpaceOAR, an absorbable polyethylene glycol hydrogel, increases the space between the prostate and rectum to reduce the radiation received by the rectum during prostate cancer radiation therapy. The objective of this systematic review was to evaluate controlled studies on the dosimetric and clinical outcomes of SpaceOAR in men undergoing external beam radiation therapy for localized prostate cancer. Eight studies were included in the review. All of the studies showed SpaceOAR to reduce the radiation dose volume to the rectum over numerous dosimetry levels. Of the four studies that assessed toxicity, one reported SpaceOAR to significantly decrease acute Grade 1 diarrhoea and two reported SpaceOAR to significantly decrease late Grade 1 and Grade ≥2 rectal toxicities. Two studies assessed cumulative incidence of toxicity at 3 years in which one reported SpaceOAR to significantly decrease urinary incontinence and Grade ≥1 and Grade ≥2 rectal toxicities, and the other reported SpaceOAR to significantly decrease Grade 1 diarrhoea and Grade 2 proctitis. Moreover, one study reported that fewer SpaceOAR patients experienced 10-point declines in bowel quality of life at 3 years, but another study reported no significant difference in 10-point declines in bowel quality of life between the SpaceOAR and control groups at 5 years. With the current research available, SpaceOAR may be beneficial to those who did not meet the standard rectal dose-volume criteria, have higher risk factors of developing rectal toxicities post-radiation, or wish to decrease the length and costs of radiotherapy by increasing the dose of radiation per fraction.
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Affiliation(s)
| | - Alan Katz
- St. Francis Hospital, Roslyn, NY, USA
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Challenges in Crohn's Disease Management after Gastrointestinal Cancer Diagnosis. Cancers (Basel) 2021; 13:cancers13030574. [PMID: 33540674 PMCID: PMC7867285 DOI: 10.3390/cancers13030574] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2020] [Revised: 01/25/2021] [Accepted: 01/29/2021] [Indexed: 12/14/2022] Open
Abstract
Simple Summary Crohn’s disease (CD) is a chronic inflammatory bowel disease affecting both young and elderly patients, involving the entire gastrointestinal tract from the mouth to anus. The chronic transmural inflammation can lead to several complications, among which gastrointestinal cancers represent one of the most life-threatening, with a higher risk of onset as compared to the general population. Moreover, diagnostic and therapeutic strategies in this subset of patients still represent a significant challenge for physicians. Thus, the aim of this review is to provide a comprehensive overview of the current evidence for an adequate diagnostic pathway and medical and surgical management of CD patients after gastrointestinal cancer onset. Abstract Crohn’s disease (CD) is a chronic inflammatory bowel disease with a progressive course, potentially affecting the entire gastrointestinal tract from mouth to anus. Several studies have shown an increased risk of both intestinal and extra-intestinal cancer in patients with CD, due to long-standing transmural inflammation and damage accumulation. The similarity of symptoms among CD, its related complications and the de novo onset of gastrointestinal cancer raises difficulties in the differential diagnosis. In addition, once a cancer diagnosis in CD patients is made, selecting the appropriate treatment can be particularly challenging. Indeed, both surgical and oncological treatments are not always the same as that of the general population, due to the inflammatory context of the gastrointestinal tract and the potential exacerbation of gastrointestinal symptoms of patients with CD; moreover, the overlap of the neoplastic disease could lead to adjustments in the pharmacological treatment of the underlying CD, especially with regard to immunosuppressive drugs. For these reasons, a case-by-case analysis in a multidisciplinary approach is often appropriate for the best diagnostic and therapeutic evaluation of patients with CD after gastrointestinal cancer onset.
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Should inflammatory bowel disease be a contraindication to radiation therapy: a systematic review of acute and late toxicities. JOURNAL OF RADIOTHERAPY IN PRACTICE 2020. [DOI: 10.1017/s1460396920000783] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
AbstractBackground:Inflammatory bowel disease (IBD) [i.e., Crohn’s disease (CD) and ulcerative colitis (UC)] has been considered a relative contraindication for radiation therapy (RT) to the abdomen or pelvis, potentially preventing patients with a diagnosis of IBD from receiving definitive therapy for their malignancy.Method:Using Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) conventions, a PubMed/MEDLINE literature search was conducted using the keywords RT, brachytherapy, inflammatory bowel disease, Crohn’s disease, ulcerative colitis and toxicity.Results:A total of 1,206 publications were screened with an addition of 8 studies identified through hand searching. Nineteen studies met the inclusion criteria for quantitative analysis. The total population across all studies was 497 patients, 50·5% having UC, 37% having CD and an additional 12·5% having unspecified IBD. Primary gastrointestinal malignancy (55%) followed by prostate cancer (40%) composed the bulk of the population. Acute and late grade 3 or greater gastrointestinal specific toxicity ranged from 0–23% to 0–13% respectively for those patients with IBD treated with RT to the abdomen or pelvis. In the literature reviewed, RT does not appear to increase fistula or stricture formation or IBD flares; however, one study did note RT to be a statistically significant risk factor for subsequent IBD flare on multivariate analysis.Conclusions:A review of reported acute and late toxicities suggests that patients with IBD should still be considered for definitive radiotherapy. Patient characteristics including IBD distribution relative to the irradiated field, inflammatory activity at the time of radiation, overall disease severity and disease phenotype in the case of CD (fistulising versus stricturing versus inflammatory only) should be considered on an individual basis when evaluating potential patients. When possible, advanced techniques with strict organ at risk dose constraints should be employed to limit toxicity in this patient population.
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Kim J, Feagins LA. Managing Patients with Inflammatory Bowel Disease Who Develop Prostate Cancer. Dig Dis Sci 2020; 65:22-30. [PMID: 31713121 DOI: 10.1007/s10620-019-05934-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2019] [Accepted: 11/01/2019] [Indexed: 02/06/2023]
Abstract
Prostate cancer is the most common cancer among men in the USA. Interestingly, recent studies suggest that patients with inflammatory bowel disease (IBD) are at increased risk of developing prostate cancer. Importantly, patients with IBD who develop prostate cancer require thoughtful care when using immunosuppressants to treat the IBD in the setting of malignancy. Further, consideration must be given to the proximity of the prostate to the gastrointestinal tract when treating with radiation where there is concern for the effects of inadvertent exposure of radiation to the diseased bowel. In general, management of immunosuppression after diagnosis of prostate cancer is contingent on the specific immunosuppressive agents, the duration of cancer remission and/or plans for cancer treatment, and the potential risks and benefits of stopping or altering the administration of those agents. Concerns that patients with IBD would have increased risk of disease exacerbation and gastrointestinal toxicity have previously limited the use of radiation. While currently no consensus has been reached regarding the safety of radiation therapy in patients with IBD, recent studies suggest that radiation therapy may be used safely in patients with IBD who develop prostate cancer, especially brachytherapy and intensity-modulated radiation therapy which may have less bowel toxicity compared to conventional methods of external beam radiation therapy. A multidisciplinary team approach including gastroenterologists, urologists, radiation oncologists, and medical oncologists should be undertaken to best treat patients with IBD and prostate cancer.
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Affiliation(s)
- Jaehyun Kim
- Department of Medicine, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Linda A Feagins
- Department of Internal Medicine, Dell Medical School, University of Texas at Austin, Z0900, 1601 Trinity Street, Building B, Austin, TX, 78712, USA.
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Sanmamed N, Glicksman RM, Helou J, Chung P, Berlin A. Case series illustrating the synergistic use of hydrogel spacer and MR-guidance to increase the radiotherapeutic index for localized prostate cancer. Tech Innov Patient Support Radiat Oncol 2019; 11:22-25. [PMID: 32095546 PMCID: PMC7033779 DOI: 10.1016/j.tipsro.2019.08.002] [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: 02/05/2019] [Revised: 07/24/2019] [Accepted: 08/30/2019] [Indexed: 12/13/2022] Open
Abstract
Polyethylene glycol hydrogel spacer allows radiotherapy in challenging scenarios. Polyethylene glycol hydrogel material properties may limit broader applicability. MRI-guided brachytherapy unique scenario to use PEG without compromising prostate resolution.
Background The risk of gastrointestinal (GI) toxicity may limit the use of curative-intent radical radiotherapy (RT) for prostate cancer (PCa) in circumstances where morbidity of treatment may exceed an acceptable threshold. Rectal spacers are used to expand the distance between the anterior rectal wall and the prostate, consequently sparing the rectum from the high-dose region. Case presentations We report three clinical scenarios of PCa patients treated at our institution, where risk of RT-associated rectal toxicity may be increased: inflammatory bowel disease (IBD), salvage brachytherapy (BT) after previous external beam RT (EBRT), and tailored dose-escalation with focal BT to the gross tumor volume followed by stereotactic body RT. Prior to RT, a polyethylene glycol (PEG) hydrogel spacer was successfully placed in all cases. Treatment comprised magnetic resonance (MR) guided high dose-rate BT ± EBRT. All patients completed treatment uneventfully, without any significant GI toxicity at last follow-up. Conclusions These cases illustrate the utility of PEG hydrogel spacer, where concerns of radiation induced toxicity may have previously limited the application of radiotherapy. The synergistic use of these novel devices together with MR-guided BT may expand the indications and therapeutic index of curative-intent RT-based treatments, while minimizing the risks of GI toxicity.
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Affiliation(s)
- Noelia Sanmamed
- Department of Radiation Oncology, University of Toronto, Canada.,Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, Canada
| | | | - Joelle Helou
- Department of Radiation Oncology, University of Toronto, Canada.,Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, Canada
| | - Peter Chung
- Department of Radiation Oncology, University of Toronto, Canada.,Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, Canada
| | - Alejandro Berlin
- Department of Radiation Oncology, University of Toronto, Canada.,Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, Canada.,Techna Institute, University Health Network, Canada
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13
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Lee C, Choi C, Kang HS, Shin SW, Kim SY, Park HC, Hong SN. NOD2 Supports Crypt Survival and Epithelial Regeneration after Radiation-Induced Injury. Int J Mol Sci 2019; 20:ijms20174297. [PMID: 31480799 PMCID: PMC6747113 DOI: 10.3390/ijms20174297] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2019] [Revised: 06/21/2019] [Accepted: 06/25/2019] [Indexed: 01/30/2023] Open
Abstract
Nucleotide-binding oligomerization domain-containing protein 2 (NOD2) affords stem cell protection and links microbes to intestinal epithelial regeneration. We investigated whether NOD2 status is associated with crypt survival and intestinal epithelial regeneration independent of microbiota-derived molecules. To assess crypt survival, a clonogenic microcolony assay was performed with 15 Gy of X-ray irradiation. The fractional crypt survival rate (46.0 ± 15.5% vs. 24.7 ± 9.2%, p < 0.01) and fractional EdU-positive crypt survival rate (29.8 ± 14.5% vs. 9.79 ± 4.37%, p = 0.015) were significantly decreased in the NOD2−/− mice compared with the wild-type (WT) mice at 3.5 days after irradiation. To evaluate intestinal epithelial regeneration capability, organoid reconstitution assays were performed. Small bowel crypts of the WT and NOD2−/− mice were isolated and seeded into Matrigel for 3D culture. In the organoid reconstitution assays, the number of organoids formed did not differ between the NOD2−/− and WT mice. Organoid formation ability was also assessed after exposure to 5 Gy irradiation. Organoid formation ability was significantly decreased in the NOD2−/− mice compared with the WT ones after exposure to 5 Gy irradiation (33.2 ± 5.9 vs. 19.7 ± 8.8/well, p < 0.01). NOD2 supports crypt survival after potentially lethal irradiation damage and is associated with intestinal epithelial regeneration.
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Affiliation(s)
- Chansu Lee
- Department of Medicine, Samsung Medical Center, Sungkyunwan University School of Medicine, Seoul 06351, Korea
| | - Changhoon Choi
- Department of Radiation Oncology, Samsung Medical Center, Seoul 06351, Korea
| | - Ho Suk Kang
- Department of Internal Medicine, Hallym University Medical Center, Anyang-si, Gyeonggi-do 14068, Korea
| | - Sung-Won Shin
- Department of Radiation Oncology, Samsung Medical Center, Seoul 06351, Korea
- Department of Radiation Oncology, Sungkyunwan University School of Medicine, Seoul 06351, Korea
| | - Shin-Yeong Kim
- Department of Radiation Oncology, Samsung Medical Center, Seoul 06351, Korea
| | - Hee Chul Park
- Department of Radiation Oncology, Samsung Medical Center, Seoul 06351, Korea.
- Department of Radiation Oncology, Sungkyunwan University School of Medicine, Seoul 06351, Korea.
| | - Sung Noh Hong
- Department of Medicine, Samsung Medical Center, Sungkyunwan University School of Medicine, Seoul 06351, Korea.
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Lehrich B, Moyses H, Kawakubo A, Ravera J, Barnes L, Mesa A, Tokita K. Long-Term Toxicity of High Dose Rate Brachytherapy in Prostate Carcinoma Patients With Inflammatory Bowel Disease. Clin Oncol (R Coll Radiol) 2019; 31:399-400. [DOI: 10.1016/j.clon.2019.01.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2018] [Accepted: 01/31/2019] [Indexed: 10/27/2022]
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15
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Rehailia-Blanchard A, He M, Rancoule C, Vallard A, Espenel S, Nivet A, Magné N, Chargari C. Physiopathologie et modulation pharmacologique de l’entérite radique. Cancer Radiother 2019; 23:240-247. [DOI: 10.1016/j.canrad.2018.05.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2018] [Revised: 05/07/2018] [Accepted: 05/11/2018] [Indexed: 01/28/2023]
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16
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Lin D, Lehrer EJ, Rosenberg J, Trifiletti DM, Zaorsky NG. Toxicity after radiotherapy in patients with historically accepted contraindications to treatment (CONTRAD): An international systematic review and meta-analysis. Radiother Oncol 2019; 135:147-152. [DOI: 10.1016/j.radonc.2019.03.006] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2019] [Revised: 03/07/2019] [Accepted: 03/07/2019] [Indexed: 10/27/2022]
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17
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SpaceOAR to improve dosimetric outcomes for monotherapy high-dose-rate prostate implantation in a patient with ulcerative colitis. J Contemp Brachytherapy 2018; 10:577-582. [PMID: 30662483 PMCID: PMC6335554 DOI: 10.5114/jcb.2018.81001] [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: 05/08/2018] [Accepted: 11/28/2018] [Indexed: 12/12/2022] Open
Abstract
High-dose-rate (HDR) brachytherapy is an attractive option for patients receiving definitive radiation therapy for prostate cancer with decreased overall dose to the pelvis. However, ulcerative colitis increases rectal toxicity risk and may be a contraindication. A synthetic hydrogel, SpaceOAR (Augmentix Inc., Waltham, MA, USA), can facilitate the use of HDR brachytherapy for patients where rectal toxicity is a limiting factor. SpaceOAR gel (13.19 cc) was utilized in a monotherapy HDR prostate treatment with Ir-192 under transrectal ultrasound guidance, with the intention of decreasing rectal dose. SpaceOAR gel was inserted transperineally into the patient 18 days prior to the procedure. The HDR brachytherapy procedure was tolerated without incident. All planning constraints were met, and the following dosimetry was achieved: Prostate - V100% = 97.3%, V150% = 35%, V200% = 14.5%; Urethra - V118% = 0%; Rectum - D2 cc = 51.6%, V75% = 0 cc. The rectum-catheter spacing was on average between 6-8 mm. Average spacing for our 10 most recent patients without SpaceOAR was 3 mm. SpaceOAR did not hinder or distort ultrasound imaging or increase treatment time. SpaceOAR successfully increases catheter-rectal wall spacing and decreases rectal dose due to improved planning capabilities, while decreasing the likelihood of rectal perforation. One application of this tool is presented to mitigate potential toxicities associated with ulcerative colitis. At five months, one week, and one day follow-up, the patient reported no bowel issues following HDR brachytherapy.
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18
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Jmour O, Pellat A, Colson-Durand L, To NH, Latorzeff I, Sargos P, Sobhani I, Belkacemi Y. [Radiation therapy in patients with inflammatory bowel disease. A review]. Bull Cancer 2018; 105:517-522. [PMID: 29653817 DOI: 10.1016/j.bulcan.2018.02.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2017] [Revised: 02/04/2018] [Accepted: 02/20/2018] [Indexed: 02/07/2023]
Abstract
Inflammatory bowel disease (IBD), including Crohn's disease and ulcerative colitis, are multifactorial diseases characterized by a chronic intestinal inflammation. Abdominal and pelvic irradiation can result in acute or chronic digestive toxicity. A few old studies on small population samples have suggested an increase of gastro-intestinal toxicities in patients with IBD in case of irradiation. Nevertheless, the physiopathology is unknown. More recent studies, including new irradiation techniques, have shown less toxicity events in these patients with IBD. There are no recommendations for irradiation in patients with IBD. This review aims to report recent data on this topic and discuss them regarding radiation parameters.
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Affiliation(s)
- Omar Jmour
- Université Paris Est Créteil (UPEC), AP-HP, hôpitaux universitaires Henri-Mondor, service d'oncologie-radiothérapie & centre sein Henri-Mondor, 51, avenue du Maréchal-de-Lattre-de-Tassigny, 94010 Créteil, France
| | - Anna Pellat
- Université Paris Est Créteil (UPEC), AP-HP, hôpitaux universitaires Henri-Mondor, service d'oncologie-radiothérapie & centre sein Henri-Mondor, 51, avenue du Maréchal-de-Lattre-de-Tassigny, 94010 Créteil, France
| | - Laurianne Colson-Durand
- Université Paris Est Créteil (UPEC), AP-HP, hôpitaux universitaires Henri-Mondor, service d'oncologie-radiothérapie & centre sein Henri-Mondor, 51, avenue du Maréchal-de-Lattre-de-Tassigny, 94010 Créteil, France
| | - Nhu Hanh To
- Université Paris Est Créteil (UPEC), AP-HP, hôpitaux universitaires Henri-Mondor, service d'oncologie-radiothérapie & centre sein Henri-Mondor, 51, avenue du Maréchal-de-Lattre-de-Tassigny, 94010 Créteil, France; Inserm unité 955 EQ 07, 94010 Créteil, France
| | - Igor Latorzeff
- Clinique Pasteur, département de radiothérapie, 45, avenue de Lombez, BP 27617, 31300 Toulouse, France
| | - Paul Sargos
- Institut Bergonié, département de radiothérapie, 229, cours de l'Argonne, 33000 Bordeaux, France
| | - Iradj Sobhani
- AP-HP, université Paris Est Créteil (UPEC), hôpitaux universitaires Henri-Mondor, service de gastro-entérologie, 51, avenue du Maréchal-de-Lattre-de-Tassigny, 94010 Créteil, France
| | - Yazid Belkacemi
- Université Paris Est Créteil (UPEC), AP-HP, hôpitaux universitaires Henri-Mondor, service d'oncologie-radiothérapie & centre sein Henri-Mondor, 51, avenue du Maréchal-de-Lattre-de-Tassigny, 94010 Créteil, France; Inserm unité 955 EQ 07, 94010 Créteil, France.
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19
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Vanneste BGL, Van Limbergen EJ, van de Beek K, van Lin E, Lutgens L, Lambin P. A biodegradable rectal balloon implant to protect the rectum during prostate cancer radiotherapy for a patient with active Crohn's disease. Tech Innov Patient Support Radiat Oncol 2018; 6:1-4. [PMID: 32095571 PMCID: PMC7033750 DOI: 10.1016/j.tipsro.2018.01.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2017] [Accepted: 01/26/2018] [Indexed: 12/22/2022] Open
Abstract
Active inflammatory bowel disease is an exclusion criterion for high-dose radiotherapy. A rectum spacer was inserted between the prostate and the rectal wall. The rectum spacer pushes the rectum outside of the high-dose area. No rectal toxicity of the radiotherapy or toxicity flare of the IBD was observed.
Background Radiotherapy in patients with active inflammatory bowel disease (IBD) is usually considered an absolute exclusion criterion for prostate cancer radiotherapy treatment. There are no reports available on the use of a biodegradable rectal balloon implantation (RBI) in patients with active IBD for prostate cancer radiotherapy. Case presentation We report on a patient with high-risk prostate cancer with the comorbidity of an active IBD with pancolitis location. He was treated with neo-adjuvant hormonal therapy and high-dose external beam radiotherapy to the prostate and the seminal vesicles. Before radiotherapy treatment, a biodegradable RBI was implanted between the prostate and the anterior rectal wall to push the rectum outside of the high-dose area. This patient at high-risk for rectal toxicity was successfully irradiated to his prostate with only a grade I urinary toxicity, no acute rectal toxicity or toxicity flare of the IBD. Conclusions This case describes the use of a RBI implantation in patients with active IBD for prostate cancer radiotherapy. The use of a biodegradable RBI proved to be a promised solution for such patients, and have to be further investigated.
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Affiliation(s)
- Ben G L Vanneste
- Department of Radiation Oncology (MAASTRO), GROW - School for Oncology and Developmental Biology, Maastricht University Medical Center+, Maastricht, The Netherlands
| | - Evert J Van Limbergen
- Department of Radiation Oncology (MAASTRO), GROW - School for Oncology and Developmental Biology, Maastricht University Medical Center+, Maastricht, The Netherlands
| | - Kees van de Beek
- Department of Urology, Maastricht University Medical Center+, Maastricht, The Netherlands
| | | | - Ludy Lutgens
- Department of Radiation Oncology (MAASTRO), GROW - School for Oncology and Developmental Biology, Maastricht University Medical Center+, Maastricht, The Netherlands
| | - Philippe Lambin
- Department of Radiation Oncology (MAASTRO), GROW - School for Oncology and Developmental Biology, Maastricht University Medical Center+, Maastricht, The Netherlands
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20
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Bosch SL, van Rooijen SJ, Bökkerink GMJ, Braam HJW, Derikx LAAP, Poortmans P, Marijnen CAM, Nagtegaal ID, de Wilt JHW. Acute toxicity and surgical complications after preoperative (chemo)radiation therapy for rectal cancer in patients with inflammatory bowel disease. Radiother Oncol 2017; 123:147-153. [PMID: 28291546 DOI: 10.1016/j.radonc.2017.02.009] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2016] [Revised: 02/16/2017] [Accepted: 02/19/2017] [Indexed: 02/07/2023]
Abstract
PURPOSE Preoperative therapy reduces local recurrences and may facilitate surgery in rectal cancer patients. However, in patients with inflammatory bowel disease (IBD) this treatment is often withheld due to the perceived risk of excessive side-effects, even though evidence is limited. The purpose of this study is to investigate the effects of preoperative therapy on acute toxicity and post-operative complications in IBD patients with rectal cancer. METHODS The Dutch pathology registry (PALGA) was searched for patients with IBD and rectal cancer treated between January 1991 and May 2010. Histopathology and clinical charts were reviewed to confirm IBD diagnosis and evaluate clinical and pathological characteristics. RESULTS Out of 161 patients, 66 received preoperative therapy (41%), including short-course radiation therapy (SC-RT), long course radiation therapy (LC-RT), and chemoradiation therapy (CRT) in 32, 13, and 21 patients respectively. Grade≥3 acute toxicity occurred in 0 patients (0.0%), 1 patient (7.7%), and 6 patients (28.6%) respectively (p=0.004). Systemic corticosteroids were used by 10.5% of patients at time of treatment. Grade≥3 post-operative 30-day complication rate (28.1% overall) was not associated with type of preoperative therapy. CONCLUSION Results did not show excessive rates of toxicity or post-operative complications and support the use of standard preoperative therapies for rectal cancer (especially SC-RT) in IBD patients with relatively indolent disease. Caution is warranted in patients with active IBD, since the exact impact of active bowel inflammation could not be determined retrospectively. Prospective studies should investigate the influence of active IBD on acute and late toxicity in patients receiving pelvic irradiation.
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Affiliation(s)
- Steven L Bosch
- Department of Pathology, Radboud University Medical Center, Nijmegen, The Netherlands.
| | - Stefan J van Rooijen
- Department of Surgery, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Guus M J Bökkerink
- Department of Surgery, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Hidde J W Braam
- Department of Surgery, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Lauranne A A P Derikx
- Department of Gastroenterology and Hepatology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Philip Poortmans
- Department of Radiation Oncology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Corrie A M Marijnen
- Department of Radiation Oncology, Leiden University Medical Center, The Netherlands
| | - Iris D Nagtegaal
- Department of Pathology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Johannes H W de Wilt
- Department of Surgery, Radboud University Medical Center, Nijmegen, The Netherlands
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Annede P, Seisen T, Klotz C, Mazeron R, Maroun P, Petit C, Deutsch E, Bossi A, Haie-Meder C, Chargari C, Blanchard P. Inflammatory bowel diseases activity in patients undergoing pelvic radiation therapy. J Gastrointest Oncol 2017; 8:173-179. [PMID: 28280621 DOI: 10.21037/jgo.2017.01.13] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Few studies with contradictory results have been published on the safety of pelvic radiation therapy (RT) in patients with inflammatory bowel disease (IBD). METHODS From 1989 to 2015, a single center retrospective analysis was performed including all IBD patients who received pelvic external beam radiation therapy (EBRT) or brachytherapy (BT) for a pelvic malignancy. Treatment characteristics, IBD activity and gastrointestinal (GI) toxicity were examined. RESULTS Overall, 28 patients with Crohn's disease (CD) (n=13) or ulcerative colitis (n=15) were included in the present study. Median follow-up time after irradiation was 5.9 years. Regarding IBD activity, only one and two patients experienced a severe episode within and after 6 months of follow-up, respectively. Grade 3/4 acute GI toxicity occurred in 3 (11%) patients, whereas one (3.6%) patient experienced late grade 3/4 GI toxicity. Only patients with rectal IBD location (P=0.016) or low body mass index (BMI) (P=0.012) experienced more severe IBD activity within or after 6 months following RT, respectively. CONCLUSIONS We report an acceptable tolerance of RT in IBD patients with pelvic malignancies. Specifically, a low risk of uncontrolled flare-up was observed.
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Affiliation(s)
- Pierre Annede
- Brachytherapy Unit, Gustave Roussy, Villejuif, France;; Department of Radiotherapy Department, Gustave Roussy, Villejuif, France
| | - Thomas Seisen
- Brachytherapy Unit, Gustave Roussy, Villejuif, France;; Department of Radiotherapy Department, Gustave Roussy, Villejuif, France
| | - Caroline Klotz
- Department of Medical Oncology, Gustave Roussy, Villejuif, France
| | - Renaud Mazeron
- Brachytherapy Unit, Gustave Roussy, Villejuif, France;; Department of Radiotherapy Department, Gustave Roussy, Villejuif, France;; INSERM1030, Gustave Roussy Cancer Campus, Villejuif, France
| | - Pierre Maroun
- Brachytherapy Unit, Gustave Roussy, Villejuif, France;; Department of Radiotherapy Department, Gustave Roussy, Villejuif, France;; INSERM1030, Gustave Roussy Cancer Campus, Villejuif, France
| | - Claire Petit
- Brachytherapy Unit, Gustave Roussy, Villejuif, France;; Department of Radiotherapy Department, Gustave Roussy, Villejuif, France
| | - Eric Deutsch
- Department of Radiotherapy Department, Gustave Roussy, Villejuif, France;; INSERM1030, Gustave Roussy Cancer Campus, Villejuif, France;; Department of Molecular Radiotherapy, University Paris-Sud, SIRIC SOCRATES, Faculté de Médecine, Le Kremlin-Bicetre, France
| | - Alberto Bossi
- Brachytherapy Unit, Gustave Roussy, Villejuif, France;; Department of Radiotherapy Department, Gustave Roussy, Villejuif, France
| | - Christine Haie-Meder
- Brachytherapy Unit, Gustave Roussy, Villejuif, France;; Department of Radiotherapy Department, Gustave Roussy, Villejuif, France
| | - Cyrus Chargari
- Brachytherapy Unit, Gustave Roussy, Villejuif, France;; Department of Radiotherapy Department, Gustave Roussy, Villejuif, France;; INSERM1030, Gustave Roussy Cancer Campus, Villejuif, France;; NRBC Department, Institut de Recherche Biomédicale des Armées, Bretigny-sur-Orge, France
| | - Pierre Blanchard
- Brachytherapy Unit, Gustave Roussy, Villejuif, France;; Department of Radiotherapy Department, Gustave Roussy, Villejuif, France;; INSERM1030, Gustave Roussy Cancer Campus, Villejuif, France
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Gestaut MM, Swanson GP. Long term clinical toxicity of radiation therapy in prostate cancer patients with Inflammatory Bowel Disease. Rep Pract Oncol Radiother 2017; 22:77-82. [PMID: 27920612 PMCID: PMC5126147 DOI: 10.1016/j.rpor.2016.10.005] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2016] [Revised: 08/05/2016] [Accepted: 10/21/2016] [Indexed: 11/19/2022] Open
Abstract
AIM The study's aim was to examine the clinical impact of radiation therapy (RT) on GI toxicity in Inflammatory Bowel Disease (IBD) patients. BACKGROUND IBD has long been considered a risk factor for increased bowel toxicity from RT; however, minimal evidence exists on patients with prostate cancer (PC) and IBD. MATERIALS AND METHODS The tumor registry was queried for patients with IBD and PC from the years 1990-2013. A retrospective review was conducted for patients who received RT. Radiation treatment and toxicity data were collected. RESULTS Average length of follow-up was 12 years (median 9.54, range 0.42-19.9). The majority had well controlled baseline bowel function on medical management. Prior to radiation, 60% of patients (9/15) and 40% (6/15) reported grade 0 (G0) and grade (G1) diarrhea at baseline, respectively. No baseline proctitis existed. Following radiation treatment, 78% (14/18) of patients experienced G0 diarrhea while 22% (4/18) reported G1 diarrhea. No patients suffered from greater than G1 diarrhea. Sixty-six percent (12/18), 17% (3/18) and 17% (3/18) of patients experienced G0, G1, and G2 proctitis, respectively. No patients suffered post-radiation stricture formation, and all patients with G2 proctitis received 3dCRT. CONCLUSIONS Limited published data is available exploring RT for patients with PC and IBD. This analysis offers valuable insight into appropriate counseling for a rare patient subset. Radiation improved late G1 diarrhea rates. Grade 2 proctitis was only encountered in 3dCRT patients. No post-radiation complications occurred. Our findings suggest that IBD patients experience minimal toxicity in the era of IMRT based RT.
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Affiliation(s)
- Matthew M. Gestaut
- Department of Radiation Oncology, Scott and White Memorial Hospital, Texas A&M University School of Medicine, Temple, TX 76508, USA
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23
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Low Toxicity in Inflammatory Bowel Disease Patients Treated With Abdominal and Pelvic Radiation Therapy. Am J Clin Oncol 2016; 38:564-9. [PMID: 24401668 DOI: 10.1097/coc.0000000000000010] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To determine the short-term and long-term toxicity of abdominal and pelvic radiation therapy in a cohort of patients with inflammatory bowel disease (IBD). We hypothesize that with newer techniques, such as intensity-modulated radiation therapy (IMRT) and 3-dimensional conformal radiotherapy (3D-CRT), patients with IBD can safely undergo abdominal and pelvic radiation, with low risk for major acute or late toxicity. MATERIALS AND METHODS Nineteen consecutive patients with IBD (14 with ulcerative colitis, 5 with Crohn disease) who were treated with abdominal or pelvic external beam radiation therapy at Stanford University from 1997 to 2011 were identified. Fourteen patients were treated with IMRT and 5 were treated with 3D-CRT. Treated sites included prostate (n=8), gastric/esophageal (n=5), rectal/anal (n=3), and liver (n=3) tumors. Charts were reviewed and toxicity was graded according to the Common Terminology Criteria for Acute Events version 4.0. Median follow-up was 32.5 months. Fisher exact test was used to determine if any clinical and/or treatment factors were associated with toxicity outcomes. RESULTS Acute grade ≥3 toxicity occurred in 2 patients (11%). Late grade ≥3 toxicity occurred in 1 patient (6%). Acute grade ≥2 toxicity occurred in 28% of patients treated with IMRT versus 100% of patients treated with 3D-CRT (P=0.01). Acute grade ≥2 gastrointestinal toxicity was lower in patients treated with IMRT versus 3D-CRT (14% vs. 100%, respectively, P=0.002). Late grade ≥2 toxicity occurred in 21% of patients. Higher total dose (Gy) and biologically effective dose (Gy) were associated with increased rates of late grade ≥2 toxicity (P=0.02 and 0.03, respectively). CONCLUSIONS These data suggest that select patients with IBD can safely undergo abdominal and pelvic radiation therapy. The use of IMRT was associated with decreased acute toxicity. Acute and late severe toxicity rates were low in this patient population with the use of modern radiation techniques.
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Thiruthaneeswaran N, Hoskin PJ. High dose rate brachytherapy for prostate cancer: Standard of care and future direction. Cancer Radiother 2016; 20:66-72. [PMID: 26811209 DOI: 10.1016/j.canrad.2016.01.001] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2015] [Revised: 12/14/2015] [Accepted: 12/16/2015] [Indexed: 10/22/2022]
Abstract
High dose rate brachytherapy is a highly conformal method of radiation dose escalation for prostate cancer and one of several treatment options for men with localised disease. The large doses per fraction exploit the low alpha/beta ratio of prostate cancer cells so that biological radiation dose delivered is substantially greater than that achieved with conventional external beam delivery. This review article presents contemporary data on the rationale for high dose rate brachytherapy including treatment technique and future directions.
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Affiliation(s)
- N Thiruthaneeswaran
- Cancer Centre, Mount Vernon Hospital, Rickmansworth Road, Northwood, HA6 2RN, United Kingdom
| | - P J Hoskin
- Cancer Centre, Mount Vernon Hospital, Rickmansworth Road, Northwood, HA6 2RN, United Kingdom.
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25
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Tromp D, Christie DRH. Acute and Late Bowel Toxicity in Radiotherapy Patients with Inflammatory Bowel Disease: A Systematic Review. Clin Oncol (R Coll Radiol) 2015; 27:536-41. [PMID: 26021592 DOI: 10.1016/j.clon.2015.05.001] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2015] [Revised: 04/17/2015] [Accepted: 05/04/2015] [Indexed: 12/13/2022]
Abstract
AIMS Inflammatory bowel disease has traditionally been considered a relative contraindication for radiotherapy due to a perceived increased risk of disease exacerbation and bowel toxicity. The aim of this review was to evaluate the current literature regarding rates of radiotherapy-induced acute and late bowel toxicity in patients with inflammatory bowel disease and to compare these data with those of patients without the disease. MATERIALS AND METHODS An Ovid Medline search was conducted to identify original articles pertaining to the review question. Using the PRISMA convention a total of 442 articles screened, resulting 8 articles which were suitable for inclusion in the review. RESULTS In general, the grading of toxicity was scored using either the Radiation Therapy Oncology Group or Common Terminology Criteria for Adverse Events scoring systems. It was found that acute bowel toxicity of ≥ grade 3 occurred in 20% of patients receiving external beam radiotherapy (EBRT) and in 7% of patients receiving brachytherapy. Late bowel toxicity ≥ grade 3 occurred in 15% of EBRT patients and in 5% of patients receiving brachytherapy. Brachytherapy was shown to have similar rates of toxicity and EBRT produced a moderate increase in both acute and late toxicity when compared with individuals without inflammatory bowel disease. CONCLUSION In view of these results, we suggest that brachytherapy should be considered as a suitable treatment option for treating pelvic malignancy in patients with inflammatory bowel disease, whereas EBRT should be used with caution.
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Affiliation(s)
- D Tromp
- Gold Coast University Hospital, Southport, Queensland, Australia; Griffith University Gold Coast Campus, Southport, Queensland, Australia.
| | - D R H Christie
- Genesis CancerCare Queensland, Tugun, Queensland, Australia; Bond University, Robina, Queensland, Australia
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Ghorbanzadeh-Moghaddam A, Gholamrezaei A, Hemati S. Vitamin D Deficiency Is Associated With the Severity of Radiation-Induced Proctitis in Cancer Patients. Int J Radiat Oncol Biol Phys 2015; 92:613-8. [PMID: 25890844 DOI: 10.1016/j.ijrobp.2015.02.011] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2014] [Revised: 01/31/2015] [Accepted: 02/05/2015] [Indexed: 12/14/2022]
Abstract
PURPOSE Radiation-induced injury to normal tissues is a common complication of radiation therapy in cancer patients. Considering the role of vitamin D in mucosal barrier hemostasis and inflammatory responses, we investigated whether vitamin D deficiency is associated with the severity of radiation-induced acute proctitis in cancer patients. METHODS AND MATERIALS This prospective observational study was conducted in cancer patients referred for pelvic radiation therapy. Serum concentration of 25-hydroxyvitamin D was measured before radiation therapy. Vitamin D deficiency was defined as 25-hydroxyvitamin D concentrations of <35 nmol/L and <40 nmol/L in male and female patients, respectively, based on available normative data. Acute proctitis was assessed after 5 weeks of radiation therapy (total received radiation dose of 50 Gy) and graded from 0 to 4 using Radiation Therapy Oncology Group (RTOG) criteria. RESULTS Ninety-eight patients (57.1% male) with a mean age of 62.8 ± 9.1 years were studied. Vitamin D deficiency was found in 57 patients (58.1%). Symptoms of acute proctitis occurred in 72 patients (73.4%) after radiation therapy. RTOG grade was significantly higher in patients with vitamin D deficiency than in normal cases (median [interquartile range] of 2 [0.5-3] vs 1 [0-2], P=.037). Vitamin D deficiency was associated with RTOG grade of ≥2, independent of possible confounding factors; odds ratio (95% confidence interval) = 3.07 (1.27-7.50), P=.013. CONCLUSIONS Vitamin D deficiency is associated with increased severity of radiation-induced acute proctitis. Investigating the underlying mechanisms of this association and evaluating the effectiveness of vitamin D therapy in preventing radiation-induced acute proctitis is warranted.
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Affiliation(s)
| | - Ali Gholamrezaei
- Medical Student's Research Center, Isfahan University of Medical Sciences, Isfahan, Iran; Poursina Hakim Research Institution, Isfahan, Iran.
| | - Simin Hemati
- Department of Radiotherapy Oncology, Isfahan University of Medical Sciences, Isfahan, Iran
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Abstract
: Restorative proctocolectomy with ileal pouch-anal anastomosis is the standard surgical treatment modality for patients with ulcerative colitis who require colectomy. There are special issues related to male gender. We performed systemic literature review on the topic, incorporating the experience in our specialized Center for Ileal Pouch Disorders, and provide recommendations for the identification and management for the gender-specific issues in male patients with ileal pouches. Chronic pouchitis, particularly ischemic pouchitis, anastomotic leak, and presacral sinus are more common in male patients than their female counterparts. Sexual dysfunction can occur after pouch surgery, particularly in those with pouch failure. Diagnosis and management of benign and malignant prostate diseases can be challenging due to the altered pelvic anatomy from the surgery. Digital rectal examination for prostate cancer screening is not reliable. Transpouch biopsy of prostate may lead to pouch fistula or abscess. Pelvic radiation therapy may have an adverse impact on the pouch function. In conclusion, sexual dysfunction and enlarged prostate can occur in patients with the ileal pouch. The measurement of serum prostate-specific antigen is a preferred method for the screening of prostate cancer. If biopsy of the prostate is needed, the perineal route is recommended. The risk for pouch dysfunction and the benefit for oncologic survival of pelvic radiation for prostate cancer should be carefully balanced.
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Pathogenesis, diagnosis, and management of ulcerative proctitis, chronic radiation proctopathy, and diversion proctitis. Inflamm Bowel Dis 2015; 21:703-15. [PMID: 25687266 DOI: 10.1097/mib.0000000000000227] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Chronic proctitis refers to persistent or relapsing inflammation of the rectum, which results from a wide range of etiologies with various pathogenic mechanisms. The patients may share similar clinical presentations. Ulcerative proctitis, chronic radiation proctitis or proctopathy, and diversion proctitis are the 3 most common forms of chronic proctitis. Although the diagnosis of these disease entities may be straightforward in the most instances based on the clinical history, endoscopic, and histologic features, differential diagnosis may sometimes become problematic, especially when their etiologies and the disease processes overlap. The treatment for the 3 forms of chronic proctitis is different, which may shed some lights on their pathogenetic pathway. This article provides an overview of the latest data on the clinical features, etiologies, diagnosis, and management of ulcerative proctitis, chronic radiation proctopathy, and diversion proctitis.
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Evaluating toxicity from definitive radiation therapy for prostate cancer in men with inflammatory bowel disease: Patient selection and dosimetric parameters with modern treatment techniques. Pract Radiat Oncol 2014; 5:e215-e222. [PMID: 25424586 DOI: 10.1016/j.prro.2014.09.004] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2014] [Revised: 09/18/2014] [Accepted: 09/22/2014] [Indexed: 11/20/2022]
Abstract
PURPOSE Inflammatory bowel disease (IBD) is considered a contraindication to abdominopelvic radiation therapy (RT). We examined our experience in men with IBD who were treated with definitive RT for prostate cancer. METHODS AND MATERIALS We queried our institutional database for patients with a diagnosis of ulcerative colitis, Crohn disease, or IBD not otherwise specified. Endpoints were: acute and late ≥grade 2 (G2) GI toxicity and IBD flare after RT. Outcomes were compared with controls using propensity scoring matched 3 to 1. We matched controls to the IBD cohort according to: RT technique, RT dose, risk group, hormone use, treatment year, and age. We determined predictors of acute outcomes using the Fisher exact test and time to outcomes using the log-rank test. RESULTS Between 1990 and 2010, 84 men were included. Sixty-three men served as matched controls and 21 with IBD: 13 ulcerative colitis, 7 Crohn disease, and 1 IBD not otherwise specified. For men with IBD, median age was 69 years, and median follow-up was 49 months. Median flare-free interval before RT was 10 years. Seven were taking IBD medications during RT. There was no difference in acute or late gastrointestinal (GI) toxicity in the IBD group versus controls. Among IBD patients, IBD medication use was the only predictor of acute ≥G2 GI toxicity: 57.1% with medication versus7.7% without (49.4% absolute difference, 95% confidence interval [CI] 10.0%-88.9%, P = .03). The 5-year risk of late GI toxicity in men with IBD versus controls was not statistically significant (hazard ratio = 1.19, 95%CI 0.28-5.01, P = .83). The crude incidence of late ≥G2 GI toxicity was 10%. CONCLUSIONS Acute GI toxicity appears to be exacerbated in patients on concomitant medical therapy for IBD. Overall, late GI toxicity was relatively low and not significantly different between patients with IBD versus no IBD. However, the small sample size limits the interpretation of our estimates and the wide confidence intervals indicate these patients warrant careful selection.
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Contemporary issues in radiotherapy for clinically localized prostate cancer. Hematol Oncol Clin North Am 2013; 27:1137-62, vii. [PMID: 24188256 DOI: 10.1016/j.hoc.2013.08.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Radiotherapy is a valid curative alternative to surgery for prostate cancer. However, patient selection is critical to ensure patients obtain benefits from therapy delivered with curative intent. Dose-escalated radiation has been shown to improve patient outcomes, facilitated by development of robust image guidance and better target delineation imaging technologies. These concepts have also rekindled interest in hypofractionated radiotherapy in the forms of stereotactic body radiotherapy and brachytherapy. Postprostatectomy radiotherapy also improves long-term biochemical outcome in men at high risk of local recurrence.
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Chemoradiotherapy followed by restorative proctocolectomy with partial intersphincteric resection for advanced rectal cancer associated with ulcerative colitis: report of a case. Surg Today 2013; 44:387-90. [PMID: 23525639 DOI: 10.1007/s00595-013-0558-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2012] [Accepted: 08/05/2012] [Indexed: 12/17/2022]
Abstract
The role of restorative proctocolectomy with ileal J-pouch anal anastomosis (IPAA) is uncertain for patients with ulcerative colitis (UC), when advanced lower rectal cancer is diagnosed. We report what to our knowledge is the first documented case of successful preoperative chemoradiotherapy followed by IPAA with partial intersphincteric resection of advanced rectal cancer associated with UC. A 59-year-old woman with a 24-year history of extensive UC was found to have advanced rectal cancer located 2 cm from the anal verge. She underwent preoperative conventional chemoradiotherapy followed by restorative proctocolectomy with total mesorectal excision. The procedure included intersphincteric resection of one quadrant and construction of an IPAA with diverting ileostomy. The postoperative course was uneventful, and the ileostomy was closed 6 months after the initial surgery. The patient was doing well with good pouch function and no evidence of recurrent disease 1 year after her initial surgery.
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Toxicity after 125I prostate brachytherapy in patients with inflammatory bowel disease. Brachytherapy 2013; 12:126-33. [DOI: 10.1016/j.brachy.2012.04.008] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2012] [Revised: 04/25/2012] [Accepted: 04/30/2012] [Indexed: 11/21/2022]
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Fuccio L, Guido A, Andreyev HJN. Management of intestinal complications in patients with pelvic radiation disease. Clin Gastroenterol Hepatol 2012; 10:1326-1334.e4. [PMID: 22858731 DOI: 10.1016/j.cgh.2012.07.017] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2012] [Revised: 06/22/2012] [Accepted: 07/20/2012] [Indexed: 02/07/2023]
Abstract
Gastrointestinal toxicity after radiotherapy for pelvic cancer is a major complication-the most commonly reported symptoms include rectal bleeding, diarrhea, and fecal incontinence, which substantially impair patients' quality of life. Management of these symptoms can be a challenge, although available treatment strategies generally are ignored or underused. Radiation-induced symptoms have multiple mechanisms of pathogenesis; the first step for the correct management is to identify the mechanism that is causing the symptoms. Optimal management requires close liaisons among physicians, gastroenterologists with specialist interests, radiotherapists, oncologists, dieticians, nurses, and surgeons. Patients should be reassured that treatment options (medical, endoscopic, and surgical) exist and are in most cases successful if patients are referred to experts in pelvic radiation disease. However, although new therapeutic approaches are not yet always supported by high-quality trials, research projects are underway to improve management of patients. Clinicians should focus on using proven treatments correctly and avoiding misuse.
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Affiliation(s)
- Lorenzo Fuccio
- Department of Clinical Medicine, S. Orsola-Malpighi Hospital, Bologna, Italy.
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Kintzinger C, Demoor-Goldschmidt C, Abderrahmani R, Paris F, Supiot S. Toxicité rectale de la radiothérapie : signes cliniques, physiopathologie et prise en charge. Cancer Radiother 2012; 16:372-6. [DOI: 10.1016/j.canrad.2012.05.014] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2012] [Accepted: 05/28/2012] [Indexed: 12/29/2022]
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Harron E, Lewis J. Bowel sparing in pediatric cranio-spinal radiotherapy: a comparison of combined electron and photon and helical TomoTherapy techniques to a standard photon method. Med Dosim 2012; 37:140-4. [DOI: 10.1016/j.meddos.2011.06.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2010] [Revised: 04/13/2011] [Accepted: 06/10/2011] [Indexed: 10/17/2022]
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Godoi DF, Cardoso CR, Silva MJB, Ferraz DB, Provinciatto PR, Cunha FDQ, da Silva JS, Voltarelli JC. Reappraisal of total body irradiation followed by bone marrow transplantation as a therapy for inflammatory bowel disease. Immunobiology 2012; 218:317-24. [PMID: 22771114 DOI: 10.1016/j.imbio.2012.05.012] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2012] [Accepted: 05/16/2012] [Indexed: 01/14/2023]
Abstract
The main current therapies for inflammatory bowel diseases (IBD) are aimed at controlling the exacerbated inflammation in the gut. Although these therapies have been successful, they are not curative and it is not possible to predict whether a beneficial response will occur or which patients will be refractory to the treatment. Total body irradiation (TBI) associated with chemotherapy is the first choice in the treatment of some hematological disorders and is an applicable option in the preparation of patients with hematologic diseases for hematopoietic stem cell transplantation. Then, in this study we investigated the association of TBI as immunosuppressive therapy and bone marrow cell (BMC) transplantation as a strategy to induce colitis recovery and immune reconstitution in the TNBS model of intestinal inflammation. TNBS mice treated with TBI associated with BMC transplantation presented elevated gain of weight and an overall better outcome of the disease when compared to those treated only with TBI. In addition, TBI associated or not with BMC reduced the frequency of inflammatory cells in the gut and restored the goblet cell counts. These results were accompanied by a down regulation in the production of inflammatory cytokines in the colon of mice treated with TBI alone or in association with BMC transplantation. The BMC infused were able to repopulate the ablated immune system and accumulate in the site of inflammation. However, although both treatments (TBI or TBI+BMC) were able to reduce gut inflammation, TBI alone was not enough to fully restore mice weight and these animals presented an extremely reduced survival rate when their immune system was not promptly reconstituted with BMC transplantation. Finally, these evidences suggest that the BMC transplantation is an efficient strategy to reduce the harmful effects of TBI in the colitis treatment, suggesting that radiotherapy may be an important immunosuppressive therapy in patients with IBD, by modulating the local inflammatory response.
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Affiliation(s)
- Dannielle Fernandes Godoi
- Departamento de Clínica Médica, Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo, Ribeirão Preto, SP, Brazil
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Yamada Y, Rogers L, Demanes DJ, Morton G, Prestidge BR, Pouliot J, Cohen GN, Zaider M, Ghilezan M, Hsu IC. American Brachytherapy Society consensus guidelines for high-dose-rate prostate brachytherapy. Brachytherapy 2012; 11:20-32. [PMID: 22265435 DOI: 10.1016/j.brachy.2011.09.008] [Citation(s) in RCA: 230] [Impact Index Per Article: 19.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2011] [Revised: 09/23/2011] [Accepted: 09/23/2011] [Indexed: 01/26/2023]
Abstract
PURPOSE A well-established body of literature supports the use of high-dose-rate (HDR) brachytherapy as definitive treatment for localized prostate cancer. Most of the articles describe HDR as a boost with adjuvant external beam radiation, but there is a growing experience with HDR monotherapy. METHODS AND MATERIALS The American Brachytherapy Society has convened a group of expert practitioners and physicists to develop guidelines for the use of HDR in the management of prostate cancer. This involved an extensive literature review and input from an expert panel. RESULTS Despite a wide variation in doses and fractionation reported, HDR brachytherapy provides biochemical control rates of 85-100%, 81-100%, and 43-93% for low-, intermediate-, and high-risk prostate cancers, respectively. Severe toxicity is rare, with most authors reporting less than 5% Grade 3 or higher toxicity. Careful attention to patient evaluation for appropriate patient selection, meticulous technique, treatment planning, and delivery are essential for successful treatment. CONCLUSION The clinical outcomes for HDR are excellent, with high rates of biochemical control, even for high-risk disease, with low morbidity. HDR monotherapy, both for primary treatment and salvage, are promising treatment modalities.
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Affiliation(s)
- Yoshiya Yamada
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA.
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Fiorino C, Rancati T, Fellin G, Vavassori V, Cagna E, Casanova Borca V, Girelli G, Menegotti L, Monti AF, Tortoreto F, Delle Canne S, Valdagni R. Late Fecal Incontinence After High-Dose Radiotherapy for Prostate Cancer: Better Prediction Using Longitudinal Definitions. Int J Radiat Oncol Biol Phys 2012; 83:38-45. [DOI: 10.1016/j.ijrobp.2011.06.1953] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2011] [Revised: 06/01/2011] [Accepted: 06/03/2011] [Indexed: 10/16/2022]
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Valdagni R, Vavassori V, Rancati T, Fellin G, Baccolini M, Bianchi C, Cagna E, Gabriele P, Mauro F, Menegotti L, Monti AF, Stasi M, Fiorino C. Increasing the risk of late rectal bleeding after high-dose radiotherapy for prostate cancer: The case of previous abdominal surgery. Results from a prospective trial. Radiother Oncol 2012; 103:252-5. [DOI: 10.1016/j.radonc.2012.03.012] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2010] [Revised: 03/23/2012] [Accepted: 03/26/2012] [Indexed: 11/25/2022]
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Inclusion of clinical risk factors into NTCP modelling of late rectal toxicity after high dose radiotherapy for prostate cancer. Radiother Oncol 2011; 100:124-30. [DOI: 10.1016/j.radonc.2011.06.032] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2011] [Revised: 06/14/2011] [Accepted: 06/14/2011] [Indexed: 12/25/2022]
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López Rodríguez M, Martín Martín M, Cerezo Padellano L, Marín Palomo A, Ibáñez Puebla Y. Gastrointestinal toxicity associated to radiation therapy. Clin Transl Oncol 2010; 12:554-61. [DOI: 10.1007/s12094-010-0553-1] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
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Martin E, Pointreau Y, Roche-Forestier S, Barillot I. [Normal tissue tolerance to external beam radiation therapy: small bowel]. Cancer Radiother 2010; 14:350-3. [PMID: 20598616 DOI: 10.1016/j.canrad.2010.03.013] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2010] [Revised: 02/22/2010] [Accepted: 03/03/2010] [Indexed: 01/12/2023]
Abstract
The small bowel is a hollow organ involved in the transit and absorption of food. In relation to its anatomical location, a significant amount of this organ is exposed in whole or in part to ionizing radiation in external radiotherapy during abdominal or pelvic irradiation either for primary cancers or metastasis. The acute functional changes during external beam radiation are mainly leading to diarrhea, abdominal pain and bloating. The main late side effects of irradiation of the small intestine are chronic diarrhea, malabsorption with steatorrhea, abdominal spasms, intestinal obstruction, bleeding and fistulas. The architecture of the small intestine may be considered as parallel with a significant correlation between the irradiated volume of small bowel and the likelihood of acute toxicity, whatever the dose. The literature analysis recommends to consider the volume of small bowel receiving 15 Gy (threshold of 100 to 200 cm(3)) but also 30 and 50 Gy (thresholds of 35 to 300 cm(3), depending on the level of dose considered). Modern techniques of conformal radiotherapy with modulated intensity will probably have beneficial impact on small bowel toxicity.
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Affiliation(s)
- E Martin
- Département de Radiothérapie, Centre Georges-Francois-Leclerc, 1 Rue du Professeur-Marion, 21079 Dijon cedex, France
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Abstract
PURPOSE OF REVIEW Injury to the small bowel from ionizing radiation occurs commonly in patients undergoing cancer therapy and less commonly in instances of accidental radiation overexposure. Several lines of evidence now suggest that dynamic interactions between the host's enteric microbiota and innate immune system are important in modulating the intestinal response to radiation. Here, we will review recent developments in the area of acute radiation enteropathy and examine the current state of knowledge regarding the impact of host-microbial interactions in the process. RECENT FINDINGS There is promise in the development and testing of new clinical biomarkers including serum citrulline. Toll-like receptor agonists and innate immune system signaling pathways including nuclear factor-kappa B profoundly alter intestinal epithelial cell apoptosis and crypt survival after radiation exposure. Germ-free conditions, probiotics and antibiotics are each identified as modifiers of disease development and course. A human study suggested that luminal microbiota composition may influence the host's intestinal response to radiation and may change in those developing postradiation diarrhea. SUMMARY New knowledge implies that investigations aimed at deciphering the microbiome-host interactions before and after small bowl radiation injury may eventually allow prediction of disease course and offer opportunities for the development of novel therapeutic or prophylactic strategies.
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Radical Prostatectomy for Prostate Cancer after Ileal Pouch-Anal Anastomosis Offers Oncologic Control and Sustains Quality of Life. J Am Coll Surg 2010; 210:232-9. [DOI: 10.1016/j.jamcollsurg.2009.09.041] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2009] [Revised: 09/30/2009] [Accepted: 09/30/2009] [Indexed: 11/22/2022]
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Williamson R, Smaldone MC, Gibbons EP, Smith RP, Beriwal S, Benoit RM. Prostate Brachytherapy After Ileal Pouch–Anal Anastomosis Reconstruction. Urology 2009; 73:369-73. [DOI: 10.1016/j.urology.2008.06.052] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2008] [Revised: 06/23/2008] [Accepted: 06/28/2008] [Indexed: 01/09/2023]
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Garg AK, Mai WY, McGary JE, Grant WH, Butler EB, Teh BS. Radiation proctopathy in the treatment of prostate cancer. Int J Radiat Oncol Biol Phys 2007; 66:1294-305. [PMID: 17126204 DOI: 10.1016/j.ijrobp.2006.07.1386] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2005] [Revised: 06/13/2006] [Accepted: 07/06/2006] [Indexed: 12/13/2022]
Abstract
PURPOSE To compile and review data on radiation proctopathy in the treatment of prostate cancer with respect to epidemiology, clinical manifestations, pathogenesis, risk factors, and treatment. METHODS Medical literature databases including PubMed and Medline were screened for pertinent reports, and critically analyzed for relevance in the scope of our purpose. RESULTS Rectal toxicity as a complication of radiotherapy has received attention over the past decade, especially with the advent of dose-escalation in prostate cancer treatment. A number of clinical criteria help to define acute and chronic radiation proctopathy, but lack of a unified grading scale makes comparing studies difficult. A variety of risk factors, related to either radiation delivery or patient, are the subject of intense study. Also, a variety of treatment options, including medical therapy, endoscopic treatments, and surgery have shown varied results, but a lack of large randomized trials evaluating their efficacy prevents forming concrete recommendations. CONCLUSION Radiation proctopathy should be an important consideration for the clinician in the treatment of prostate cancer especially with dose escalation. With further study of possible risk factors, the advent of a standardized grading scale, and more randomized trials to evaluate treatments, patients and physicians will be better armed to make appropriate management decisions.
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Affiliation(s)
- Amit K Garg
- Department of Radiation Oncology, MD Anderson Cancer Center, Houston, TX, USA
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Peters CA, Cesaretti JA, Stone NN, Stock RG. Low-dose rate prostate brachytherapy is well tolerated in patients with a history of inflammatory bowel disease. Int J Radiat Oncol Biol Phys 2006; 66:424-9. [PMID: 16887295 DOI: 10.1016/j.ijrobp.2006.05.027] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2006] [Revised: 05/04/2006] [Accepted: 05/05/2006] [Indexed: 11/24/2022]
Abstract
PURPOSE We report on the follow-up of 24 patients with a prior history of inflammatory bowel disease (IBD) treated with brachytherapy for early-stage prostate cancer. METHODS AND MATERIALS Twenty-four patients with a history of inflammatory bowel disease (17 with ulcerative colitis (UC), 7 with Crohn's disease [CD]) underwent prostate brachytherapy between 1992 and 2004. Fifteen patients were treated with I-125 implantation and 6 patients were treated with Pd-103 alone or in combination with 45 Gy external beam radiation. Charts were reviewed for all patients, and all living patients were contacted by phone. National Cancer Institute common toxicity scores for proctitis were assigned to all patients. Actuarial risk of late toxicity was calculated by the Kaplan-Meier method. Statistical analysis was performed using SPSS software. Follow-up ranged from 3 to 126 months (median, 48.5 months; mean, 56.8 months). RESULTS None of the patients experienced Grade 3 or 4 rectal toxicity. Four patients experienced Grade 2 late rectal toxicity. The 5-year actuarial freedom from developing late Grade 2 rectal toxicity was 81%. At a median follow-up of 48.5 months, 23 patients were alive and had no evidence of disease with a median prostate-specific antigen for the sample of 0.1 ng/mL (range, <0.05-0.88 ng/mL). One patient died of other causes unrelated to his prostate cancer. CONCLUSIONS Prostate brachytherapy is well tolerated in patients with a history of controlled IBD. Therefore, brachytherapy should be considered a viable therapeutic option in this patient population.
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Affiliation(s)
- Christopher A Peters
- Department of Radiation Oncology, Mount Sinai School of Medicine, New York, NY 10029, USA.
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Guckenberger M, Flentje M. Late small bowel toxicity after adjuvant treatment for rectal cancer. Int J Colorectal Dis 2006; 21:209-20. [PMID: 16052309 DOI: 10.1007/s00384-005-0765-y] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/17/2005] [Indexed: 02/04/2023]
Abstract
BACKGROUND For locally advanced rectal cancer surgery as sole treatment results in poor local control and survival. After adjuvant radiotherapy for locally advanced rectal cancer, small bowel toxicity has been the most frequent and serious side effect. The gain in survival and local control was accompanied by severe late chronic toxicity reducing the benefit of adjuvant treatment. REVIEW Clinical factors, pathology and treatment of late small bowel toxicity after adjuvant radiotherapy for locally advanced rectal cancer will be discussed. This review will focus on different surgical and radiotherapeutic means reducing the risk of late small bowel damage.
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Affiliation(s)
- Matthias Guckenberger
- Department of Radiation Oncology, Klinik und Poliklinik für Strahlentherapie der Universität Würzburg, Josef-Schneider-Strasse 11, 97080 Würzburg, Germany.
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Roach M. Reducing the toxicity associated with the use of radiotherapy in men with localized prostate cancer. Urol Clin North Am 2004; 31:353-66. [PMID: 15123413 DOI: 10.1016/j.ucl.2004.02.001] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
The risk for serious complications associated with modern radiotherapy is relatively low. Compared with conventional radiotherapy, 3DCRT and IMRT allow higher doses to be given more safely. The use of IMRT increases the time and effort required by physicians and physicists. Although there is a clear move toward IMRT, 3DCRT is considered standard. The quality assurance procedures for and fundamental questions regarding IMRT are evolving, including the radiobiologic consequences of altered time-dose fractionation and the greater dose heterogeneity in the target. Defining an accurate target volume and routinely correcting for set-up error and organ movement before each treatment promise to reduce the complications associated with EBRT in the next 5 years. Complications following prostate brachytherapy are better understood now than 10 years ago. Dosimetric or patient selection factors that correlate with a higher risk for complications, such as acute retention, strictures, severe prolonged urinary symptoms, fistulas, proctitis, and impotence, often can be accounted for or avoided. Finally, the role of radiation protectors is beginning to be addressed. It is hoped that these advances will eliminate toxicity associated with radiotherapy and increase cure rates.
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Affiliation(s)
- Mack Roach
- Department of Radiation Oncology, University of California, San Francisco, UCSF/Mt Zion NCI-Designated Comprehensive Cancer, 1600 Divisadero Street, San Francisco, CA 94143-1708, USA.
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