Radiation-induced bowel injury: the impact of radiotherapy on survivorship after treatment for gynaecological cancers

Precision assessment of bowel motion quantification using 3D cine-MRI for radiotherapy

Objective. The bowel is an important organ at risk for toxicity during pelvic and abdominal radiotherapy. Identifying regions of high and low bowel motion with MRI during radiotherapy may help to understand the development of bowel toxicity, but the acquisition time of MRI is rather long. The aim of this study is to retrospectively evaluate the precision of bowel motion quantification and to estimate the minimum MRI acquisition time.Approach. We included 22 gynaecologic cancer patients receiving definitive radiotherapy with curative intent. The 10 min pre-treatment 3D cine-MRI scan consisted of 160 dynamics with an acquisition time of 3.7 s per volume. Deformable registration of consecutive images generated 159 deformation vector fields (DVFs). We defined two motion metrics, the 50th percentile vector lengths (VL50) of the complete set of DVFs was used to measure median bowel motion. The 95th percentile vector lengths (VL95) was used to quantify high motion of the bowel. The precision of these metrics was assessed by calculating their variation (interquartile range) in three different time frames, defined as subsets of 40, 80, and 120 consecutive images, corresponding to acquisition times of 2.5, 5.0, and 7.5 min, respectively.Main results. For the full 10 min scan, the minimum motion per frame of 50% of the bowel volume (M50%) ranged from 0.6-3.5 mm for the VL50 motion metric and 2.3-9.0 mm for the VL95 motion metric, across all patients. At 7.5 min scan time, the variation in M50% was less than 0.5 mm in 100% (VL50) and 95% (VL95) of the subsets. A scan time of 5.0 and 2.5 min achieved a variation within 0.5 mm in 95.2%/81% and 85.7%/57.1% of the subsets, respectively.Significance. Our 3D cine-MRI technique quantifies bowel loop motion with 95%-100% confidence with a precision of 0.5 mm variation or less, using a 7.5 min scan time.

The ambivalence of radiotherapy: Re-framing effects and their temporalities in treatment for gynaecological cancer

Within the biomedical paradigm, treatment effects are typically split into primary and secondary effects with temporality playing a key role in this separation. Yet, this kind of ordering of effects with some effects understood as happening on the 'side', secondary and temporary, does not fit with how they are experienced by many patients who undergo treatment for cancer. Drawing on empirical data from a research project that gathered narratives of women's experiences of radiotherapy for gynaecological cancer, we observe radiotherapeutic effects that are experienced as ambivalent and temporally diverse and as overlapping demands that the women endure and manage. We propose Derrida's concept of pharmakon as a relevant and useful analytic for understanding radiotherapy treatment, thus bringing into focus the ambivalent effects of radiotherapy - it is both therapeutic and toxic. Pharmakon, we argue, offers a way of disrupting the logics that govern current practices of therapeutic radiotherapy, and provides a way to re-negotiate the ordering and temporal understandings and practices of therapeutic efficacy, outcome and accountability of radiotherapy treatment - away from a temporal fragmentation of treatment effects and patients' bodily experiences to a focus on how best to support the whole patient in living with the ambivalent, temporally diverse and overlapping effects and demands of treatment.

Administration of modified Gegen Qinlian decoction for hemorrhagic chronic radiation proctitis: A case report and review of literature

BACKGROUND

Hemorrhagic chronic radiation proctitis (CRP) is a common late complication of irradiation of the pelvis and seriously impairs life quality. There is no standard treatment for hemorrhagic CRP. Medical treatment, interventional treatment, and surgery are available, but they are limited in their applications due to nondefinite efficacy or side effects. Chinese herbal medicine (CHM), as a complementary or alternative therapy, may provide another option for hemorrhagic CRP treatment.

CASE SUMMARY

A 51-year-old woman with cervical cancer received intensity-modulated radiation therapy and brachytherapy with a total dose of 93 Gy fifteen days after hysterectomy and bilateral adnexectomy. She received six additional cycles of chemotherapy with carboplatin and paclitaxel. Nine months after radiotherapy treatment, she mainly complained of 5-6 times diarrhea daily and bloody purulent stools for over 10 d. After colonoscopy examinations, she was diagnosed with hemorrhagic CRP with a giant ulcer. After assessment, she received CHM treatment. The specific regimen was 150 mL of modified Gegen Qinlian decoction (GQD) used as a retention enema for 1 mo, followed by replacement with oral administration of 150 mL of modified GQD three times per day for 5 mo. After the whole treatment, her diarrhea reduced to 1-2 times a day. Her rectal tenesmus and mild pain in lower abdomen disappeared. Both colonoscopy and magnetic resonance imaging confirmed its significant improvement. During treatment, there were no side effects, such as liver and renal function damage.

CONCLUSION

Modified GQD may be another effective and safe option for hemorrhagic CRP patients with giant ulcers.

Radiation-Induced Intestinal Normal Tissue Toxicity: Implications for Altered Proteome Profile

Radiation-induced toxicity to healthy/normal intestinal tissues, especially during radiotherapy, limits the radiation dose necessary to effectively eradicate tumors of the abdomen and pelvis. Although the pathogenesis of intestinal radiation toxicity is highly complex, understanding post-irradiation alterations in protein profiles can provide crucial insights that make radiotherapy safer and more efficient and allow for increasing the radiation dose during cancer treatment. Recent preclinical and clinical studies have advanced our current understanding of the molecular changes associated with radiation-induced intestinal damage by assessing changes in protein expression with mass spectrometry-based approaches and 2-dimensional difference gel electrophoresis. Studies by various groups have demonstrated that proteins that are involved in the inflammatory response, the apoptotic pathway, reactive oxygen species scavenging, and cell proliferation can be targeted to develop effective radiation countermeasures. Moreover, altered protein profiles serve as a crucial biomarkers for intestinal radiation damage. In this review, we present alterations in protein signatures following intestinal radiation damage as detected by proteomics approaches in preclinical and clinical models with the aim of providing a better understanding of how to accomplish intestinal protection against radiation damage.

Ionizing Radiation from Radiopharmaceuticals and the Human Gut Microbiota: An Ex Vivo Approach

This study aimed to determine the effect of three widely used radiopharmaceuticals with intestinal excretion on selected relevant bacteria that are part of the human gut microbiota, using an ex vivo approach. Fecal samples obtained from healthy volunteers were analyzed. Each sample was divided into four smaller aliquots. One served as the non-irradiated control. The other three were homogenized with three radiopharmaceutical solutions ([¹³¹I]NaI, [^99mTc]NaTcO₄, and [²²³Ra]RaCl₂). Relative quantification of each taxa was determined by the 2^−ΔΔC method, using the ribosomal gene 16S as an internal control (primers 534/385). Twelve fecal samples were analysed: three controls and nine irradiated. Our experiment showed fold changes in all analyzed taxa with all radiopharmaceuticals, but results were more significant with I-131, ranging from 1.87–83.58; whereas no relevant differences were found with Tc-99m and Ra-223, ranging from 0.98–1.58 and 0.83–1.97, respectively. This study corroborates limited existing research on how ionizing radiation changes the gut microbiota composition, providing novel data regarding the ex vivo effect of radiopharmaceuticals. Our findings justify the need for future larger scale projects.

Vitamin B12 absorption and malabsorption

Vitamin B12 is assimilated and transported by complex mechanisms that involve three transport proteins, intrinsic factor (IF), haptocorrin (HC) and transcobalamin (TC) and their respective membrane receptors. Vitamin deficiency is mainly due to inadequate dietary intake in vegans, and B12 malabsorption is related to digestive diseases. This review explores the physiology of vitamin B12 absorption and the mechanisms and diseases that produce malabsorption. In the stomach, B12 is released from food carrier proteins and binds to HC. The degradation of HC by pancreatic proteases and the pH change trigger the transfer of B12 to IF in the duodenum. Cubilin and amnionless are the two components of the receptor that mediates the uptake of B12 in the distal ileum. Part of liver B12 is excreted in bile, and undergoes an enterohepatic circulation. The main causes of B12 malabsorption include inherited disorders (Intrinsic factor deficiency, Imerslund-Gräsbeck disease, Addison's pernicious anemia, obesity, bariatric surgery and gastrectomies. Other causes include pancreatic insufficiency, obstructive Jaundice, tropical sprue and celiac disease, bacterial overgrowth, parasitic infestations, Zollinger-Ellison syndrome, inflammatory bowel diseases, chronic radiation enteritis of the distal ileum and short bowel. The assessment of B12 deficit is recommended in the follow-up of subjects with bariatric surgery. The genetic causes of B12 malabsorption are probably underestimated in adult cases with B12 deficit. Despite its high prevalence in the general population and in the elderly, B12 malabsorption cannot be anymore assessed by the Schilling test, pointing out the urgent need for an equivalent reliable test.

Hospitalization rates from radiotherapy complications in the United States

Hospitalizations due to radiotherapy (RT) complications result in significant healthcare expenditures and adversely affect the quality of life of cancer patients. Using a nationally representative dataset, the objective of this study is to identify trends in the incidence of these hospitalizations, their causes, and the resulting financial burden. Data from the National Inpatient Sample was retrospectively analyzed from 2005 to 2016. RT complications were identified using ICD-9 and ICD-10 external cause-of-injury codes. The hospitalization rate was the primary endpoint, with cost and in-hospital death as secondary outcomes. 443,222,223 weighted hospitalizations occurred during the study period, of which 482,525 (0.11%) were attributed to RT. The 3 most common reasons for RT-related hospitalization were cystitis (4.8%, standard error [SE] = 0.09), gastroenteritis/colitis (3.7%, SE = 0.07), and esophagitis (3.5%, SE = 0.07). Aspiration pneumonitis (1.4-fold) and mucositis (1.3-fold) had the highest relative increases among these hospitalizations from 2005 to 2016, while esophagitis (0.58-fold) and disorders of the rectum and anus were the lowest (0.67-fold). The median length of stay of patient for hospitalization for RT complications was 4.1 (IQR, 2.2–7.5) days and the median charge per patient was $10,097 (IQR, 5755–18,891) and the total cost during the study period was $4.9 billion. Hospitalization for RT-related complications is relatively rare, but those that are admitted incur a substantial cost. Use of advanced RT techniques should be employed whenever possible to mitigate the risk of severe toxicity and therefore reduce the need to admit patients.

Upstaging by para-aortic lymph node dissection in patients with locally advanced cervical cancer: A systematic review and meta-analysis

BACKGROUND

Accurate staging of para-aortic nodal status in cervical cancer is of great importance for individualizing treatment and impacting outcomes. Three-dimensional imaging (i.e. PET, CT, MRI) may miss para-aortic lymph node (PALN) metastases. The aim of this study was to systematically review and meta-analyze the proportion of upstaging by PALN dissection in patients with locally advanced cervical cancer without suspicious PALNs on imaging.

METHODS

PubMed/MEDLINE and Embase were systematically searched. The analysis included diagnostic studies that reported on 3D imaging and pre-therapeutic surgical assessment of PALN status in patients with cervical cancer. An overall pooled upstaging rate was calculated using a random-effects model.

RESULTS

The search identified 16 eligible studies including 18 cohorts with a total of 1530 patients. Pooling of 12 cohorts demonstrated an upstaging rate of 12% (95% confidence interval [CI] 10-15%) by PALN dissection after negative PET or PET-CT. Pooling of 6 cohorts demonstrated a pooled upstaging rate of 11% (95% CI: 8-16%) by PALN dissection after negative MRI or CT. No significant heterogeneity in upstaging proportions across cohorts was observed (I² = 0% and 27%, respectively). In 7 cohorts including only patients with pelvic nodal metastases on imaging (but no suspicion of PALN involvement) a pooled upstaging rate by PALN dissection of 21% (95% CI: 17-26%) was found (I² = 0%).

CONCLUSIONS

This meta-analysis demonstrates that in case of no suspicious PALN on PET-CT or MRI, PALN dissection still identifies lymph node metastases in a considerable amount of patients with locally advanced cervical cancer and especially in those patients with confirmed pelvic nodal metastases.

Nutrition risk screening and implications for patients with gynaecological cancers undergoing pelvic radiotherapy and/or other treatment modalities: A retrospective observational study

AIM

There is scarcity of research for the nutritional management of pelvic radiotherapy in gynaecological malignancies and delivery of specialised nutrition care is limited due to the current knowledge gap in guidelines. This study aimed to better understand the nutritional risk, weight changes and pattern of nutrition impact symptoms occurring at various treatment timepoints in this population, to inform an effective model of care.

METHODS

This retrospective, observational study included women with gynaecological cancers receiving pelvic radiotherapy at a tertiary hospital from January 2017 to December 2018 (n = 104). Information was collected on: first day of radiotherapy; weekly during treatment; acute-phase post-treatment (0-6 weeks); and intermediate-phase post-treatment (6 weeks to 6 months). This study reported on incidence of clinically significant weight change (±5%), documented nutrition impact symptoms and the current nutrition care model (nutrition screening, referral, assessment and interventions).

RESULTS

Clinically significant weight loss was experienced by 38% (n = 40/104) of patients prior to commencing treatment and 19% (n = 14/73) during treatment. Diarrhoea (n = 40/79), fatigue (n = 54/79), nausea (n = 38/79) and pain (n = 31/79) were frequently reported during treatment, and fatigue (n = 33/92) and pain (n = 25/92) continued acutely post-treatment. Despite high rates of weight loss and prevalence of nutrition impact symptoms, only 38% (n = 40/104) of patients were referred to a dietitian.

CONCLUSIONS

A considerable proportion of patients with gynaecological cancers are at nutrition risk before and during treatment due to clinically significant weight loss and prevalence of nutrition impact symptoms experienced. This highlights the importance of nutrition-risk screening and access to specialised dietetic care as part of their model of care.

Functional Changes of the Genitourinary and Gastrointestinal Systems before and after the Treatment of Endometrial Cancer-A Systematic Review

Simple Summary

Endometrial cancer is currently one of the most common gynecological cancer and accounts for around 5% of all female cancers. The treatment strategy most often includes surgery and adjuvant radiation therapy. Thanks to the high effectiveness of used treatment methods, the patients can live longer lives. Unfortunately their quality of life can be negatively affected by side effects resulting from weakening pelvic floor such as urinary incontinence, pelvic organ prolapse and fecal incontinence. In our paper we analyzed the studies published between 2010 and 2020 that touch upon the prevalence and management of pelvic floor dysfunction in endometrial cancer patients. Our results show increase in the incidence of pelvic floor disorders after various forms of endometrial cancer treatment and the need for more good quality research in the subject to be able to provide patients with holistic care focused on minimizing treatment side effects and prioritizing their quality of life.

Abstract

The incidence of endometrial cancer (EC), which coexists with such civilization diseases as diabetes, obesity or hypertension, is constantly increasing. Treatment includes surgery as well as brachytherapy, teletherapy, rarely chemotherapy or hormone therapy. Due to the good results of the treatment, the occurrence of side effects of therapy becomes a problem for the patients. One of the large groups of side effects includes the pelvic organ prolapse, urinary and fecal incontinence. The aim of this study was to present current knowledge on the occurrence of pelvic floor dysfunction in women treated for EC. A literature review was conducted in the PubMED and WoS databases, including articles on pelvic floor dysfunction in women with EC. PRISMA principles were followed in the research methodology. A total of 1361 publications were retrieved. Based on the inclusion and exclusion criteria, 24 papers were eligible for the review. Mostly retrospective studies based on different questionnaires were evaluated. No prospective studies were found in which, in addition to subjective assessment, clinical examination and objective assessment of urinary incontinence were used. Studies show a significant increase in the incidence of pelvic floor disorders, including urinary incontinence, after various forms of EC treatment. We believe that assessment of complications after endometrial cancer treatment is clinically relevant. The review emphasizes the importance of programming prospective studies to prevent and address these disorders at each stage of oncologic treatment.

Impact of dose-escalated chemoradiation on quality of life in patients with locally advanced rectal cancer: two year follow-up of the randomized RECTAL-BOOST trial

BACKGROUND

Dose-escalated chemoradiation (CRT) for locally advanced rectal cancer (LARC) did not result in higher complete response rates, but initiated more tumor regression in the randomized XXXXX trial (Clinicaltrials.gov XXXXX). This study compared patient reported outcomes (PROs) between patients who received dose-escalated CRT (5 × 3Gy boost + CRT) or standard CRT for two years following randomization.

METHODS

Patients with LARC, participating in the XXXXX trial, filled out EORTC QLQ-C30 and CR29 questionnaires on quality of life (QoL) and symptoms at baseline, 3, 6, 12, 18 and 24 months following start of treatment. Between-group differences in functional QoL domains were estimated using a linear mixed-effects model and expressed as effect size (ES). Symptom scores were compared using Mann-Whitney U test.

RESULTS

Patients treated with dose-escalated CRT (boost group, n=51) experienced a significantly stronger decline in global health at 3 and 6 months (ES -0,4 and ES -0,4), physical functioning at 6 months (ES -1,1), role functioning at 3 and 6 months (ES -0,8 and ES -0,6) and social functioning at 6 months (ES -0,6) compared to patients treated with standard CRT (control group, n=64). The boost group reported significantly more fatigue at 3 and 6 months (83% vs. 66% resp. 89% vs. 76%), pain at 3 and 6 months (67% vs. 36% resp. 80% vs. 44%) and diarrhea at 3 months (45% vs. 29%) compared to the control group. From 12 months onwards, QoL and symptoms were similar between groups, apart from more blood/mucus in stool in the boost group.

CONCLUSION

In patients with LARC, dose-escalated CRT resulted in a transient deterioration in global health, physical, role, and social functioning and more pain, fatigue and diarrhea at 3 and 6 months following start of treatment compared to standard CRT. From 12 months onwards, the impact of dose-escalated CRT on QoL largely resolved.

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

Background

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

Methods

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

Results

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

Conclusion

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

Adaptive Magnetic Resonance-Guided Stereotactic Body Radiotherapy: The Next Step in the Treatment of Renal Cell Carcinoma

Adaptive MR-guided radiotherapy (MRgRT) is a new treatment paradigm and its role as a non-invasive treatment option for renal cell carcinoma is evolving. The early clinical experience to date shows that real-time plan adaptation based on the daily MRI anatomy can lead to improved target coverage and normal tissue sparing. Continued technological innovations will further mitigate the challenges of organ motion and enable more advanced treatment adaptation, and potentially lead to enhanced oncologic outcomes and preservation of renal function. Future applications look promising to make a positive clinical impact and further the personalization of radiotherapy in the management of renal cell carcinoma.

Management of Long-Term Toxicity From Pelvic Radiation Therapy

Pelvic radiation therapy is an integral component in the treatment of various gastrointestinal, gynecologic, and genitourinary cancers. As survival rates from these malignancies improve, the prevalence of toxicity secondary to pelvic radiation has increased. Gastrointestinal toxicities are the most common complications and greatly impact quality of life. Toxicities can present in acute or late stages; although symptoms may be similar during both, the management may differ. Acute toxicities represent an inflammatory reaction in response to the radiation exposure, whereas late toxicities may arise as a result of small vessel disease, ischemia, and fibrosis. Currently, there are no large clinical trials and only limited guidelines on the management of late gastrointestinal radiation toxicities. Therapy is generally approached in a stepwise manner from medical to endoscopic to surgical methods. Several endoscopic therapies, such as the treatment of radiation proctitis with argon plasma coagulation and dilation of radiation bowel strictures, may prevent the need for surgical intervention, which may be associated with high morbidity and mortality. Given that late toxicities can occur years after radiation therapy, they are often difficult to recognize and diagnose. Successful management of late toxicities requires recognition, an understanding of the underlying pathophysiology, and a multidisciplinary approach. More dedicated research could clarify the prevalence of gastrointestinal pelvic radiation toxicities, permit a better understanding of the efficacy and safety profile of current therapies, and allow for the development of novel therapeutic approaches.

Association of bowel radiation dose-volume with skeletal muscle loss during pelvic intensity-modulated radiotherapy in cervical cancer

BACKGROUND

Radiation-induced bowel damage may compromise nutrient absorption and digestion and affect body composition during pelvic radiotherapy in patients with locally advanced cervical cancer (LACC). This study aimed to evaluate the relationship between bowel radiation dose-volume and body composition changes during pelvic radiotherapy.

METHODS

Data of 301 LACC patients treated with chemoradiotherapy were analyzed. Changes in skeletal muscle index (SMI) and density (SMD), and total adipose tissue index (TATI) were measured from computed tomography images at the L3 vertebral level. A reduction in SMI, SMD, or TATI of ≥10% was classified as "loss." Bowel V45 indicates the bowel volume (mL) receiving a radiation dose of ≥45 Gy. The relationship between body composition and bowel V45 was analyzed using logistic regression models.

RESULTS

After treatment, 61 (20.3%), 81 (26.9%), and 97 (32.2%) patients experienced SMI, SMD, and TATI loss, respectively. Increased bowel V45 was independently associated with increased odds of SMI loss (odds ratio [OR]: 1.012; 95% confidence interval [CI]: 1.007-1.018; p<0.001) and TATI loss (OR: 1.006; 95% CI: 1.001-1.010; p=0.01), but not with SMD loss (OR: 1.005; 95% CI: 1.000-1.009; p=0.054). The cut-off value with the highest accuracy for predicting SMI loss was V45 ≥222 mL; a higher rate of SMI loss was noted in 40.0% of patients with V45 ≥222 mL than in 13.7% of patients with V45 <222 mL (p<0.001).

CONCLUSIONS

Higher bowel dose-volume was significantly associated with muscle loss during pelvic radiotherapy. Bowel dose-volume consideration is required in individualized nutritional counseling and supportive care in clinical practice.

Acute chemoradiotherapy toxicity in cervical cancer patients

During radiotherapy treatment for cervical cancer, up to 84% of patients exhibit some form of acute radiation toxicity (ART). The primary aim of this clinical study is to determine the impact of angiotensin-converting enzyme (ACE) inhibitors, β-blockers and other risk factors such as the patient’s anatomical characteristics on ART emergence in patients with locally advanced cervical cancer treated by chemoradiotherapy. This is a combination of two nested case–control studies within the cohort of patients with locally advanced cervical cancer based on the analysis of potential risk factors for the onset of ART in patients treated with 3D conformal radiotherapy (3D-CRT) and 2D conventional radiotherapy (2D-RT), prospectively followed up from January 2017 to September 2018 in a tertiary care hospital. The ACE inhibitors and bladder volume were identified as factors that significantly affect the occurrence of ART in patients treated with 3D-CRT. In patients treated with 2D-RT, the factors that significantly affect the occurrence of ART were ACE inhibitors, body mass index (BMI), brachytherapy rectal and bladder dose. This study has shown that BMI, radiation dose received by the bladder and rectum are of exceptional importance for the occurrence of the ART and also that therapy with ACE inhibitors was associated with the decreased chances of the ART.

Dietary Habits of Women with Gynecological Cancer before, during and after Treatment: A Long-Term Prospective Cohort Study

BACKGROUND AND AIM

Over 21,000 new cases of gynecological cancer are diagnosed annually in the United Kingdom. There is evidence of cancer patients altering their eating habits before and during treatment. Some women with gynecological cancer make conscious decisions to change their diet as self-management for their cancer symptoms and to adopt a healthier lifestyle. Little is known about the impact of treatment on dietary habits. This study aimed to identify and describe the dietary habits of women with gynecological cancer before, during and after treatment.

METHODS

This was a longitudinal prospective cohort study using seven-day food diaries to collect dietary intake data before treatment and up to two years after gynecological cancer treatment. Nutritics© software was used for analysis of the diaries. A general linear mixed model was used for the statistical analysis, adjusted for multiple comparisons.

RESULTS

15 women with gynecological cancer participated; 69 food diaries were analyzed. There were no statistically significant changes in dietary habits or weight for this cohort during the two-year follow-up, except for caffeine intake which increased at 2 years (p < 0.05).

CONCLUSIONS

Despite the importance of maintaining a healthy dietary intake and weight after cancer treatment, participants' diets did not change.

A Systematic Review: Dietary Habits of Women with Gynecological Cancer before, during and after Treatment

INTRODUCTION

Cancer treatment can affect eating habits and some patients treated with pelvic radiotherapy develop chronic changes in their bowel function which may impact on dietary intake. This systematic review summarizes current research on dietary habits before, during and after treatment in women with a gynecological malignancy.

METHODS

MEDLINE, EMBASE, CINAHL and PubMed databases were searched until August 1, 2019, with no language restrictions. PRISMA guidelines for systematic reviews were used to ensure transparent and complete reporting (Liberati et al., 2009). Quantitative studies exploring dietary habits before, during or after treatment for gynecological cancer were included.

RESULTS

Three prospective cohort studies (98 participants) were included. All patients were treated with radiotherapy; some also had surgery and chemotherapy. Studies reported similar changes in weight, BMI and energy intake and found that patients lose weight during treatment, but this was not long-lasting. Long-term results suggest that fat and protein intake increase significantly (p < 0.01). There was no correlation of symptoms with any nutritional parameters.

CONCLUSION

Evidence from three studies suggests further studies including long-term assessment of dietary intake in women treated for a gynecological malignancy are warranted to explore the impact of cancer treatments on dietary intake and its relation to developing long-term gastrointestinal toxicity.

Diverting colostomy is an effective procedure for ulcerative chronic radiation proctitis patients after pelvic malignancy radiation

Background

Chronic radiation proctitis (CRP) with rectal ulcer is a common complication after pelvic malignancy radiation, and gradually deteriorating ulcers will result in severe complications such as fistula. The aim of this study was to evaluate effect of colostomy on ulcerative CRP and to identify associated influence factors with effectiveness of colostomy.

Methods

Between November 2011 to February 2019, 811 hospitalized patients were diagnosed with radiation-induced enteritis (RE) in Sun Yat-sen University Sixth Affiliated Hospital, among which 284 patients presented with rectal ulcer, and 61 ulcerative CRP patients were retrospectively collected and analyzed.

Results

The overall effective rate of colostomy on ulcerative CRP was 49.2%, with a highest effective rate of 88.2% within 12 to 24 months after colostomy. 9 (31.1%) CRP patients with ulcers were cured after colostomy and 12 (19.67%) patients restored intestinal continuity, among which including 2 (3.3%) patients ever with rectovaginal fistula. 100% (55/55) patients with rectal bleeding and 91.4% (32/35) patients with anal pain were remarkably alleviated. Additionally, multivariable analysis showed the duration of stoma [OR 1.211, 95% CI (1.060–1.382), P = 0.005] and albumin (ALB) level post-colostomy [OR 1.437, 95% CI (1.102–1.875), P = 0.007] were two independent influence factors for the effectiveness of colostomy on the rectal ulcer of CRP patients.

Conclusions

Colostomy was an effective and safe procedure for treating rectal ulcer of CRP patients, and also a potential strategy for preventing and treating fistula. Duration of stoma for 12–24 months and higher ALB level could significantly improve the effectiveness of colostomy on ulcerative CRP patients.

Multicentre clinical radiotherapy audit in rectal cancer: results of the IROCA project

PURPOSE

To perform a clinical audit to assess adherence to standard clinical practice for the diagnosis, treatment, and follow-up of patients undergoing radiotherapy for rectal cancer treatment in four European countries.

MATERIALS AND METHODS

Multi-institutional, retrospective cohort study of 221 patients treated for rectal cancer in 2015 at six European cancer centres. Clinical indicators applicable to general radiotherapy processes were evaluated. All data were obtained from electronic medical records.

RESULTS

The audits were performed in the year 2017. We found substantial inter-centre variability in adherence to standard clinical practices: 1) presentation of cases at departmental clinical sessions (range, 0-100%) or multidisciplinary tumour board (50-95%); 2) pretreatment MRI (61.5-100%) and thoracoabdominal CT (15.0-100%). Large inter-centre differences were observed in the mean interval between biopsy and first visit to the radiotherapy department (range, 21.6-58.6 days) and between the first visit and start of treatment (15.1-38.8 days). Treatment interruptions ≥ 1 day occurred in 43.9% (2.5-90%) of cases overall. Treatment compensation was performed in 2.1% of cases. Treatment was completed in the prescribed time in 55.7% of cases.

CONCLUSIONS

This multi-institutional clinical audit revealed that most centres adhered to standard clinical practices for most of the radiotherapy processes-related variables assessed. However, the audit revealed marked inter-centre variability for certain quality indicators, particularly inconsistent record keeping. Multiple targets for improvement and/or harmonisation were identified, confirming the value of routine clinical audits to detect potential deviations from standard clinical practice.

Patients with radiation enteritis present regulatory T cell impairment associated with CTLA-4

Radiation enteritis is one of the most common side effects of ionizing radiation in patients with pelvic cancers. Increasing amounts of evidence indicate that pro-inflammatory responses significantly contribute to the development of radiation enteritis. In this study, we investigated the association between T regulatory (Treg) cells and the risk of developing radiation enteritis in cervical cancer patients. The following observations were made. First, the frequencies of CD25^hiFoxp3⁺ Treg cells were significantly lower in patients with radiation enteritis than in both healthy subjects and cervical cancer patients without radiation enteritis. Also, patients with the more severe grade 3 enteritis presented significantly lower Treg levels than patients with the more common grade 1 enteritis. Second, the expression of several molecules associated with Treg function, including CTLA-4, IL-10, TGF-β, and perforin, was significantly lower in patients with radiation enteritis than in healthy subjects. In patients without radiation enteritis, however, only CTLA-4, but not other Treg-associated suppressive molecules, was reduced in Treg cells. Third, Treg cells can markedly suppress CD8 T cell proliferation, but in patients with radiation enteritis, this function of Treg cells was significantly impaired, in a manner that was associated with lower CTLA-4 expression. Overall, these data suggest that the frequency and function of Treg cells is negatively associated with the risk of developing enteritis following radiation. In clinical practice, the characteristics of Treg cells may be considered to evaluate the risk of developing enteritis if the cancer patient is receiving ionizing radiation.

Anti-tumor activities of probiotics in cervical cancer

Cervical cancer is considered as an important malignancy among women worldwide. Currently-used treatments of cervical cancer are reported to be cytotoxic for patients. Moreover, these therapies have shown some side effects which can negatively affect the lives of women suffering from this cancer. Therefore, there is need for anti-tumor agents that are less toxic than common therapeutic drugs. Besides, applying agents for preventing or reducing the side effects of cervical cancer therapies can be effective in improving the life quality of cervical cancer patients. Studies have shown that probiotics have several effects on biological processes. One of the most prominent aspects in which probiotics play a role is in the field of cancer. There are multiple studies which have focused on the functions of probiotics in diagnosis, prevention, or treatment of cancer. Besides their direct anti-tumor activities, probiotics can be used as an additional agent for enhancing or modulating other diagnostic and therapeutic methods. Herein, the effects of probiotics on cervical cancer cells are discussed, which may be useful in the prevention and treatment of this cancer. We review the studies concerned with the roles of probiotics in modulating and reducing the gastrointestinal adverse effects caused by cervical cancer therapies. Furthermore, we cover the investigations focusing on the combination of probiotics with other drugs for diagnosis or treatment of cervical cancer.

The mystery of the ureteric stent in the lumen of the terminal ileum

A 65-year-old comorbid female patient presented to our urology department with a history of multiple interventions to treat severe overactive bladder symptoms. She had a history of clam ileocystoplasty, which was then converted to an ileal conduit due to failure to resolve her symptoms. She subsequently developed multiple complications, most significantly ureteroileal stenosis, managed with bilateral ureteric stents. She later decided on bilateral nephrostomies and subsequent antegrade stent insertion. At follow-up, the proximal end of the left stent remained within the kidney and the distal end was free within the abdominal cavity. There was further migration of the stent in its entirety into the lumen of the terminal ileum on subsequent imaging. She denied any significant gastrointestinal symptoms, signs or peritonitis. Consideration was made for the endoscopic removal of the stent by the gastrointestinal team; however, the patient refused any further procedures preferring to be monitored.

When is parenteral nutrition indicated in the hospitalized, acutely ill patient?

PURPOSE OF REVIEW

The current review discusses current practices regarding appropriate indications for parenteral nutrition in acutely ill hospitalized patients. We address-specific indications for parenteral nutrition in the perioperative period, and in inflammatory bowel disease, oncology, hepatobiliary, critical care and end-stage renal disease patients.

RECENT FINDINGS

Acutely ill hospitalized patients can develop intestinal failure requiring parenteral nutrition. Recent studies have provided insight into the main indications. The most common indications for inpatient parenteral nutrition include postsurgical complications, including prolonged ileus, sepsis, fistula and leaks, and bowel obstruction, predominantly malignant. Severe or complicated inflammatory bowel disease and cancer treatment-related mucosal enteropathies (mucositis, enterocolitis, gut graft-versus-host disease) are the next commonest indications. Less frequent indications are primary motility disorders and inability to secure enteral access for enteral nutrition. Gastrointestinal failure of the intensive care patient is a separate entity resulting from multiple mechanisms, including an enteropathy and dysmotility.

SUMMARY

Despite the wider availability of nutrition support teams, use of parenteral nutrition is not without risk. The risks and benefits of parenteral nutrition in the acute setting need to be carefully considered even when it is indicated.

Dislocation Engineered PtPdMo Alloy With Enhanced Antioxidant Activity for Intestinal Injury

Radiotherapy is the mainstay for abdomen and pelvis cancers treatment. However, high energy ray would inflict gastrointestinal (GI) system and adversely disrupt the treatment. The anti-oxidative agents provide a potential route for protecting body from radiation-induced injuries. Herein, highly catalytic nanocubes with dislocation structure are developed for treatment of intestinal injury. Structural and catalytic properties show that Mo incorporation can enhance antioxidant activity by dislocation structure in the alloy. In vitro studies showed that PtPdMo improved cell survival by scavenging radiation-induced ROS accumulation. Furthermore, after animals were exposed to lethal dose of radiation, the survival was increased by 50% with the PtPdMo i.p. treatment. Radioprotection mechanism revealed that PtPdMo alleviated the oxidative stress in multi-organs especially the small intestine by inhibiting intestinal epithelium apoptosis, reducing DNA strands breaks and enhancing repairing ability. In addition, PtPdMo protected hematopoietic system by improving the number of bone marrow and peripheral blood cells.

ASGE guideline on the role of endoscopy for bleeding from chronic radiation proctopathy

Chronic radiation proctopathy is a common sequela of radiation therapy for malignancies in the pelvic region. A variety of medical and endoscopic therapies have been used for the management of bleeding from chronic radiation proctopathy. In this guideline, we reviewed the results of a systematic search of the literature from 1946 to 2017 to formulate clinical questions and recommendations on the role of endoscopy for bleeding from chronic radiation proctopathy. The following endoscopic modalities are discussed in our document: argon plasma coagulation, bipolar electrocoagulation, heater probe, radiofrequency ablation, and cryoablation. Most studies were small observational studies, and the evidence for effectiveness of endoscopic therapy for chronic radiation proctopathy was limited because of a lack of controlled trials and comparative studies. Despite this limitation, our systematic review found that argon plasma coagulation, bipolar electrocoagulation, heater probe, and radiofrequency ablation were effective in the treatment of rectal bleeding from chronic radiation proctopathy.

Total Reference Air Kerma is Associated with Late Bowel Morbidity in Locally Advanced Cervical Cancer Patients Treated with Image-Guided Adaptive Brachytherapy

No dose volume parameter has been identified to predict late bowel toxicities in locally advanced cervical cancer (LACC) patients treated with image-guided adaptive brachytherapy. We examined the incidence of bowel toxicities according to the total reference air kerma (TRAK) in 260 LACC patients. In both univariate and multivariate analysis, late morbidity positively correlated with a TRAK ≥2 cGy (centigray) at 1 meter, emphasizing the importance of this parameter in term of late bowel morbidity. Objective: There is no validated dose volume parameter to predict late bowel toxicities in cervical cancer patients treated with image-guided adaptive brachytherapy (IGABT). We examined the incidence of bowel toxicities according to the TRAK, which is proportional to the integral dose to the patients. Material/Methods: Clinical data of 260 LACC patients treated with curative intent from 2004 to 2016 were examined. Patients received chemoradiation plus a pulse-dose rate IGABT boost. The relationship between TRAK and morbidity was assessed by Kaplan-Meier method, log-rank tests, and Cox proportional-hazards model on event-free periods. Results: Median follow-up was 5.2 years (SE (Standard Error): 0.21). Probability of survival without late bowel toxicity Grade ≥ 2 rate for patients without recurrence (n = 227) at 5 years was 66.4% (SE 3.7). In univariate analysis, bowel and/or sigmoid dose/volume parameters were not significant. Late morbidity positively correlated with active smoking, CTVHR volume >25 cm³, and a TRAK ≥2 cGy at 1 meter. In multivariate analysis, the following factors were significant: Active smoking (p < 0.001; HR: 2.6; 95%CI: 1.4–5.0), and the TRAK (p = 0.02; HR: 2.4; 95%CI: 1.2–5.0). Conclusion: TRAK was associated with late bowel toxicities probability, suggesting that the integral dose should be considered, even in the era of IGABT.

Intake of citrus fruits and vegetables and the intensity of defecation urgency syndrome among gynecological cancer survivors

Background

Despite the experimental evidence that certain dietary compounds lower the risk of radiation-induced damage to the intestine, clinical data are missing and dietary advice to irradiated patients is not evidence-based.

Materials and methods

We have previously identified 28 intestinal health-related symptoms among 623 gynaecological-cancer survivors (three to fifteen years after radiotherapy) and 344 matched population-based controls. The 28 symptoms were grouped into five radiation-induced survivorship syndromes: defecation-urgency syndrome, fecal-leakage syndrome, excessive mucus discharge, excessive gas discharge and blood discharge. The grouping was based on factor scores produced by Exploratory Factor Analysis in combination with the Variable Cutoff Method. Frequency of food intake was measured by a questionnaire. We evaluated the relationship between dietary intake and the intensity of the five syndromes.

Results

With the exception of excessive mucus discharge, the intensity of all syndromes declined with increasing intake of citrus fruits. The intensity of defecation-urgency and fecal-leakage syndrome declined with combined intake of vegetables and citrus fruits. The intensity of excessive mucus discharge was increased with increasing intake of gluten.

Conclusion

In this observational study, we found an association between a high intake of citrus fruits and vegetables and a lower intensity of the studied radiation-induced cancer survivorship syndromes. Our data suggest it may be worthwhile to continue to search for a role of the diet before, during and after radiotherapy to help the cancer survivor restore her or his intestinal health after irradiation.

Specific Members of the Gut Microbiota are Reliable Biomarkers of Irradiation Intensity and Lethality in Large Animal Models of Human Health

The development of effective biomarkers for detecting the magnitude of radiation exposure and resiliency of host response is crucial to identifying appropriate treatment strategies after radiation exposure. We hypothesized that the gastrointestinal resident bacteria would demonstrate predictable, dose-dependent changes after radiation exposure across two large animal models of acute radiation syndrome. Here, Göttingen minipigs (GMP) (n = 50) and rhesus macaques (n = 48) were exposed to five dose levels (resulting in mortality rates of 33-100% and 25-68.7%, respectively). Fecal samples taken prior to and after irradiation (day 0 for GMP; day 0, 3 and 14 for macaques) were used for 16S rRNA gene sequence amplicon high-throughput sequencing. Baseline gut microbiota profiles were dissimilar between GMP and macaques, however, radiation appeared to have similar effect at the phylum level, resulting in Bacteroidetes decrease and Firmicutes increase in both models. The abundance of the main Bacteroidetes genus ( Bacteroides for GMP, Prevotella for macaques) was profoundly decreased by irradiation. Intracellular symbionts [Elusimicrobia in GMP, Treponema (Spirochaetes) in macaques] consistently increased after irradiation, suggesting their use as potential biomarkers of intestinal injury, and potential negative effect on health. Prevotella, Lactobacillus, Clostridium XIVa, Oscillibacter and Elusimicrobium/ Treponema abundances were found to be very significantly correlated with radiation intensity. Furthermore, Prevotella, Enterorhabdus and Ruminococcus and Enterorhabdus maintenance was strongly associated with survival in GMP, while Prevotella, Oscillibacter and Treponema were strongly associated with survival and Streptococcus with death in macaques. Overall, we found that a wide range of gut bacterial genera known to be abundant in the human gut microbiota are excellent biomarkers of radiation intensity and resilience in animal models, and that detrimental effects can be monitored, and potentially prevented, by targeting selected genera.

A comparative analysis of gut microbiota disturbances in the Gottingen minipig and rhesus macaque models of acute radiation syndrome following bioequivalent radiation exposures

In rodent studies, the gut microbiota has been implicated in facilitating both radioresistance, by protecting the epithelium from apoptotic responses and radiosensitivity, inducing endothelial apoptotic responses. Despite the observation that large animal models, such as the Chinese Rhesus macaque and the Gottingen Minipig, demonstrate similarity to human physiologic responses to radiation, little is known about radiation-induced changes of the gut microbiome in these models. To compare the two models, we used bioequivalent radiation doses which resulted in an LD50 for Gottingen Minipigs and Chinese Rhesus macaques, 1.9 Gy and 6.8 Gy, respectively. Fecal samples taken prior and 3 days post-radiation were used for 16S rRNA gene sequence amplicon high throughput sequencing (Illumina MiSeq). Baseline gut microbiota profiles were dissimilar between minipigs and rhesus macaques. Irradiation profoundly impacted gut microbiota profiles in both animals. Significant increases of intracellular symbionts were common to both models and to reported changes in rodents suggesting universality of these findings post-radiation. Remarkably, opposite dynamics were observed for the main phyla, with increase of Firmicutes and decrease of Bacteroidetes and Proteobacteria in minipigs but with enrichment of Bacteroidetes in rhesus macaques. Minipig changes in magnitude and in variety of species affected were more extensive than those observed in rhesus macaques. This pilot study provides an important first step in comparing the radiosensitive pig model to the comparatively more radioresistant macaque model, for the identification of microbial elements which may influence radiosensitivity.

The radiobiological impact of motion tracking of liver, pancreas and kidney SBRT tumors in a MR-linac

The purpose of this work is to evaluate and quantify the potential radiobiological advantages of tumor tracking using the MR-linac for three disease sites: liver, pancreas and kidney. From each disease site, three patients were selected and 4DCT data sets were used. We applied two planning methods using the Monaco treatment planning system (Elekta AB,Stockholm,Sweden): (1) the conventional ITV method using a 6MV Agility beam and (2) a simulated tracking method using MLC GTV tracking with a 7MV MR-linac beam model incorporating a 1.5 T transverse magnetic field. A 5 mm isotropic PTV margin was added to the ITV or the GTV, and 95% of the PTV volume received 100% of the prescription dose. To evaluate the potential radiobiological advantages of tumor tracking, the normal tissue complication probabilities (NTCPs) were calculated for each organ at risk (OAR) using the Layman Kutcher Burman (LKB) model. The average reduction in the target volume, due to tracking, was 31.1%, 26.3% and 26.9% for liver, pancreas and kidney patients, respectively. For each OAR, the % differences in NTCP between the two methods were calculated. The mean 2 Gy equivalent OAR dose for all patients was less than 29.1 Gy, below which the NTCP for most OARs was not sensitive to equivalent uniform dose (EUD). As a result, a NTCP benefit, due to tracking, was observed in 26% of the data. For all three disease sites, the maximum NTCP improvements were for the normal kidney, the bowels, and the duodenum, with reductions in associated toxicities of 79% (radiation nephropathy), 69% (stricture/fistula) and 25% (ulceration), respectively. This study demonstrates the potential benefit of using a MR-linac tracking system to reduce NTCPs. The normal kidney, the bowels and the duodenum showed the largest NTCP improvements. This, in part, is due to the rapid changes in NTCP for small EUD changes.

Enterovaginal and colovesical fistulas as late complications of pelvic radiotherapy

A 72-year-old Japanese woman presented with a fever, diarrhea, intermittent spotting, and constant fluid discharge from the vagina. Imaging studies revealed an enterovaginal fistula. She underwent radical hysterectomy and radiotherapy 35 years previously. She also had a surgical history of nephrostomy, nephrectomy, ileoascending anastomosis, and colostomy. As bleeding from the enterovaginal fistula was uncontrollable, ileocecal resection was performed. However, a colovesical fistula with urinary tract infection occurred 3 months later. The present case indicates that fistula formation occurs and causes various symptoms in patients who underwent postpelvic radiotherapy, particularly in those with prior surgeries in the irradiated field.

Expression of vascular endothelial growth factor and its correlation with clinical symptoms and endoscopic findings in patients with chronic radiation proctitis

AIM

The aim of this study was to assess the expression of vascular endothelial growth factor (VEGF) as a key proangiogenic factor and determine whether there is any correlation between its expression and clinical symptoms or endoscopic changes in patients with chronic radiation proctitis (ChRP).

METHOD

Fifty patients who had all undergone radiotherapy for prostate, cervical or uterine cancer were included in the study (37 women, 13 men). There was a control group of 20 patients (9 women, 11 men). The Radiation Therapy Oncology Group/European Organization for Research and Treatment of Cancer (RTOG/EORTC) scoring system was used for grading the severity of the proctitis. Endoscopic scoring of late rectal mucosal damage was performed using Gilinsky's classification. Serum levels of VEGF were analysed by the enzyme-linked immunosorbent assay method.

RESULTS

Most patients presented with Grade 1 symptoms. Endoscopic assessment showed that most patients had Grade 1 late rectal mucosal damage. The predominant endoscopic finding was the presence of telangiectasia. Assessment of VEGF correlation between the control group and the degrees of endoscopic changes showed statistically significant differences for all three degrees (P < 0.0001, P = 0.0251 and P = 0.0005, respectively). Due to the small numbers of patients with Grades 2 and 3 symptoms using the RTOG/EORTC scoring system, they were grouped with Grades 1 and 4 respectively forming two groups for statistical purposes. VEGF expression differed significantly between controls and group I and between controls and group II (P = 0.0001, P = 0.0009, respectively).

CONCLUSION

A significant increase in VEGF expression was found to correlate with clinical symptoms and endoscopic rectal mucosa changes in patients with ChRP, suggesting that it may play an important role in pathological angiogenesis.

Body Composition Early Identifies Cancer Patients With Radiotherapy at Risk for Malnutrition

CONTEXT

The side effects of radiotherapy (RT) and the occurrence of comorbidity often result in appetite loss in patients, which leads to serious nutritional problems, significantly affecting the patients' treatment results and disease prognosis.

OBJECTIVES

We aimed to investigate changes in the body composition of patients with cancer from the time they received RT to three months after completion of RT.

METHODS

A total of 101 cancer patients who received RT, which included head or neck cancer, chest or breast cancer, and abdominal or pelvic cancer patients, were recruited. A longitudinal study design was adopted, in which the body composition analyzer In Body3.0 was used to obtain patient data at six different time points. The data were analyzed through generalized estimating equation.

RESULTS

All patients with cancer had the lowest body mass index at the end of RT. For head or neck cancer patients, their total body water and muscle mass decreased significantly in the fourth week of RT and at the end of RT. For chest or breast cancer patients, their body fat mass changed significantly in the second and fourth weeks of RT (β = -0.57, P = 0.0233; β = -3.23, P = 0.0254). For abdominal or pelvic cancer patients, their total body weight and muscle mass decreased significantly in the second week of RT and at the end of RT (β = -1.07, P = 0.0248; β = -5.13, P = 0.0017; β = -1.37, P = 0.0245; β = -6.50, P = 0.0016); their body fat mass increased significantly in the third month after RT (β = 4.61, P = 0.0072).

CONCLUSION

Body composition analysis can be used to promptly and effectively monitor changes in the nutritional status of patients with cancer during the cancer treatment period; changes in the body composition at different repetitions differ between patients with dissimilar cancers.

Role of Systematic Lymphadenectomy to Tailor Adjuvant Therapy in Early Endometrial Cancer

OBJECTIVE

The long-standing protocol at our center for apparent stage I and II endometrial cancers comprises hysterectomy and bilateral salpingo-oophorectomy without lymphadenectomy. Adjuvant treatment is based in line with Postoperative Radiation Therapy in Endometrial Carcinoma 1 protocol. Our aim was to quantify the number of patients who would avoid external beam radiation therapy (EBRT) in our institution if we adopted a protocol of lymphadenectomy to tailor adjuvant EBRT and its impact on cost and quality of life.

DESIGN

Retrospective case-cohort study.

SETTING

Gynecological oncology center.

METHODS

All endometrial cancers treated from 2007 to 2012 were included. The European Organization for Research and Treatment of Cancer (EORTC) quality of life (QLQ-30) and endometrial cancer specific (EN-24) questionnaires were used to measure the quality of life. The NHS tariff for EBRT, VBT and lymphadenectomy were obtained from our Trust's contract with the local commissioning groups.

MAIN OUTCOME MEASURES

Quality of life and cost.

RESULTS

Systematic pelvic lymphadenectomy in early endometrial cancers of all grades would avoid EBRT in 23.3% of patients, and if performed for grade 2 and 3 cancers, 39.5% of patients would avoid EBRT. The global health scores were significantly lower, and pain scores were considerably higher in patients who received EBRT. Performing systematic lymphadenectomy and tailored adjuvant therapy in grade 2 and 3 endometrial cancers would save £134,691 and for all grades save £37,161 for every 100 patients treated with early endometrial cancer.

CONCLUSION

Systematic lymphadenectomy with tailored adjuvant therapy may offer better QoL with reduced cost to NHS without a reduction in overall survival.

Late small bowel toxicity after aggressive abdominopelvic intensity modulated radiation therapy

Purpose

We retrospectively analyzed late small bowel toxicity in patients who received abdominal or pelvic intensity modulated radiation therapy (IMRT) to the small bowel with a maximum dose greater than the generally accepted maximal tolerable dose of 45 Gy.

Methods and materials

All patients (N = 94) who received IMRT with a point dose of at least 45 Gy to tightly contoured small bowel between 2005 and 2014 at our institution were included. The median prescribed treatment dose was 70.2 Gy. The median follow-up was 20.1 months. Late small bowel toxicity was assessed using the Common Terminology Criteria for Adverse Events Version 3.0. Dosimetric variables and clinical factors were assessed for their relationship to small bowel toxicity.

Results

The median maximal small bowel point dose (D_max) was 6546.5 cGy. The estimated 5-year rates of freedom from at least grade 1, at least grade 2, and at least grade 3 late small bowel toxicity were 72.4% (95% confidence interval [CI], 60.7%-86.5%), 91.9% (95% CI, 84.1%-100%), and 93.6% (95% CI, 86.2%-100%), respectively. One patient (1.1%) developed grade 3 late toxicity, and 2 patients (2.1%) developed grade 4 late toxicity. Use of capecitabine/5-fluorouracil treatment was a significant predictor (P < 0.001) of at least grade 1 and at least grade 2 small bowel toxicity. No other clinical factors were associated with toxicity. None of the dose-volume parameters were significant predictors of small bowel toxicity.

Conclusion

It may be possible with IMRT to deliver high doses to small volumes of small bowel with low rates of significant long-term complications. Further studies should explore tolerable dose-volume relationships in cases in which aggressive abdominal or pelvic treatment may be warranted to treat the underlying malignancy.

Robotic Placement of the FENIX Continence Restoration System in a Patient with Previous Radiation to the Pelvis: A Case Report

Fecal incontinence (FI) is a disabling problem affecting women. Conservative treatment includes dietary modification, antimotility agents, and pelvic floor physical therapy. If conservative medical management is unsuccessful, surgical intervention may be required. Surgical options include rectal sphincteroplasty, bulking agent injection, radiofrequency anal sphincter remodeling, and sacral nerve stimulation therapy. Recently, a new therapy for FI, the FENIX Continence Restoration System (Torax Medical, Inc., Shoreview, MN), has become available. The FENIX device is placed through a perineal incision; however, pelvic radiation and previous anal carcinoma are both contraindications. We report the case of a 62-year-old woman with FI after anal carcinoma. Treatment included surgery, chemotherapy, and pelvic radiation. Initially, she was treated with conservative therapy and sacral nerve stimulation, which were only partially effective. A physical examination showed perineal skin changes consistent with previous radiation, which increased the patient's risk of infection and a nonhealing wound. Therefore, a robotic approach was used to place the FENIX device and improve the patient's quality of life. Our case sets a precedent for expanding the treatment options of FI in patients with previous pelvic radiation and using a robotic approach for the placement of the FENIX device.

Late radiation-induced bowel syndromes, tobacco smoking, age at treatment and time since treatment - gynecological cancer survivors

BACKGROUND

It is unknown whether smoking; age at time of radiotherapy or time since radiotherapy influence the intensity of late radiation-induced bowel syndromes.

MATERIAL AND METHODS

We have previously identified 28 symptoms decreasing bowel health among 623 gynecological-cancer survivors (three to twelve years after radiotherapy) and 344 matched population-based controls. The 28 symptoms were grouped into five separate late bowel syndromes through factor analysis. Here, we related possible predictors of bowel health to syndrome intensity, by combining factor analysis weights and symptom frequency on a person-incidence scale.

RESULTS

A strong (p < .001) association between smoking and radiation-induced urgency syndrome was found with a syndrome intensity (normalized factor score) of 0.4 (never smoker), 1.2 (former smoker) and 2.5 (current smoker). Excessive gas discharge was also related to smoking (p = .001). Younger age at treatment resulted in a higher intensity, except for the leakage syndrome. For the urgency syndrome, intensity decreased with time since treatment.

CONCLUSIONS

Smoking aggravates the radiation-induced urgency syndrome and excessive gas discharge syndrome. Smoking cessation may promote bowel health among gynecological-cancer survivors. Furthermore, by understanding the mechanism for the decline in urgency-syndrome intensity over time, we may identify new strategies for prevention and alleviation.

Safety and efficacy of semiextended field intensity-modulated radiation therapy and concurrent cisplatin in locally advanced cervical cancer patients: An observational study of 10-year experience

Patients with locally advanced cervical cancer (LACC) are at risk of para-aortic lymph node (PALN) metastasis. Pelvic concurrent chemoradiotherapy, the current standard treatment for LACC, has a PALN failure rate of 9% according to the Radiation Therapy Oncology Group Trial 90-01, suggesting that it may not completely eliminate all microscopic tumors in the PALNs. To minimize the toxicities associated with conventional prophylactic extended-field radiotherapy, our institute use prophylactic semiextended field radiotherapy that includes only the PALNs below the level of the renal vessels. Use of intensity-modulated radiotherapy (IMRT) is another means of reducing the incidence of toxicity. This study evaluated the safety and efficacy of prophylactic semiextended field IMRT (SEF-IMRT) and concurrent cisplatin chemotherapy in patients with LACC.We retrospectively assessed survival and toxicity in 76 patients with stage IB2-IVA cervical cancer and negative PALNs who received prophylactic SEF-IMRT and concurrent weekly cisplatin (40 mg/m) between 2004 and 2013. The region targeted by SEF-IMRT included the PALNs below the level of the renal vessels, and the prescribed dose was 50.4 Gy in 28 fractions. Brachytherapy was administered at a dose of 30 Gy in 6 fractions. Survival outcomes were calculated by using the Kaplan-Meier method, and acute and late toxicities were scored according to the Common Terminology Criteria for Adverse Events, version 3.0.All patients completed the planned SEF-IMRT, as well as brachytherapy. Acute grade ≥3 gastrointestinal, genitourinary, and hematologic toxicities were observed in 2, 0, and 41 patients, respectively. The median follow-up time after SEF-IMRT was 55 (range, 11-124) months. Eight patients developed out-field distant recurrences without PALN failure, and 1 patient experienced out-field PALN failure with simultaneous distant metastasis. No patients had late genitourinary toxicities, and 3 patients had late grade 3 gastrointestinal toxicities. The 5-year overall survival, disease-free survival, local failure-free survival, regional failure-free survival, PALN failure-free survival, and distant metastasis-free survival rates were 85.0%, 84.4%, 96.0%, 97.3%, 98.6%, and 88.4%, respectively.For patients with LACC, prophylactic PALN irradiation up to the level of the renal vessels reduced PALN recurrence and resulted in favorable outcomes with few severe toxicities.

A Factor Analysis Approach for Clustering Patient Reported Outcomes

BACKGROUND

In the field of radiation oncology, the use of extensive patient reported outcomes is increasingly common to measure adverse side effects after radiotherapy in cancer patients. Factor analysis has the potential to identify an optimal number of latent factors (i.e., symptom groups). However, the ultimate goal of treatment response modeling is to understand the relationship between treatment variables such as radiation dose and symptom groups resulting from FA. Hence, it is crucial to identify clinically more relevant symptom groups and improved response variables from those symptom groups for a quantitative analysis.

OBJECTIVES

The goal of this study is to design a computational method for finding clinically relevant symptom groups from PROs and to test associations between symptom groups and radiation dose.

METHODS

We propose a novel approach where exploratory factor analysis is followed by confirmatory factor analysis to determine the relevant number of symptom groups. We also propose to use a combination of symptoms in a symptom group identified as a new response variable in linear regression analysis to investigate the relationship between the symptom group and dose-volume variables.

RESULTS

We analyzed patient-reported gastrointestinal symptom profiles from 3 datasets in prostate cancer patients treated with radiotherapy. The final structural model of each dataset was validated using the other two datasets and compared to four other existing FA methods. Our systematic EFA-CFA approach provided clinically more relevant solutions than other methods, resulting in new clinically relevant outcome variables that enabled a quantitative analysis. As a result, statistically significant correlations were found between some dose-volume variables to relevant anatomic structures and symptom groups identified by FA.

CONCLUSIONS

Our proposed method can aid in the process of understanding PROs and provide a basis for improving our understanding of radiation-induced side effects.

Enhancing Care of the Survivor of Gynecologic Cancer: Managing the Menopause and Radiation Toxicity

It is expected that there will be 290,000 cases of gynecologic cancers in 2016. Of these cancers, 60,000 will be endometrial and 22,000 will be ovarian-the two most common gynecologic cancers. Endometrial and ovarian cancers occur in menopausal women with mean ages of 60 and 63, respectively. The majority of endometrial cancers are early stage, and 5-year survival is considered good at upwards of 75%. For ovarian cancer, while survival rates have improved, the 5-year survival rate for the most common stage (stage III) is 40%. Thus, a substantial number of patients with gynecologic cancer are menopausal, and a significant number of patients are survivors, particularly of endometrial cancers. It will be important for survivors of gynecologic cancers to receive care tailored to their needs as women and to mitigate gender-specific side effects of their cancer treatment.

Outcome of international Federation of gynecology and obstetrics stage IIb cervical cancer from 2003 to 2012: an evaluation of treatments and prognosis: a retrospective study

OBJECTIVE

To compare the clinical outcomes of patients with International Federation of Gynecology and Obstetrics (FIGO) stage IIB cervical carcinoma receiving neoadjuvant chemotherapy followed by radical hysterectomy (RH) with those of patients receiving chemoradiation therapy (CRT) alone.

METHODS

We retrospectively reviewed the medical records of patients with FIGO stage IIB cervical carcinoma. A total of 621 patients were eligible for the study according to the surgery-based or radiotherapy-based treatment; 285 patients received cisplatin-based neoadjuvant chemotherapy (NACT) followed by RH, and 336 patients underwent sequential or concurrent chemoradiation. The disease-free survival, overall survival, recurrence rates, and late complications were compared. Cox regression analysis was used to identify potential prognostic factors.

RESULTS

Complete or partial response was seen in 77.6% (221/285) of the NACT-treated patients. Disease-free survival and overall survival rates of the patients who had NACT-sensitive responses were significantly higher than those who did not response (P = 0.021 and P = 0.008). Overall survival rates in the NACT + RH group were comparable with the concurrent chemoradiotherapy or chemoradiation groups (P > 0.05). Neoadjuvant chemotherapy followed by RH significantly decreased the recurrence rate (22.6% vs 35.5%), resulted in fewer treatment-related complications, and ultimately improved survival when compared with concurrent CRT. A survival benefit was observed for 63.9% of the patients in the NACT + RH group without adjuvant radiotherapy or CRT.

CONCLUSIONS

Compared with concurrent chemoradiotherapy, NACT followed by RH achieved comparable survival outcomes for patients with FIGO stage IIB cervical cancer. This treatment method was significantly effective at reducing radiotherapy rates and complications, and it is worthy of recommending for younger patients.

Should Systematic Infrarenal Para-aortic Dissection Be the Rule in the Pretherapeutic Staging of Primary or Recurrent Locally Advanced Cervix Cancer Patients With a Negative Preoperative Para-aortic PET Imaging?

Background

Extended-field chemoradiation is the usual management of patients with locally advanced cervical cancer (LACC) and para-aortic node metastases (PA pN1). It is efficient but not without morbidity. Assessment of PA lymph node positivity by PA lymphadenectomy is the most accurate method to select the candidates for this treatment. Hence, to clarify the dissection pattern, we wanted to test the true incidence of isolated/skip node metastasis, above the level of the inferior mesenteric artery (IMA).

Materials and Methods

All patients with LACC and negative magnetic resonance imaging and positron emission tomography–computed tomography imaging at the PA level were offered a laparoscopic staging encompassing a diagnostic laparoscopy followed, if negative, by an extraperitoneal PA lymphadenectomy. All nodes were removed from both common iliac bifurcations up to the left renal vein. Node groups, below and above the IMA, were separately sent to the pathologist for definitive examination.

Results

From January 2010 to December 2013, 196 stage IB1 with pelvic pN1, IB2, to IVA LACC patients from 2 cancer centers who fulfilled the criteria were included in this institutional review board–approved study after informed consent. Thirty patients (15%) had PA pN1. Only 1 patient had positive nodes exclusively located above the IMA (3.3% of the pN1 group; 95% confidence interval, 0%–9.7%). Complications were observed in 15 (7.6%) of 196 patients.

Conclusions

Given the very low rate of skip metastases above the IMA and the potential additional morbidity of a systematic extended dissection, a bilateral ilioinframesenteric dissection seems to be an acceptable pattern of PA lymphadenectomy in LACC patients.

Optimal Extent of Prophylactic Irradiation of Paraaortic Lymph Nodes in Patients with Uterine Cervical Cancer

Purpose

The purpose of this study was to determine optimal extent of prophylactic irradiation of paraaortic lymph nodes (PALN) in patients with uterine cervical cancer who had metastatic pelvic LNs.

Methods and Materials

We retrospectively evaluated 103 patients with cervical cancer and pelvic lymph node metastasis who were treated with prophylactic semi-extended field radiotherapy (SEFRT) between 1990 and 2012. The semi-extended field included PALN below the second lumbar spine with prescribed doses of 45 to 50 Gy. Survival outcomes were calculated using the Kaplan-Meier method, and acute and late toxicities were scored using the Radiation Therapy Oncology Group and European Organisation for Research and Treatment of Cancer toxicity criteria.

Results

The median follow-up after SEFRT was 61 (range 5–296) months. Overall, 28 patients (27.2%) experienced treatment failures, which were classified as local in 8 patients (7.8%), regional in 8 patients (7.8%), and distant in 13 patients (12.6%). Of the regional failures, only two involved PALN failure around the renal artery or the renal hilum area at the upper margin of the semi-extended field. At 5 years, the overall survival was 82%. Grade 3 or higher acute gastrointestinal and genitourinary toxicities occurred in one and two patients, respectively. As a late toxicity, one patient developed grade 3 small bowel obstruction.

Conclusion

Prophylactic SEFRT provided favorable outcomes with little acute or late gastrointestinal toxicity. For prophylaxis of PALN recurrences, upper part of PALN might not need to be included in patients with uterine cervical cancer and metastatic pelvic LNs.

Chronic radiation proctitis: tricks to prevent and treat

OBJECTIVE

The purpose of this study was to give an overview of the measures used to prevent chronic radiation proctitis (CRP) and to provide an algorithm for the treatment of CRP.

METHODS

Medical literature databases including PubMed and Medline were screened and critically analyzed for relevance in the scope of our purpose.

RESULTS

CRP is a relatively frequent late side effect (5-20%) and mainly dependent on the dose and volume of irradiated rectum. Radiation treatment (RT) techniques to prevent CRP are constantly improving thanks to image-guided RT and intensity-modulated RT. Also, newer techniques like protons and new devices such as rectum spacers and balloons have been developed to spare rectal structures. Biopsies do not contribute to diagnosing CRP and should be avoided because of the risk of severe rectal wall damage, such as necrosis and fistulas. There is no consensus on the optimal treatment of CRP. A variety of possibilities is available and includes topical and oral agents, hyperbaric oxygen therapy, and endoscopic interventions.

CONCLUSIONS

CRP has a natural history of improving over time, even without treatment. This is important to take into account when considering these treatments: first be conservative (topical and oral agents) and be aware that invasive treatments can be very toxic.