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Kohoutova D, Wilson A, Gee C, Elhusseiny R, Wanders L, Cunningham D. Intrarectal formalin treatment for haemorrhagic radiation-induced proctopathy: efficacy and safety. Colorectal Dis 2024; 26:932-939. [PMID: 38519847 DOI: 10.1111/codi.16956] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2022] [Revised: 01/15/2024] [Accepted: 03/01/2024] [Indexed: 03/25/2024]
Abstract
AIM Pelvic radiotherapy is limited by dose-dependent toxicity to surrounding organs. The aim of this prospective study was to evaluate the efficacy and safety of intrarectal formalin treatment for radiotherapy-induced haemorrhagic proctopathy (RHP) at the Royal Marsden Hospital. METHOD Adult patients were enrolled. Haemoglobin was evaluated before and after formalin treatment. Antiplatelet and/or anticoagulation treatment and administration of transfusion were recorded. The interval between completion of radiotherapy and the first intrarectal 5% formalin treatment was assessed and the dose of radiotherapy was evaluated. Clinical assessment of the frequency and amount of rectal bleeding (rectal bleeding score 1-6) and endoscopic appearance (grade 0-3) were classified. Complications were recorded. RESULTS Nineteen patients were enrolled, comprising 13 men (68%) and 6 women. The mean age was 75 ± 9 years. The median time between completion of radiotherapy and the first treatment was 20 months [interquartile range (IQR) 15 months] and the median dose of radiotherapy was 68 Gy (IQR 14 Gy). Thirty-two procedures were performed (average 1.7 per patient). In total, 9/19 (47%) patients were receiving anticoagulation and/or antiplatelet medication and 5/19 (26%) received transfusion prior to treatment. The mean value of serum haemoglobin before the first treatment was 110 ± 18 g/L and afterwards it was 123 ± 16 g/L (p = 0.022). The median rectal bleeding score before the first treatment was 6 (IQR 0) and afterwards 2 (IQR 1-4; p < 0.001), while the median endoscopy score on the day of first treatment was 3 (IQR 0) compared with 1 (IQR 1-2) on the day of the last treatment 1 (p < 0.001). One female patient with a persistent rectal ulcer that eventually healed (18 months of healing) subsequently developed rectovaginal fistula (complication rate 1/19, 5%). CONCLUSIONS Treatment with intrarectal formalin in RHP is effective and safe.
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Affiliation(s)
| | - Ana Wilson
- The Royal Marsden Hospital NHS Foundation Trust, London, UK
- St Mark's Hospital, London, UK
| | - Caroline Gee
- The Royal Marsden Hospital NHS Foundation Trust, London, UK
| | | | - Linda Wanders
- The Royal Marsden Hospital NHS Foundation Trust, London, UK
- Amsterdam UMC, Location VUMC, Amsterdam, The Netherlands
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Sauvage LM, Bentahila R, Tran Y, Guénégou-Arnoux A, Fabiano E, Bats AS, Borghese B, Durdux C. Radiation Proctitis in Patients With Locally Advanced Cervical Cancer Treated by Chemoradiation: Analysis and Predictive Factors From a Retrospective Cohort. Am J Clin Oncol 2024:00000421-990000000-00181. [PMID: 38557436 DOI: 10.1097/coc.0000000000001092] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/04/2024]
Abstract
BACKGROUND Radiation proctitis is a misunderstanding complication of chemoradiation in locally advanced cervical cancer. The objective of our study is to provide a detailed description and analysis of predictive factors associated with radiation proctitis in a retrospective cohort of patients treated by chemoradiation for locally advanced cervical cancer. METHODS All patients treated by exclusive chemoradiation or chemoradiation followed by brachytherapy for locally advanced cervical cancer from 2011 to 2017 were included in the study. A bivariate analysis was conducted to establish correlations between the occurrence of radiation proctitis and various clinical and technical variables. RESULTS A total of 128 patients were included in the study. The mean dose (SD) to the planning target volume was 47.1 Gy (6.2). Fifty-nine (46.1%) patients underwent brachytherapy. Sixteen patients (12.5%) developed radiation proctitis, grade 2 or higher in 12 patients (9.3%). In univariate analysis, anticoagulant or antiplatelet treatments (P=0.039), older age (P=0.049), rectal volume irradiated at 40 Gy (P=0.01) and 30 Gy (P=0.037) were significantly associated with the occurrence of a grade ≥2 radiation proctitis. The delivered dose to 2 cm3 of rectum (D2cm3) showed a potential association with the occurrence of radiation proctitis of all grades (P=0.064). CONCLUSION This study highlights clinical and technical factors that should be considered in assessing the risk of radiation proctitis. These results contribute to a better understanding of this complication.
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Affiliation(s)
- Louis-Marie Sauvage
- Department of Clinical Research, Clinical Investigations-Epidemiology Center, INSERM
| | - Rita Bentahila
- Department of Clinical Research, Clinical Investigations-Epidemiology Center, INSERM
| | - Yohan Tran
- Department of Clinical Research, Clinical Investigations-Epidemiology Center, INSERM
| | | | - Emmanuelle Fabiano
- Department of Clinical Research, Clinical Investigations-Epidemiology Center, INSERM
| | | | - Bruno Borghese
- Department of Gynecology, Cochin-Port Royal Hospital, Paris-Cité University, Paris, France
| | - Catherine Durdux
- Department of Clinical Research, Clinical Investigations-Epidemiology Center, INSERM
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3
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Tang CE, Cheng KC, Wu KL, Chen HH, Lee KC. A Retrospective Single-Arm Cohort Study in a Single Center of Radiofrequency Ablation in Treatment of Chronic Radiation Proctitis. Life (Basel) 2023; 13:life13020566. [PMID: 36836925 PMCID: PMC9958826 DOI: 10.3390/life13020566] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2022] [Revised: 01/21/2023] [Accepted: 02/15/2023] [Indexed: 02/22/2023] Open
Abstract
BACKGROUND Chronic radiation proctitis (CRP) may develop in patients within months to years after undergoing pelvic radiotherapy. Numerous treatment modalities are available to achieve hemostasis in CRP, but the optimal treatment remains controversial. We report our clinical experience and long-term outcomes using radiofrequency ablation (RFA) in patients with CRP. METHODS We retrospectively reviewed patients who underwent RFA for CRP at Kaohsiung Chang Gung Memorial Hospital between October 2015 and March 2021. The patient characteristics, endoscopic findings, and clinical outcomes were collected and analyzed. RESULTS 35 total patients were enrolled in the study. The mean age was 70.5 ± 12.4 years. All patients sustained repeated rectal bleeding before RFA, and 15 of 35 patients needed blood transfusion. Bleeding cessation was achieved in all patients. Mean follow-up time was 18.6 months (ranging from 2 to 52 months). The hemoglobin (Hb) levels at 6 months after RFA revealed significant improvement from 11.0 ± 2.3 to 11.8 ± 1.9 g/dL (p = 0.048). The rectal telangiectasia density (RTD) scores also showed significant improvement from 2.96 ± 0.2 to 0.85 ± 0.7 (p < 0.0001). In conclusion, RFA treatment is safe and effective in controlling rectal bleeding in CRP without serious complications and can be considered as a first-line or alternative endoscopic treatment for patients with CRP.
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Affiliation(s)
| | | | | | | | - Ko-Chao Lee
- Correspondence: ; Tel.: +886-7-7317123; Fax: +886-7-7318762
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4
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Zeng Q, Cheng J, Wu H, Liang W, Cui Y. The dynamic cellular and molecular features during the development of radiation proctitis revealed by transcriptomic profiling in mice. BMC Genomics 2022; 23:431. [PMID: 35681125 PMCID: PMC9178886 DOI: 10.1186/s12864-022-08668-5] [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: 03/08/2022] [Accepted: 05/30/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Radiation proctitis (RP) is the most common complication of radiotherapy for pelvic tumor. Currently there is a lack of effective clinical treatment and its underlying mechanism is poorly understood. In this study, we aimed to dynamically reveal the mechanism of RP progression from the perspective of RNomics using a mouse model, so as to help develop reasonable therapeutic strategies for RP. RESULTS Mice were delivered a single dose of 25 Gy rectal irradiation, and the rectal tissues were removed at 4 h, 1 day, 3 days, 2 weeks and 8 weeks post-irradiation (PI) for both histopathological assessment and RNA-seq analysis. According to the histopathological characteristics, we divided the development process of our RP animal model into three stages: acute (4 h, 1 day and 3 days PI), subacute (2 weeks PI) and chronic (8 weeks PI), which could recapitulate the features of different stages of human RP. Bioinformatics analysis of the RNA-seq data showed that in the acute injury period after radiation, the altered genes were mainly enriched in DNA damage response, p53 signaling pathway and metabolic changes; while in the subacute and chronic stages of tissue reconstruction, genes involved in the biological processes of vessel development, extracellular matrix organization, inflammatory and immune responses were dysregulated. We further identified the hub genes in the most significant biological process at each time point using protein-protein interaction analysis and verified the differential expression of these genes by quantitative real-time-PCR analysis. CONCLUSIONS Our study reveals the molecular events sequentially occurred during the course of RP development and might provide molecular basis for designing drugs targeting different stages of RP development.
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Affiliation(s)
- Qingzhi Zeng
- Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, Guangdong Institute of Gastroenterology, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, 510655, China
| | - Jingyang Cheng
- Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, Guangdong Institute of Gastroenterology, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, 510655, China
| | - Haiyong Wu
- Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, Guangdong Institute of Gastroenterology, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, 510655, China
| | - Wenfeng Liang
- Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, Guangdong Institute of Gastroenterology, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, 510655, China
| | - Yanmei Cui
- Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, Guangdong Institute of Gastroenterology, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, 510655, China.
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5
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Sammour T, Kahokehr AA. Pelvic Radiation Disease. Clin Colon Rectal Surg 2022; 35:204-211. [PMID: 35966384 PMCID: PMC9374535 DOI: 10.1055/s-0041-1740041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/14/2023]
Abstract
Pelvic radiation is increasingly being used for the neoadjuvant and definitive treatment of pelvic organ malignancy. While this treatment can be highly effective, and may assist in organ sparing, it is also associated with significant toxicity and devastating adverse events that need to be considered. In broad terms, pelvic radiation disease affects both the primary target organ as well as adjacent organs and soft tissue structures, with complications that can be classified and graded according to consensus criteria. The complication grade is often modality, dose, and area dependent. The most common manifestations are proctitis, cystitis, recto-urethral fistula, ureteric stricture, and bone involvement. Toxicity can be misdiagnosed for many years, resulting in significant management delays. Complications can be difficult to prevent and challenging to treat, requiring specialized multi-disciplinary input to achieve the best possible strategy to minimize impact and improve patient quality of life.
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Affiliation(s)
- Tarik Sammour
- Department of Colorectal Surgery, University of Adelaide, Royal Adelaide Hospital, Wayfinding, Adelaide, Australia,Address for correspondence Tarik Sammour, MBChB, FRACS, CSSANZ, PhD Colorectal Unit, Department of Surgery, Royal Adelaide HospitalWayfinding 5E.334, Port Road, Adelaide, SA 5000Australia
| | - Arman A. Kahokehr
- Department of Urology, Flinders University, Lyell McEwin Hospital, Adelaide, Australia
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6
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Lu W, Xie Y, Huang B, Ma T, Wang H, Deng B, Zou S, Wang W, Tang Q, Yang Z, Li X, Wang L, Fang L. Platelet-derived growth factor C signaling is a potential therapeutic target for radiation proctopathy. Sci Transl Med 2021; 13:13/582/eabc2344. [PMID: 33627485 DOI: 10.1126/scitranslmed.abc2344] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2020] [Accepted: 02/03/2021] [Indexed: 12/17/2022]
Abstract
Radiation proctopathy (RP) is characterized by inflammation of colorectal tissue and is a common complication of radiation therapy for pelvic malignancies with high incidence but lacking effective treatment. Here, we found that platelet-derived growth factor C (PDGF-C) and fibrosis markers were up-regulated in tissue samples from patients with RP and in rectal tissues after irradiation in a mouse model of RP. Genetic deletion of Pdgf-c in mice ameliorated RP-induced injuries. Genome-wide gene expression profiling and in vitro assays revealed that the promotive effect of PDGF-C in RP development was mediated by activation of PDGF receptors (PDGFRs) and C-X-C motif chemokine receptor 4, a proinflammatory chemokine regulated by transcription factor ETS variant transcription factor 1. Treatment with crenolanib, a selective inhibitor of PDGFRs, prevented or reduced RP in mice after irradiation. These results reveal that inhibition of PDGF-C signaling may have therapeutic value for the treatment of RP.
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Affiliation(s)
- Weisi Lu
- Guangdong Provincial Key laboratory of Colorectal and Pelvic Floor Disease, Guangdong Research Institute of Gastroenterology, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou 510655, China. .,State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-sen University, Guangzhou 510655, China
| | - Yunling Xie
- Guangdong Provincial Key laboratory of Colorectal and Pelvic Floor Disease, Guangdong Research Institute of Gastroenterology, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou 510655, China
| | - Binjie Huang
- Guangdong Provincial Key laboratory of Colorectal and Pelvic Floor Disease, Guangdong Research Institute of Gastroenterology, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou 510655, China
| | - Tenghui Ma
- Department of Colorectal Surgery, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou 510655, China
| | - Huaiming Wang
- Department of Colorectal Surgery, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou 510655, China
| | - Boxiong Deng
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-sen University, Guangzhou 510655, China
| | - Shaomin Zou
- Guangdong Provincial Key laboratory of Colorectal and Pelvic Floor Disease, Guangdong Research Institute of Gastroenterology, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou 510655, China
| | - Wencong Wang
- Guangdong Provincial Key laboratory of Colorectal and Pelvic Floor Disease, Guangdong Research Institute of Gastroenterology, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou 510655, China
| | - Qin Tang
- Guangdong Provincial Key laboratory of Colorectal and Pelvic Floor Disease, Guangdong Research Institute of Gastroenterology, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou 510655, China
| | - Ziqing Yang
- Guangdong Provincial Key laboratory of Colorectal and Pelvic Floor Disease, Guangdong Research Institute of Gastroenterology, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou 510655, China.,Department of Colorectal Surgery, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou 510655, China
| | - Xuri Li
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-sen University, Guangzhou 510655, China.
| | - Lei Wang
- Guangdong Provincial Key laboratory of Colorectal and Pelvic Floor Disease, Guangdong Research Institute of Gastroenterology, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou 510655, China.,Department of Colorectal Surgery, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou 510655, China
| | - Lekun Fang
- Guangdong Provincial Key laboratory of Colorectal and Pelvic Floor Disease, Guangdong Research Institute of Gastroenterology, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou 510655, China. .,Department of Colorectal Surgery, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou 510655, China
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7
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Proktologische Nebenwirkungen nach Strahlentherapie gynäkologischer Tumoren. COLOPROCTOLOGY 2021. [DOI: 10.1007/s00053-021-00548-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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8
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Araujo IK, Muñoz-Guglielmetti D, Mollà M. Radiation-induced damage in the lower gastrointestinal tract: Clinical presentation, diagnostic tests and treatment options. Best Pract Res Clin Gastroenterol 2020; 48-49:101707. [PMID: 33317789 DOI: 10.1016/j.bpg.2020.101707] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Revised: 10/15/2020] [Accepted: 11/05/2020] [Indexed: 01/31/2023]
Abstract
Radiation therapy is an important ally when treating malignant lesions in the pelvic area, but it is not exempt of adverse events. There are some measures that can be taken to reduce the possibility of these effects, but some are non-modifiable factors related to previous treatments, location of the lesions or comorbidities. There is a wide variety of clinical presentations that can be of an acute or chronic onset that go from mild to severe forms or that can have a great impact in the quality of life. Medical available therapies as metronidazole, sucralfate, mesalizine or probiotics, can be of aid although some lack of solid evidence of efficacy. Endoscopic treatment can be performed with argon plasma coagulation, bipolar cautery, radiofrequency, laser therapy or dilation. Hyperbaric therapy can be applied in refractory cases and surgery must be reserved to selected patients due to its high morbidity and mortality.
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Affiliation(s)
- Isis K Araujo
- Endoscopy and Motility Unit, Gastroenterology Department, Hospital Clínic de Barcelona, Barcelona, Spain.
| | | | - Meritxell Mollà
- Radiation Oncology Department, Hospital Clínic de Barcelona, Barcelona, Spain.
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9
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Cai Y, Ma T, Zhong Q, Qin Q, Cao W, Liu Z, Ke J, Wang H. Quantitative CT measurement of left colonic and pelvic mesenteric adipose volume in radiation proctitis. ANNALS OF TRANSLATIONAL MEDICINE 2020; 8:882. [PMID: 32793726 DOI: 10.21037/atm-20-5102] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Background The edema of left colonic and pelvic mesenteric adipose tissues has long been recognized in surgery as a characteristic feature of radiation proctitis (RP). However, the correlation between mesenteric adipose volume and RP has not been extensively clarified. The purpose of this study was thus to assess the variation of left colonic and pelvic mesenteric adipose volume in RP. Methods From March 2013 to June 2015, the data of 52 patients with locally advanced rectal cancer who underwent neoadjuvant chemoradiotherapy, including 23 patients with RP and 29 with non-RP (nRP), were retrieved. The mesenteric adipose volume was quantified via a computed tomography (CT) reconstruction method. Corresponding analyses were conducted to observe the correlation between the relative change of mesenteric adipose volume and the thickening degree of the rectal wall. Results The baseline data of the RP group and the nRP group were comparable. There was no significant difference in the relative change of the left colonic mesenteric adipose volume in each vertebral space from the third lumbar vertebra to the first sacral vertebra before and after radiotherapy. The relative change of pelvic mesenteric adipose volume (ΔVp%) was notably higher in the RP group compared to the nRP group. With a ΔVp% cutoff value of 3.67%, the sensitivity and specificity for the diagnosis of RP were 65.2% and 86.2%, respectively. According to the correlation analysis, ΔVp% in the RP group was significantly correlated with the thickening degree of the rectal wall after radiotherapy (r=0.47, P=0.024). Conclusions The increment of the relative change of pelvic mesenteric adipose volume quantitatively measured by CT can be clinically useful in identifying RP.
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Affiliation(s)
- Yonghua Cai
- Department of Colorectal Surgery, the Sixth Affiliated Hospital of Sun Yat-sen University, Guangzhou, China.,Guangdong Institute of Gastroenterology, the Sixth Affiliated Hospital of Sun Yat-sen University, Guangzhou, China.,Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, the Sixth Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Tenghui Ma
- Department of Colorectal Surgery, the Sixth Affiliated Hospital of Sun Yat-sen University, Guangzhou, China.,Guangdong Institute of Gastroenterology, the Sixth Affiliated Hospital of Sun Yat-sen University, Guangzhou, China.,Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, the Sixth Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Qinghua Zhong
- Department of Colorectal Surgery, the Sixth Affiliated Hospital of Sun Yat-sen University, Guangzhou, China.,Guangdong Institute of Gastroenterology, the Sixth Affiliated Hospital of Sun Yat-sen University, Guangzhou, China.,Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, the Sixth Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Qiyuan Qin
- Department of Colorectal Surgery, the Sixth Affiliated Hospital of Sun Yat-sen University, Guangzhou, China.,Guangdong Institute of Gastroenterology, the Sixth Affiliated Hospital of Sun Yat-sen University, Guangzhou, China.,Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, the Sixth Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Wuteng Cao
- Department of Radiology, the Sixth Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Zhanzhen Liu
- Department of Colorectal Surgery, the Sixth Affiliated Hospital of Sun Yat-sen University, Guangzhou, China.,Guangdong Institute of Gastroenterology, the Sixth Affiliated Hospital of Sun Yat-sen University, Guangzhou, China.,Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, the Sixth Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Jia Ke
- Department of Colorectal Surgery, the Sixth Affiliated Hospital of Sun Yat-sen University, Guangzhou, China.,Guangdong Institute of Gastroenterology, the Sixth Affiliated Hospital of Sun Yat-sen University, Guangzhou, China.,Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, the Sixth Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Hui Wang
- Department of Colorectal Surgery, the Sixth Affiliated Hospital of Sun Yat-sen University, Guangzhou, China.,Guangdong Institute of Gastroenterology, the Sixth Affiliated Hospital of Sun Yat-sen University, Guangzhou, China.,Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, the Sixth Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
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10
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van Tol RR, Kleijnen J, Watson AJM, Jongen J, Altomare DF, Qvist N, Higuero T, Muris JWM, Breukink SO. European Society of ColoProctology: guideline for haemorrhoidal disease. Colorectal Dis 2020; 22:650-662. [PMID: 32067353 DOI: 10.1111/codi.14975] [Citation(s) in RCA: 67] [Impact Index Per Article: 16.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2019] [Accepted: 01/03/2020] [Indexed: 12/15/2022]
Abstract
AIM The goal of this European Society of ColoProctology project was to establish a multidisciplinary, international guideline for haemorrhoidal disease (HD) and to provide guidance on the most effective (surgical) treatment for patients with HD. METHODS The development process consisted of six phases. In phase one we defined the scope of the guideline. The patient population included patients with all stages of haemorrhoids. The target group for the guideline was all practitioners treating patients with haemorrhoids and, in addition, healthcare workers and patients who desired information regarding the treatment management of HD. The guideline needed to address both the diagnosis of and the therapeutic modalities for HD. Phase two consisted of the compilation of the guideline development group (GDG). All clinical members needed to have affinity with the diagnosis and treatment of haemorrhoids. Further, attention was paid to the geographical distribution of the clinicians. Each GDG member identified at least one patient in their country who could read English to comment on the draft guideline. In phase three review questions were formulated, using a reversed process, starting with possible recommendations based on the GDG's knowledge. In phase four a literature search was performed in MEDLINE (Ovid), PubMed, Embase (Ovid) and the Cochrane Database of Systematic Reviews. The search was focused on existing systematic reviews addressing each review question, supplemented by other studies published after the time frame covered by the systematic reviews. In phase five data of the included papers were extracted by the surgical resident (RT) and checked by the methodologist (JK) and the GDG. If needed, meta-analysis of the systematic reviews was updated by the surgical resident and the methodologist using Review Manager. During phase six the GDG members decided what recommendations could be made based on the evidence found in the literature using GRADE. RESULTS There were six sections: (i) symptoms, diagnosis and classification; (ii) basic treatment; (iii) outpatient procedures; (iv) surgical interventions; (v) special situations; (vi) other surgical techniques. Thirty-four recommendations were formulated. CONCLUSION This international, multidisciplinary guideline provides an up to date and evidence based summary of the current knowledge of the management of HD and may serve as a useful guide for patients and clinicians.
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Affiliation(s)
- R R van Tol
- Department of Surgery, Maastricht University Medical Centre+, Maastricht, The Netherlands
| | - J Kleijnen
- Care and Public Health Research Institute (CAPHRI), Maastricht University Medical Center+, Maastricht, The Netherlands
| | - A J M Watson
- Department of Surgery, Raigmore Hospital, Inverness, UK
| | - J Jongen
- Department of Surgical Proctology, Proktologische Praxis Kiel,, Kiel, Germany
| | - D F Altomare
- Department of Emergency and Organ Transplantation, University of Aldo Moro of Bari, Bari, Italy
| | - N Qvist
- Surgical Department A, Odense University Hospital, Odense C, Denmark
| | - T Higuero
- Clinique Saint Antoine, Nice, France
| | - J W M Muris
- Department of Family Medicine/General Practice, Research Institute CAPHRI, Maastricht University, Maastricht, The Netherlands
| | - S O Breukink
- Department of Surgery, Maastricht University Medical Centre+, Maastricht, The Netherlands
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11
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Özkan EE, Erdemoğlu E, Raoufi J. Impact of diabetes on gastrointestinal and urinary toxicity after radiotherapy for gynecologic malignancy. Turk J Obstet Gynecol 2020; 16:260-265. [PMID: 32231858 PMCID: PMC7090259 DOI: 10.4274/tjod.galenos.2019.56957] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2019] [Accepted: 10/12/2019] [Indexed: 12/31/2022] Open
Abstract
Objective Although diabetes is a common co-morbidity in patients with gynecologic cancer, information about its impact on radiation toxicity in patients with gynecologic cancer treated with external pelvic irradiation is scarce. We aimed to investigate the relation of diabetes with acute toxicity in patients with gynecologic tumors who underwent pelvic +/- paraaortic radiotherapy. Materials and Methods One hundred twenty-nine patients with endometrium or cervix carcinoma were enrolled in the study. Demographic features, presence of diabetes, incidence and severity of upper gastrointestinal (UGIS), lower gastrointestinal (LGIS), and urinary symptoms were recorded from files. Correlation and logistic regression analysis was used to determine the impact of diabetes, age, chemotherapy, paraaortic irradiation on toxicities, and a prediction model was developed. Results The median age of 77 patients with endometrium cancer and 52 cervix cancer was 61 (range, 25-92) years, and 28 (21.7%) of them had diabetes. The median pelvic and tumor/tumor bed dose was 5040+247.65 cGy and 5040+222.91 cGy, respectively. Age and Gr 0 UGIS toxicity were significantly related (p=0.047). LGIS Gr 0 toxicity was found to be significantly higher in patients with diabetes (p=0.045). Gr 0 and 2 UGIS toxicities were both found to be significantly correlated with paraaortic irradiation (both p<0.001). Diabetes is also an important determinant on UGIS toxicity in patients who underwent paraaortic irradiation. Conclusion The correlation we found between toxicity and diabetes, concurrent chemotherapy or paraaortic radiation necessitates special care and risk stratification for patients with diabetes. Further prospective studies with long follow-up and larger patient groups are warranted.
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Affiliation(s)
- Emine Elif Özkan
- Süleyman Demirel University Faculty of Medicine, Department of Radiation Oncology, Isparta, Turkey
| | - Evrim Erdemoğlu
- Süleyman Demirel University Faculty of Medicine, Department of Gynecologic Oncology, Isparta, Turkey
| | - Jalal Raoufi
- Süleyman Demirel University Faculty of Medicine, Department of Gynecologic Oncology, Isparta, Turkey
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12
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Guerri S, Danti G, Frezzetti G, Lucarelli E, Pradella S, Miele V. Clostridium difficile colitis: CT findings and differential diagnosis. Radiol Med 2019; 124:1185-1198. [PMID: 31302848 DOI: 10.1007/s11547-019-01066-0] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2019] [Accepted: 07/07/2019] [Indexed: 12/17/2022]
Abstract
Clostridium difficile infection (CDI) is a severe and potentially deadly infectious colitis whose incidence is dramatically increasing in the last decades, with more virulent strains. CDI should be suspected in case of unexplained diarrhea and abdominal pain in patients with a recent history of antibiotic use and healthcare exposures; diagnosis is based on a combination of clinical and laboratory findings with demonstration of C. difficile toxins by stool test. The advantages of contrast-enhanced computed tomography (CECT) are the noninvasiveness and the ability to evaluate both the colonic wall and the adjacent soft tissues. Considerable overlap exists between the CECT findings of CDI and those of colitis of other origins, such as typhlitis, ischemic colitis, graft-versus-host disease, radiation colitis and inflammatory bowel diseases; however, some features may help distinguish between these conditions. This paper provides a comprehensive overview of the imaging features of Clostridium difficile colitis and its mimics, with a view to assist the radiologist in reaching the correct diagnosis.
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Affiliation(s)
- Sara Guerri
- Department of Radiology, Azienda Ospedaliero-Universitaria Careggi, Largo G.A. Brambilla 3, 50134, Florence, Italy
- Department of Experimental, Diagnostic and Specialty Medicine (DIMES), University of Bologna, S. Orsola-Malpighi Hospital, Via Massarenti 9, 40138, Bologna, Italy
| | - Ginevra Danti
- Department of Radiology, Azienda Ospedaliero-Universitaria Careggi, Largo G.A. Brambilla 3, 50134, Florence, Italy
| | - Gianluca Frezzetti
- Department of Radiology, Azienda Ospedaliero-Universitaria Careggi, Largo G.A. Brambilla 3, 50134, Florence, Italy
| | - Edvige Lucarelli
- Department of Radiology, Azienda Ospedaliero-Universitaria Careggi, Largo G.A. Brambilla 3, 50134, Florence, Italy
| | - Silvia Pradella
- Department of Radiology, Azienda Ospedaliero-Universitaria Careggi, Largo G.A. Brambilla 3, 50134, Florence, Italy.
| | - Vittorio Miele
- Department of Radiology, Azienda Ospedaliero-Universitaria Careggi, Largo G.A. Brambilla 3, 50134, Florence, Italy
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Ferrero VT, Oset MM, Masferrer JP, Pardo EH, Sorolla EJ, Largo SC. Prevalence and characterization of breakthrough pain in cancer patients with proctalgia treated with 3D pelvic radiotherapy. Clin Transl Oncol 2019; 21:1707-1711. [PMID: 30949931 DOI: 10.1007/s12094-019-02102-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2019] [Accepted: 03/22/2019] [Indexed: 12/11/2022]
Abstract
PURPOSE Radiotherapy-induced dysfunction of the gastrointestinal tract is common in cancer patients and has a significant impact on their quality of life. In this study, we investigated the prevalence of breakthrough cancer pain (BTcP) in patients undergoing 3D pelvic radiotherapy and who had proctalgia. METHODS This observational, multicenter, cross-sectional epidemiological study was performed in 13 Spanish hospitals. Data were obtained on the presence and characteristics of BTcP, demographics, common comorbidities, and treatments prescribed to the patients. RESULTS The prevalence of BTcP in patients undergoing pelvic 3D external radiotherapy with proctalgia (N = 105) was 48.6% (95% CI 39.0-58.1%). BTcP was further characterized in 59 patients. The mean (± SD) intensity of the BTcP episodes was 7.45 ± 1.47 in a visual analog scale. We found several statistically significant associations between the descriptive variables of BTcP with demographic and clinical variables associated with the tumor or the patient, such as an increased number of BTcP episodes per day depending on the presence or absence of diabetes (p = 0.001, Chi-square) or time to the onset of pain relief depending on the location of the tumor (p = 0.019, Chi-square). Fentanyl was the drug of choice in BTcP episodes for 95% of the patients. CONCLUSIONS This study demonstrated a high prevalence of BTcP prevalence in cancer patients undergoing pelvic 3D radiotherapy and with proctalgia. Although the variables determining the onset of BTcP are still unclear, our results could help in the design of future clinical studies addressing the treatment of BTcP in these patients.
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Affiliation(s)
- V T Ferrero
- Department of Radiation Oncology, Hospital Universitary de Sant Joan D'Alacant, Carretera Nacional 332 Alicante-Valencia s/n, Sant Joan D'Alacant, 03550, Alicante, Spain.
| | - M M Oset
- Department of Radiation Oncology, Hospital Universitary de Sant Joan D'Alacant, Carretera Nacional 332 Alicante-Valencia s/n, Sant Joan D'Alacant, 03550, Alicante, Spain
| | - J P Masferrer
- Department of Radiation Oncology, Hospital Universitari Son Espases, Palma de Mallorca, Spain
| | - E H Pardo
- Department of Radiation Oncology, Hospital Universitario de Araba, Vitoria, Spain
| | - E J Sorolla
- Department of Radiotherapy, Hospital Clínico Universitario de Valencia, Valencia, Spain
| | - S C Largo
- Department of Radiation Oncology, Hospital Clínico San Carlos, Madrid, Spain
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14
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De Robles MS, Young CJ. Rubber Band Ligation of Hemorrhoids is often a Necessary Complement in the Management of Hemorrhagic Radiation Proctitis. Scand J Surg 2019; 109:108-114. [PMID: 30632450 DOI: 10.1177/1457496918822619] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
BACKGROUND Management of radiation proctitis presents a treatment challenge. Limited data exist on the management of symptomatic hemorrhoids in radiated patients. This study aims to present a practical approach to the management of radiation proctitis, particularly in patients with synchronous hemorrhoids. METHODS A total of 52 consecutive cases of radiation proctitis managed between September 1999 and October 2017 were retrospectively reviewed. The primary treatment was formalin application, plus rubber band ligation in conjunction with formalin when hemorrhoids were a significant component of bleeding, and occasionally argon plasma coagulation. RESULTS The primary indication for radiotherapy was for the treatment of prostate cancer (71%), anal squamous cell carcinoma (10%), and gynecological malignancies (18%). More than half of the patients (52%) presented with radiation proctitis and concomitant internal hemorrhoids. The hemorrhoids were managed with rubber band ligation (56%) and stapled hemorrhoidectomy (7%), at the same procedure as formalin application. At a median follow-up of 12 months, no recurrent rectal bleeding occurred, and no further treatment was needed for most patients. One patient experienced a short period of perianal pain, which was treated with analgesics. CONCLUSION Formalin application has consistently demonstrated an excellent cure rate and safety profile comparable with the published results as a primary treatment for radiation proctitis. The prolapse of irradiated mucosa over the internal hemorrhoids appears to exacerbate bleeding. Local hemorrhoid treatment is often required as an adjunct in the management of these patients.
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Affiliation(s)
- M S De Robles
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, NSW, Australia
| | - C J Young
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, NSW, Australia.,Discipline of Surgery, The University of Sydney, Sydney, NSW, Australia.,RPAH Medical Centre, Newtown, NSW, Australia
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15
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Trzcinski R, Dziki A, Brys M, Moszynska-Zielinska M, Chalubinska-Fendler J, Mik M, Kujawski R, Dziki L. Expression of vascular endothelial growth factor and its correlation with clinical symptoms and endoscopic findings in patients with chronic radiation proctitis. Colorectal Dis 2018; 20:321-330. [PMID: 28963746 DOI: 10.1111/codi.13902] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2017] [Accepted: 09/04/2017] [Indexed: 12/12/2022]
Abstract
AIM The aim of this study was to assess the expression of vascular endothelial growth factor (VEGF) as a key proangiogenic factor and determine whether there is any correlation between its expression and clinical symptoms or endoscopic changes in patients with chronic radiation proctitis (ChRP). METHOD Fifty patients who had all undergone radiotherapy for prostate, cervical or uterine cancer were included in the study (37 women, 13 men). There was a control group of 20 patients (9 women, 11 men). The Radiation Therapy Oncology Group/European Organization for Research and Treatment of Cancer (RTOG/EORTC) scoring system was used for grading the severity of the proctitis. Endoscopic scoring of late rectal mucosal damage was performed using Gilinsky's classification. Serum levels of VEGF were analysed by the enzyme-linked immunosorbent assay method. RESULTS Most patients presented with Grade 1 symptoms. Endoscopic assessment showed that most patients had Grade 1 late rectal mucosal damage. The predominant endoscopic finding was the presence of telangiectasia. Assessment of VEGF correlation between the control group and the degrees of endoscopic changes showed statistically significant differences for all three degrees (P < 0.0001, P = 0.0251 and P = 0.0005, respectively). Due to the small numbers of patients with Grades 2 and 3 symptoms using the RTOG/EORTC scoring system, they were grouped with Grades 1 and 4 respectively forming two groups for statistical purposes. VEGF expression differed significantly between controls and group I and between controls and group II (P = 0.0001, P = 0.0009, respectively). CONCLUSION A significant increase in VEGF expression was found to correlate with clinical symptoms and endoscopic rectal mucosa changes in patients with ChRP, suggesting that it may play an important role in pathological angiogenesis.
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Affiliation(s)
- R Trzcinski
- Department of General and Colorectal Surgery, Medical University of Lodz, Lodz, Poland
| | - A Dziki
- Department of General and Colorectal Surgery, Medical University of Lodz, Lodz, Poland
| | - M Brys
- Department of Cytobiochemistry, University of Lodz, Lodz, Poland
| | - M Moszynska-Zielinska
- Department of Radiotherapy, Copernicus Memorial Hospital, Regional Cancer Center, Lodz, Poland
| | | | - M Mik
- Department of General and Colorectal Surgery, Medical University of Lodz, Lodz, Poland
| | - R Kujawski
- Department of General and Colorectal Surgery, Medical University of Lodz, Lodz, Poland
| | - L Dziki
- Department of General and Colorectal Surgery, Medical University of Lodz, Lodz, Poland
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16
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Yavuz E, Ercan G, Karagulle OO, Bayrak BY, Biricik A, Ercetin C, Gokcek B, Yigitbas H, Kusaslan R, Celik A, Gulcicek OB. Evaluation of prophylactic and therapeutic effects of sildenafil on acute radiation proctitis in rats. Acta Cir Bras 2018; 33:362-374. [DOI: 10.1590/s0102-865020180040000008] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2017] [Accepted: 05/20/2018] [Indexed: 01/27/2023] Open
Affiliation(s)
- Erkan Yavuz
- University of Health Science Bagcilar Training and Research Hospital, Turkey
| | - Gulcin Ercan
- University of Health Science Bagcilar Training and Research Hospital, Turkey
| | | | | | - Aytac Biricik
- University of Health Science Bagcilar Training and Research Hospital, Turkey
| | - Candas Ercetin
- University of Health Science Bagcilar Training and Research Hospital, Turkey
| | - Berk Gokcek
- University of Health Science Okmeydanı Training and Research Hospital, Turkey
| | - Hakan Yigitbas
- University of Health Science Bagcilar Training and Research Hospital, Turkey
| | - Ramazan Kusaslan
- University of Health Science Bagcilar Training and Research Hospital, Turkey
| | - Atilla Celik
- University of Health Science Bagcilar Training and Research Hospital, Turkey
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17
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Yavuz E, Karagulle OO, Ercan G, Celik A, Yigitbas H, Bayrak BY, Tartar R, Kusaslan R, Altinel Y, Gulcicek OB. Evaluation of prophylactic and therapeutic effects of ruscogenin on acute radiation proctitis: an experimental rat model. Ann Surg Treat Res 2018; 94:174-182. [PMID: 29629351 PMCID: PMC5880974 DOI: 10.4174/astr.2018.94.4.174] [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: 07/06/2017] [Revised: 08/22/2017] [Accepted: 08/26/2017] [Indexed: 01/27/2023] Open
Abstract
Purpose Radiation proctitis (RP) is inflammation and damage to the rectum, manifested secondary to ionizing radiation utilized for treatment. In this study, we evaluated the anti-inflammatory therapeutical and protective effects of ruscogenin in a model of acute RP. Methods Thirty-two Sprague-Dawley rats were divided into 4 groups (n = 8) as sham, control, treatment, and prophylaxis groups. Prophylaxis group and treatment group were dosed ruscogenin by oral gavage for 14 days pre- and postradiation. At the end of the 28th day, all subjects were sacrificed. Results Histopathological analysis showed a significant increase in cryptitis abscess, cryptitis and reactive atypia, and depth of lymphocytic infiltration of the control group, compared to the other groups (P < 0.05), while treatment and prophylaxis groups showed significant decreases (P < 0.05). Immunohistochemical analysis indicated that immunoreactivity were significantly higher in control group (P < 0.05, P < 0.001, and P < 0.01, respectively), but vice versa for treatment and prophylaxis groups. There was not any significant difference for fibroblast growth factor 2 immunoreactivity. The epithelium of control rectums indicated an increase in TNF-α immunoreactivity while other groups had significant decrease (P < 0.01). Electron microscopical findings were parallel to light microscopy. Conclusion In this study, ruscogenin was observed to be effective on prophylaxis or treatment of acute RP. Although there are various reports on the treatment of the rectum damaged by acute RP in the literature, this could be the first study since there is no research indicating the ultrastructural effect of ruscogenin.
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Affiliation(s)
- Erkan Yavuz
- Department of General Surgery, Istanbul Bagcilar Training and Research Hospital, Istanbul, Turkey
| | - Onur Olgac Karagulle
- Department of General Surgery, Istanbul Bagcilar Training and Research Hospital, Istanbul, Turkey
| | - Gulcin Ercan
- Department of General Surgery, Istanbul Bagcilar Training and Research Hospital, Istanbul, Turkey
| | - Atilla Celik
- Department of General Surgery, Istanbul Bagcilar Training and Research Hospital, Istanbul, Turkey
| | - Hakan Yigitbas
- Department of General Surgery, Istanbul Bagcilar Training and Research Hospital, Istanbul, Turkey
| | - Busra Yaprak Bayrak
- Department of Pathology, Kocaeli Derince Training and Research Hospital, Kocaeli, Turkey
| | - Rumeysa Tartar
- Department of General Surgery, Istanbul Bagcilar Training and Research Hospital, Istanbul, Turkey
| | - Ramazan Kusaslan
- Department of General Surgery, Istanbul Bagcilar Training and Research Hospital, Istanbul, Turkey
| | - Yuksel Altinel
- Department of General Surgery, Istanbul Bagcilar Training and Research Hospital, Istanbul, Turkey
| | - Osman Bilgin Gulcicek
- Department of General Surgery, Istanbul Bagcilar Training and Research Hospital, Istanbul, Turkey
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18
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Pita I, Bastos P, Dinis-Ribeiro M. Pelvic Catastrophe after Elastic Band Ligation in an Irradiated Rectum. GE-PORTUGUESE JOURNAL OF GASTROENTEROLOGY 2018; 25:42-46. [PMID: 29457050 DOI: 10.1159/000477769] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/14/2017] [Revised: 05/23/2017] [Indexed: 12/16/2022]
Abstract
Chronic radiation proctopathy is a frequent complication after both pelvic external radiation therapy and brachytherapy and most commonly presents as rectal bleeding. Deep rectal ulcers and fistulae are much rarer and more clinically challenging consequences. We present the case of a 72-year-old male with a history of prostate adenocarcinoma treated with brachytherapy, who was referred to our institution due to a deep painful rectal ulcer refractory to medical treatment. The ulcer presented shortly after a haemorrhoid elastic band ligation and progressed to rectourethral fistulisation despite both faecal and urinary diversion. Our case demonstrates the importance of favouring a conservative approach when dealing with an irradiated rectum.
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Affiliation(s)
- Inês Pita
- Serviço de Gastroenterologia, Instituto Português de Oncologia Francisco Gentil, Porto, Portugal
| | - Pedro Bastos
- Serviço de Gastroenterologia, Instituto Português de Oncologia Francisco Gentil, Porto, Portugal
| | - Mário Dinis-Ribeiro
- Serviço de Gastroenterologia, Instituto Português de Oncologia Francisco Gentil, Porto, Portugal
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19
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Santos DA, Alseidi A, Shannon VR, Messick C, Song G, Ledet CR, Lee H, Ngo-Huang A, Francis GJ, Asher A. Management of surgical challenges in actively treated cancer patients. Curr Probl Surg 2017; 54:612-654. [DOI: 10.1067/j.cpsurg.2017.11.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
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20
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Alashkham A, Paterson C, Hubbard S, Nabi G. What is the impact of diabetes mellitus on radiation induced acute proctitis after radical radiotherapy for adenocarcinoma prostate? A prospective longitudinal study. Clin Transl Radiat Oncol 2017; 14:59-63. [PMID: 30623118 PMCID: PMC6318439 DOI: 10.1016/j.ctro.2017.02.003] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2016] [Revised: 02/18/2017] [Accepted: 02/19/2017] [Indexed: 12/13/2022] Open
Abstract
Background Long-term complications of diabetes include cardiovascular disease, retinopathy, nephropathy, and neuropathy. Diabetic patients with prostate cancer could be at a high risk of radiation-induced acute proctitis following radical radiotherapy. Our aims were to analyse the incidence, severity, and duration of radiation proctitis in diabetic patients treated by radical radiotherapy and combined androgen deprivation for prostate cancer. Material and methods On the bases of inclusion and exclusion criteria 716 patients with prostate cancer were retrospectively recruited. Patients were stratified into diabetic patients and non-diabetic patients. The incidence, severity, and duration of proctitis were the main outcomes. A polynomial ordered logistic regression was fitted to determine the influence of diabetes status, age, blood pressures medication, co-morbidities, Gleason score, PSA after treatment, and tumour stage on the grades of proctitis. Time to resolution per year was modelled as a negative binomial generalised linear model. Results The overall mean age of patients was 67.44 (SD 6.77) years with a follow-up time of 3.36 (SD 2.05) years. Data exploratory analysis suggested that the only highly significant explanatory variable was the presence or absence of diabetes. Polynomial ordered logistic regression, however, showed that the presence (or not) of diabetes remained as the only significant predictor (t = -2.74; p = 0.0059) of severity of proctitis. A negative binomial generalised linear model showed that both grade of proctitis (z = -17.178; p < 0.001), and diabetes (z = -5.92; p < 0.001), were highly significant predictors of time to resolution. Conclusions Diabetic patients were significantly more likely to have proctitis after radical radiation therapy for prostate cancer. Diabetes was significantly associated with an induced risk of radiation induced proctitis and also with deceleration of its resolution.
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Affiliation(s)
- Abduelmenem Alashkham
- Academic Section of Urology, Division of Cancer Research, School of Medicine, University of Dundee, Scotland, United Kingdom
- Centre for Human Anatomy, School of Biomedical Sciences, University of Edinburgh, Edinburgh, United Kingdom
- Corresponding author at: Edinburgh Medical School: Biomedical Sciences, The University of Edinburgh, Medical School, Teviot Place, Edinburgh EH8 9AG, United Kingdom.
| | - Catherine Paterson
- Academic Section of Urology, Division of Cancer Research, School of Medicine, University of Dundee, Scotland, United Kingdom
| | - Stephen Hubbard
- School of the Environment, University of Dundee, Dundee, Scotland, United Kingdom
| | - Ghulam Nabi
- Academic Section of Urology, Division of Cancer Research, School of Medicine, University of Dundee, Scotland, United Kingdom
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21
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Zhong Q, Yuan Z, Ma T, Wang H, Qin Q, Chu L, Wang J, Wang L. Restorative resection of radiation rectovaginal fistula can better relieve anorectal symptoms than colostomy only. World J Surg Oncol 2017; 15:37. [PMID: 28153025 PMCID: PMC5288935 DOI: 10.1186/s12957-017-1100-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2016] [Accepted: 01/12/2017] [Indexed: 12/17/2022] Open
Abstract
Background Radiation-induced rectovaginal fistula (RVF) is a severe and difficult complication after pelvic malignancy radiation. This study was to retrospectively compare the outcomes of restorative resection and colostomy only in remission of anorectal symptoms. Methods We enrolled a cohort of 26 consecutive cases who developed RVF after pelvic radiation. Two main procedures for these patients in our institution were used: one was restorative resection and pull-through coloanal anastomosis with a prophylactic colostomy, and another was a simple colostomy without resection. Thus, we divided these patients into these two groups. Anorectal symptoms including rectal pain, bleeding, tenesmus, and perineal mucous discharge were recorded and scored prior to surgery and at postoperative multiple time points. Results The baseline was similar among the two groups. All patients acquired good efficacy with improved symptoms at postoperative 6, 12, and 24 months, when compared to baseline. In addition, the resection group showed a better remission of tenesmus (6 months 33.3 vs 0%; 12 months 66.7 vs 16.7%) and perineal mucous discharge (6 months 88.9 vs 6.7%; 12 months 77.8 vs 15.4%; 24 months 85.7 vs 25.0%). Furthermore, three (30%) patients in the resection group successfully reversed stomas while no stoma was closed in the simple colostomy group. Conclusions Both restorative resection procedure and colostomy only can improve anorectal symptoms of radiation-induced RVF, but restorative resection can completely relieve anorectal symptoms in selected cases.
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Affiliation(s)
- Qinghua Zhong
- Department of Colorectal Surgery, The Sixth Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong Province, China
| | - Zixu Yuan
- Department of Colorectal Surgery, The Sixth Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong Province, China.,Clinical Research Division, Fred Hutchinson Cancer Research Center, University of Washington, Seattle, WA, USA
| | - Tenghui Ma
- Department of Colorectal Surgery, The Sixth Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong Province, China
| | - Huaiming Wang
- Department of Colorectal Surgery, The Sixth Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong Province, China
| | - Qiyuan Qin
- Department of Colorectal Surgery, The Sixth Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong Province, China
| | - Lili Chu
- Department of Colorectal Surgery, The Sixth Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong Province, China
| | - Jianping Wang
- Department of Colorectal Surgery, The Sixth Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong Province, China.,Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor, Sun Yat-sen University, No.26, Road Yuancun ErHeng Road, Tianhe District, Guangzhou, 510655, China
| | - Lei Wang
- Department of Colorectal Surgery, The Sixth Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong Province, China. .,Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor, Sun Yat-sen University, No.26, Road Yuancun ErHeng Road, Tianhe District, Guangzhou, 510655, China.
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22
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[Nonhealing ulcer after hemorrhoid treatment]. Urologe A 2016; 56:358-360. [PMID: 27787582 DOI: 10.1007/s00120-016-0257-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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23
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Hsu LF, Hung CL, Kuo LJ, Tsai PS. An abbreviated Faecal Incontinence Quality of Life Scale for Chinese-speaking population with colorectal cancer after surgery: cultural adaptation and item reduction. Eur J Cancer Care (Engl) 2016; 26. [DOI: 10.1111/ecc.12547] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/10/2016] [Indexed: 12/28/2022]
Affiliation(s)
- L.-F. Hsu
- School of Nursing; College of Nursing; Taipei Medical University; Taipei Taiwan
| | - C.-L. Hung
- Department of Radiation Oncology; Cardinal Tien Hospital; New Taipei City Taiwan
| | - L.-J. Kuo
- Division of Colorectal Surgery; Department of Surgery; Taipei Medical University Hospital; Taipei Taiwan
| | - P.-S. Tsai
- School of Nursing; College of Nursing; Taipei Medical University; Taipei Taiwan
- Department of Nursing; Taipei Medical University-Municipal Wan Fang Hospital; Taipei Taiwan
- Sleep Science Center; Taipei Medical University Hospital; Taipei Taiwan
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Tsujinaka S, Baig MK, Gornev R, de la Garza C, Hwang JK, Sands D, Weiss EG, Nogueras JJ, Efron J, Vernava AM, Wexner SD. Formalin Instillation for Hemorrhagic Radiation Proctitis. Surg Innov 2016; 12:123-8. [PMID: 16034500 DOI: 10.1177/155335060501200209] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Although formalin instillation has been proven to be an effective treatment of hemorrhagic radiation proctitis, different tech niques with varying success rates have been reported. The aim of this study was to assess our experience with formalin instillation for the treatment of radiation proctitis. After Institutional Review Board approval, all patients who presented with radiation proctitis and were treated with 4% formalin instillation were identified from a prospective database. Techniques of instillation were as follows: a formalin-soaked sponge stick was applied via a proctoscope (SS) and placed at each quadrant with a mean contact of 2.5 minutes (range, 0.5-3 minutes), or the formalin solution was introduced through a proctoscope in aliquots for a total of 350 to 400 mL irrigation (IR), with a mean contact time of 30 seconds in each aliquot. The patients were divided into two groups according to the method of formalin instillation and their outcomes were compared. Between March 1995 and September 2003, 21 patients who underwent formalin treatment were identified: 17 patients were in the SS and 4 patients were in the IR group. The mean age was 74.8 6.4 years and 70.5 6.8 years and the male/female ratio was 16:1 and 3:1 in the SS and IR groups, respectively. Indications for radiation therapy were prostate cancer in 19 patients: 16 (95.1%) SS patients and 3 (75%) IR patients. Four (23.5%) patients in the SS group were receiving anticoagulants or antiplatelet medications before the procedure. The mean duration of bleeding before formalin instillation was 11.7 months (range, 2-48 months) in the SS and 10.5 months (range, 7-12 months) in the IR group. Sixteen (94.1%) patients in the SS and 4 (100%) in the IR group had previous treatments for radiation proctitis, including hydrocortisone enema, 5-aminosalicylate mesalamine, and endoscopic coagulation. Eight (47.1%) patients in the SS and 2 (50%) in the IR group received a preprocedural blood transfusion, and 1 patient in the SS group required a blood transfusion after the formalin instillation. This patient subsequently underwent restorative proctosigmoidectomy because of persistent bleeding. The mean length of the procedure was 27.1 10.8 minutes in the SS group and 22.5 6.5 minutes in the IR group. The bleeding was successfully stopped on the first attempt in 14 patients (82.4%) in the SS group and 3 (75%) in the IR group. The instillation was repeated in 1 patient (5.9%) in the SS group and in 1 (25%) in the IR group. Four patients (23.5%) in the SS group experienced rectal pain after the procedure. One patient (5.9%) developed a new onset of fecal incontinence, while another (5.9%) had anococcygeal pain accompanied by worsening of fecal incontinence. One patient (25%) in the IR group developed acute colitis consistent with formalin instillation, which was managed by intravenous antibiotics. The patients were followed for a mean of 10 months (range, 1 to 38 months). Formalin instillation is effective in controlling refractory hemorrhage secondary to radiation proctitis.
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Affiliation(s)
- Shingo Tsujinaka
- Department of Colorectal Surgery, Cleveland Clinic Florida, Weston, FL 33331, USA
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Tang Y, Huang Y, Mo X, Yi G, Wen H, Guo Z, Feng K, Liu Y, Bu Q, JiAng W. Efficacy and safety of Yunxiangjing derived from Chinese herbal medicine administered as an enema in the management of acute radiation-induced proctitis in patients with pelvic malignancy. J TRADIT CHIN MED 2016; 36:45-50. [PMID: 26946618 DOI: 10.1016/s0254-6272(16)30007-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
OBJECTIVE To assess the efficacy and safety of Yunxiangjing (YXJ), derived from Chinese herbal medicine, in the management of acute radiation-induced proctitis (ARIP) in patients with pelvic malignancy. METHODS Forty-eight patients with grade 2 ARIP were administered YXJ as an enema (1 : 30 dilution) for 2 weeks and followed up for 2 years. All were assessed for response and ARIP grade. Quality of life (QOL) was assessed with the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire-Core 30. RESULTS Of the 48 patients, six (12.5%) achieved complete remission of ARIP and 28 (58.3%) showed a decrease from grade 2 to grade 1 ARIP. No patient experienced a grade ≥3 toxicity. At the end of radiotherapy, patients showed significant improvements in QOL (P < 0.05). Two years after treatment, 46 patients showed no late toxicity, with only two experiencing grade 1 late toxicity. CONCLUSION YXJ can be used as an enema to manage acute radiation-induced proctitis in cancer patients undergoing radiotherapy. These findings suggest that YXJ enema may be an alternative treatment of ARIP.
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Liang Z, Ding W, Chen W, Wang Z, Du P, Cui L. Therapeutic Evaluation of Biofeedback Therapy in the Treatment of Anterior Resection Syndrome After Sphincter-Saving Surgery for Rectal Cancer. Clin Colorectal Cancer 2015; 15:e101-7. [PMID: 26732640 DOI: 10.1016/j.clcc.2015.11.002] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2015] [Revised: 11/02/2015] [Accepted: 11/23/2015] [Indexed: 12/13/2022]
Abstract
BACKGROUND Anterior resection syndrome (ARS) is common after sphincter-saving surgery for rectal cancer. It includes changes in the frequency and urgency of bowel movements and fecal incontinence. The therapeutic efficacy of biofeedback on ARS is unclear. We sought to evaluate the effectiveness of biofeedback therapy in patients with ARS after anterior resection for rectal cancer and to investigate the associated factors for therapeutic success. PATIENTS AND METHODS The study was designed as a retrospective review of the data from 61 patients with ARS collected from a prospectively maintained institutional cancer database. Therapeutic efficacy was evaluated using anorectal manometry, the number of bowel movements daily, and fecal incontinence scoring systems (Vaizey and/or Wexner scores). Changes of > 15% in the Vaizey and/or Wexner scores were considered to indicate effectiveness. Stepwise logistic regression models were performed to evaluate whether the associated factors influenced therapeutic efficacy. RESULTS The parameters of anorectal manometry in patients with rectal cancer were significantly lower than those in control group (P < .01). After biofeedback therapy, significant improvements were observed in the incontinence scale scores (P < .001), number of bowel movements (P < .001), and anorectal manometry data (maximum resting pressure, P < .001; maximum squeeze pressure, P = .001; and rectal capacity, P = .015). In contrast, no significant difference in the rectal initial sensation threshold was observed (P = .089). Patients with fecal incontinence as the primary symptom experienced significant improvements in all variables (P < .01), except for the rectal initial sensation threshold (P = .125). Age at surgery, current smoking status, diabetes, treatment cycles, laparoscopic surgery, interval from surgery to biofeedback therapy, and the use of radiation therapy were closely associated with therapeutic success. On multivariate analysis, current smoking status (odds ratio [OR], 0.09; 95% confidence interval [CI], 0.01-0.87), number of biofeedback therapy cycles (OR, 0.01; 95% CI, 0.00-0.06), and laparoscopic surgery (OR, 11.53; 95% CI, 1.17-113.61) were factors contributing to biofeedback therapeutic success. CONCLUSION Biofeedback therapy can improve the anal function of patients after restorative resection for rectal cancer.
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Affiliation(s)
- Zhonglin Liang
- Department of Colorectal Surgery, Xinhua Hospital, Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Wenjun Ding
- Department of Colorectal Surgery, Xinhua Hospital, Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Wei Chen
- Department of Colorectal Surgery, Xinhua Hospital, Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Zhongchuan Wang
- Department of Colorectal Surgery, Xinhua Hospital, Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Peng Du
- Department of Colorectal Surgery, Xinhua Hospital, Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China.
| | - Long Cui
- Department of Colorectal Surgery, Xinhua Hospital, Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
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Brieau B, Lepère C, Walter T, Lecomte T, Guimbaud R, Manfredi S, Tougeron D, Desseigne F, Lourenco N, Afchain P, El Hajbi F, Terris B, Rougier P, Coriat R. Radiochemotherapy Versus Surgery in Nonmetastatic Anorectal Neuroendocrine Carcinoma: A Multicenter Study by the Association des Gastro-Entérologues Oncologues. Medicine (Baltimore) 2015; 94:e1864. [PMID: 26496341 PMCID: PMC4620767 DOI: 10.1097/md.0000000000001864] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Neuroendocrine carcinomas (NEC) of the anus or the rectum are a rare disease, accounting for less than 1% of all digestive malignancies. Most are metastatic at diagnosis and treated with a platinum-based chemotherapy. No guidelines for localized tumors exist. The purpose of this study was to describe the characteristics of anorectal localized NEC, their management and their outcomes.We retrospectively reviewed patients from 11 French centers with anorectal localized NEC. We compared 2 therapeutic managements: surgery (group A) versus chemotherapy with or without radiation (group B). Progression-free survival (PFS) and overall survival (OS) were estimated with the Kaplan-Meier method.A total of 24 patients were identified with a median follow-up of 25 months (3-60 months). Median age was 63 years old and 17 had a rectal tumor (71%). Mean Ki-67 was 72% (range: 20-100), and 75% of the tumors had a high proliferative index (Ki-67 > 50%). Global PFS and OS were 13.1 and 44.1 months, respectively. Thirty-seven percent of patients were in group A and 63% in group B. There was no difference between group A and group B, whether in terms of PFS (13.0 months vs. 13.2 months, P = 0.75) or OS (49.1 months vs. 39.2 months, P = 0.42).In patients with anorectal localized NEC, chemotherapy with or without radiation obtained a similar outcome as surgery and this conservative approach could be deemed a reasonable option.
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Affiliation(s)
- Bertrand Brieau
- From the Department of Gastroenterology and Digestive Oncology, Cochin Teaching Hospital, Paris Descartes University, Paris, France (BB, RC); Department of Digestive Oncology, Georges Pompidou European Hospital, Paris Descartes University, Paris, France (CL, PR); Department of Gastroenterology, Edouard Herriot Hospital, Lyon, France (TW); Department of Gastroenterology, Tours Teaching Hospital, Tours Cedex 9, France (TL); Department of Medical Oncology, Claudius Regaud Institute, Toulouse, France (RG); Department of Gastroenterology, Rennes Teaching Hospital, Rennes, France (SM); Department of Gastroenterology, Poitiers Teaching Hospital, Poitiers, France (DT); Department of Medical Oncology, Leon Berard Hospital, Lyon, France (FD); Department of Gastroenterology, Saint Louis Hospital, Paris, France (NL); Department of Digestive Oncology, Saint Antoine Hospital, Paris, France (PA); Department of Medical Oncology, Oscar Lambret Hospital, Lille, France (FEH); and Department of Pathology, Cochin Teaching Hospital, Paris Descartes University, Paris, France (BT)
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Alashkham A, Paterson C, Rauchhaus P, Nabi G. Can Angiotensin-Converting Enzyme Inhibitors Reduce the Incidence, Severity, and Duration of Radiation Proctitis? Int J Radiat Oncol Biol Phys 2015; 94:93-101. [PMID: 26547382 DOI: 10.1016/j.ijrobp.2015.09.013] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2015] [Revised: 08/18/2015] [Accepted: 09/10/2015] [Indexed: 01/13/2023]
Abstract
PURPOSE To determine whether participants taking angiotensin-converting enzyme inhibitors (ACEIs) and treated with radical radiation therapy with neoadjuvant/adjuvant hormone therapy have less incidence, severity, and duration of radiation proctitis. METHODS AND MATERIALS A propensity score analysis of 817 patients who underwent radical radiation therapy with neoadjuvant or adjuvant hormone therapy as primary line management in a cohort study during 2009 to 2013 was conducted. Patients were stratified as follows: group 1, hypertensive patients taking ACEIs (as a study group); group 2, nonhypertensive patients not taking ACEIs; and group 3, hypertensive patients not taking ACEIs (both as control groups). The incidence, severity, and duration of proctitis were the main outcome. χ(2) tests, Mann-Whitney U tests, analysis of variance, risk ratio (RR), confidence interval (CI), Kaplan-Meier plots, and log-rank tests were used. RESULTS The mean age of the participants was 68.91 years, with a follow-up time of 3.38 years. Based on disease and age-matched comparison, there was a statistically significant difference of proctitis grading between the 3 groups: χ(2) (8, n=308) = 72.52, P<.001. The Mann-Whitney U test indicated that grades of proctitis were significantly lower in hypertensive patients taking ACEIs than in nonhypertensive patients not taking ACEIs and hypertensive patients not taking ACEIs (P<.001). The risk ratio (RR) of proctitis in hypertensive patients taking ACEIs was significantly lower than in hypertensive patients not taking ACEIs (RR 0.40, 95% CI 0.30-0.53, P<.001) and in nonhypertensive patients not taking ACEIs (RR 0.58, 95% CI 0.44-0.77, P<.001). Time to event analysis revealed that hypertensive patients taking ACEIs were significantly different from the control groups (P<.0001). Furthermore, hypertensive patients taking ACEIs had significantly faster resolution of proctitis (P<.0001). CONCLUSION Patients who were taking ACEIs were significantly less likely to have high-grade proctitis after radical radiation therapy with neoadjuvant or adjuvant hormone therapy (P<.001). The intake of ACEIs was significantly associated with a reduced risk of radiation-induced proctitis and also with acceleration of its resolution.
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Affiliation(s)
- Abduelmenem Alashkham
- Academic Section of Urology, Division of Cancer Research, School of Medicine, University of Dundee, Scotland, UK.
| | - Catherine Paterson
- Academic Section of Urology, Division of Cancer Research, School of Medicine, University of Dundee, Scotland, UK
| | - Petra Rauchhaus
- Tayside Clinical Trials Unit, School of Medicine, University of Dundee, Scotland, UK
| | - Ghulam Nabi
- Academic Section of Urology, Division of Cancer Research, School of Medicine, University of Dundee, Scotland, UK
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Abstract
Radiation therapy is a widely utilized treatment modality for pelvic malignancies, including prostate cancer, rectal cancer, and cervical cancer. Given its fixed position in the pelvis, the rectum is at a high risk for injury secondary to ionizing radiation. Despite advances made in radiation science, up to 75% of the patients will suffer from acute radiation proctitis and up to 20% may experience chronic symptoms. Symptoms can be variable and include diarrhea, bleeding, incontinence, and fistulization. A multitude of treatment options exist. This article summarizes the latest knowledge relating to radiation proctopathy focusing on the vast array of treatment options.
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Affiliation(s)
- Marc B. Grodsky
- Section of Colon and Rectal Surgery, MedStar Washington Hospital Center, Washington, District of Columbia
| | - Shafik M. Sidani
- Department of Colorectal Surgery, Virginia Hospital Center Physician Group, Arlington, Virginia
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Brandenbarg D, Roorda C, Groenhof F, Havenga K, Berger MY, de Bock GH, Berendsen AJ. Increased primary health care use in the first year after colorectal cancer diagnosis. Scand J Prim Health Care 2014; 32:55-61. [PMID: 24931639 PMCID: PMC4075017 DOI: 10.3109/02813432.2014.929811] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVE The view that the general practitioner (GP) should be more involved during the curative treatment of cancer is gaining support. This study aimed to assess the current role of the GP during treatment of patients with colorectal cancer (CRC). DESIGN Historical prospective study, using primary care data from two cohorts. SETTING Registration Network Groningen (RNG) consisting of 18 GPs in three group practices with a dynamic population of about 30,000 patients. SUBJECTS Patients who underwent curative treatment for CRC (n = 124) and matched primary care patients without CRC (reference population; n = 358). MAIN OUTCOME MEASURES Primary healthcare use in the period 1998-2009. FINDINGS Patients with CRC had higher primary healthcare use in the year after diagnosis compared with the reference population. After correction for age, gender, and consultation behaviour, CRC patients had 54% (range 23-92%) more face-to-face contacts, 68% (range 36-108%) more drug prescriptions, and 35% (range -4-90%) more referrals compared with reference patients. Patients consulted their GP more often for reasons related to anaemia, abdominal pain, constipation, skin problems, and urinary infections. GPs also prescribed more acid reflux drugs, laxatives, anti-anaemic preparations, analgesics, and psycholeptics for CRC patients. CONCLUSIONS The GP plays a significant role in the year after CRC diagnosis. This role may be associated with treatment-related side effects and psychological problems. Formal guidelines on the involvement of the GP during CRC treatment might ensure more effective allocation and communication of care between primary and secondary healthcare services.
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Affiliation(s)
- Daan Brandenbarg
- Department of General Practice, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Carriene Roorda
- Department of General Practice, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Feikje Groenhof
- Department of General Practice, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Klaas Havenga
- Department of Surgery, Division of Abdominal Surgery, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Marjolein Y. Berger
- Department of General Practice, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Geertruida H. de Bock
- Department of Epidemiology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Annette J. Berendsen
- Department of General Practice, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
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Maris A, Penninckx F, Devreese AM, Staes F, Moons P, Van Cutsem E, Haustermans K, D'Hoore A. Persisting anorectal dysfunction after rectal cancer surgery. Colorectal Dis 2013; 15:e672-9. [PMID: 23692392 DOI: 10.1111/codi.12291] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2012] [Accepted: 02/21/2013] [Indexed: 02/08/2023]
Abstract
AIM Sphincter-saving rectal cancer management affects anorectal function. This study evaluated persisting anorectal dysfunction and its impact on patients' well-being. METHOD Seventy-nine patients with a follow-up of 12-37 (median 22) months and 79 age- and sex-matched control subjects completed questionnaires. RESULTS The median number of diurnal bowel movements was three in patients and one in controls (P < 0.0001). Nocturnal defaecation occurred in 53% of patients. The median Vaizey score was 8 in patients and 4 in controls (P < 0.0001). Urgency without incontinence was reported by 47% of patients and 49% of controls (P = 0.873), soiling by 28% of patients and 3% of controls (P < 0.0001), incontinence for flatus by 73% of patients and 49% of controls (P = 0.0019), and incontinence for solid stools by 16% of patients and 4% of controls (P = 0.0153). Incontinence of liquid stools occurred in 17 of 20 patients and in one of five controls who had liquid stools (P = 0.0123). Incontinence for gas, liquid or solid stool occurred once or more weekly in 47%, 19% and 6% of patients respectively. Evacuation difficulties were reported by 98% of patients, but also by 77% of controls. Neoadjuvant radio(chemo)therapy adversely affected defaecation frequency and continence. Incontinence was associated with severe discomfort in 50% of patients, severe anxiety in 40% and severe embarrassment in 48%. CONCLUSION Anorectal dysfunction is a frequent problem after management of rectal cancer with an impact on the well-being of patients.
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Affiliation(s)
- A Maris
- Department of Rehabilitation Sciences, Neuromotor Rehabilitation Research Group, KU Leuven, Leuven, Belgium
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Kołodziejczak M, Santoro GA, Słapa RZ, Szopiński T, Sudoł-Szopińska I. Usefulness of 3D transperineal ultrasound in severe stenosis of the anal canal: preliminary experience in four cases. Tech Coloproctol 2013; 18:495-501. [PMID: 24081548 PMCID: PMC3996354 DOI: 10.1007/s10151-013-1078-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2013] [Accepted: 09/17/2013] [Indexed: 12/25/2022]
Abstract
Background Organic or functional anal canal stenoses are uncommon conditions that occur in the majority of cases as a consequence of anal diseases. A proper assessment is fundamental for decision making; however, proctological examination and endoanal ultrasound are often unfeasible or very difficult to perform even under local or general anesthesia. We therefore began to use 3D transperineal ultrasound to assess patients. The aim of this study was to compare the results of evacuation proctography and 3D transperineal ultrasound in patients with severe anal canal stenosis. Methods Four consecutive patients with high-grade anal canal stenosis were evaluated using both proctography and 3D transperineal ultrasound with a micro-convex transducer between March and June 2011. Results In all cases, 3D transperineal ultrasound provided detailed information on the length and level of stenosis and on the integrity of the anal sphincters. Conclusions Our preliminary experience suggests that 3D transperineal ultrasound makes it possible to plan optimal surgical treatment.
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Affiliation(s)
- M Kołodziejczak
- Department of Proctology, Hospital at Solec, 00-382, Warsaw, Poland
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Kim TG, Huh SJ, Park W. Endoscopic findings of rectal mucosal damage after pelvic radiotherapy for cervical carcinoma: correlation of rectal mucosal damage with radiation dose and clinical symptoms. Radiat Oncol J 2013; 31:81-7. [PMID: 23865004 PMCID: PMC3712177 DOI: 10.3857/roj.2013.31.2.81] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2013] [Revised: 04/29/2013] [Accepted: 05/05/2013] [Indexed: 12/27/2022] Open
Abstract
PURPOSE To describe chronic rectal mucosal damage after pelvic radiotherapy (RT) for cervical cancer and correlate these findings with clinical symptoms and radiation dose. MATERIALS AND METHODS Thirty-two patients who underwent pelvic RT were diagnosed with radiation-induced proctitis based on endoscopy findings. The median follow-up period was 35 months after external beam radiotherapy (EBRT) and intracavitary radiotherapy (ICR). The Vienna Rectoscopy Score (VRS) was used to describe the endoscopic findings and compared to the European Organization for Research and Treatment of Cancer (EORTC)/Radiation Therapy Oncology Group (RTOG) morbidity score and the dosimetric parameters of RT (the ratio of rectal dose calculated at the rectal point [RP] to the prescribed dose, biologically effective dose [BED] at the RP in the ICR and EBRT plans, α/β = 3). RESULTS Rectal symptoms were noted in 28 patients (rectal bleeding in 21 patients, bowel habit changes in 6, mucosal stools in 1), and 4 patients had no symptoms. Endoscopic findings included telangiectasia in 18 patients, congested mucosa in 20, ulceration in 5, and stricture in 1. The RP ratio, BEDICR, BEDICR+EBRT was significantly associated with the VRS (RP ratio, median 76.5%; BEDICR, median 37.1 Gy3; BEDICR+EBRT, median 102.5 Gy3; p < 0.001). The VRS was significantly associated with the EORTC/RTOG score (p = 0.038). CONCLUSION The most prevalent endoscopic findings of RT-induced proctitis were telangiectasia and congested mucosa. The VRS was significantly associated with the EORTC/RTOG score and RP radiation dose.
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Affiliation(s)
- Tae Gyu Kim
- Department of Radiation Oncology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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Chronic radiation-induced proctitis: the 4 % formalin application as non-surgical treatment. Int J Colorectal Dis 2013; 28:261-6. [PMID: 22932907 DOI: 10.1007/s00384-012-1571-y] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/14/2012] [Indexed: 02/06/2023]
Abstract
PURPOSE Radiation proctitis is a known complication following radiation therapy for pelvic malignancy. The majority of cases are treated nonsurgically. Rectal instillation of formalin solution has been described as a successful treatment for chronic radiation-induced hemorrhagic proctitis resistant to medical treatment. We present our results in patients undergoing treatment with application of 4 % formalin for radiation-induced injury to the rectum. METHODS All patients were treated under anesthesia by direct application of 4 % formalin solution to the affected rectal areas. Patient gender, initial malignancy, grade of proctitis, need for blood transfusion, previous therapy, number of applications and response to treatment with formalin, complications, and length of follow-up were reviewed. RESULTS A total of 15 patients with a mean age of 68.9 (range, 48-77) years were followed for 31.3 (range, 18-51) months. The mean interval from the conclusion of radiotherapy and the onset of symptoms was 6.9 months. The mean duration of hemorrhagic proctitis before formalin application was 7.9 months. Ten patients had only one formalin application and five patients required a second application because of the persistent bleeding. Thirteen patients (87 %) had complete cessation of bleeding. No complications related to the formalin treatment were observed. CONCLUSIONS According to a revision of the literature and our experience, despite the small number of patients in our trial, we can state that the application of 4 % formalin solution is an effective, safe, and well-tolerated treatment for chronic radiation-induced hemorrhagic proctitis with minimal discomfort and no severe complications.
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A surgeon's help with the management of bowel problems related to gynecology is truly needed - comparison of two periods spanning 24 years. Taiwan J Obstet Gynecol 2013; 51:612-5. [PMID: 23276566 DOI: 10.1016/j.tjog.2012.09.017] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/12/2012] [Indexed: 11/21/2022] Open
Abstract
OBJECTIVE Colorectal surgeons are frequently on call to provide help to gynecologists who are managing bowel problems that occur either during or following gynecological surgery. This is a retrospective analysis of a single surgeon's experiences associated with such instances. The analysis focuses on whether there have been any changes in referral patterns, surgical techniques and/or results. MATERIALS AND METHODS From July 1984 to June 2008, 282 patients were operated on by a single colorectal surgeon, for problems that were related to gynecology. These consisted of 137 patients operated on during the first 12-year period, from July 1984 to June 1996. During this first period, 85 patients were operated on for cervical cancer related problems, 39 patients were operated on for problems related to other gynecological malignancies and nine patients were operated on for iatrogenic bowel injury during surgery. During the second 12-year period, from July 1996 to June 2008, 145 patients were operated on. Of these, 85 patients were operated on for cervical cancer related problems, 44 patients were operated on for problems related to other gynecological malignancies and eight patients were operated on for iatrogenic bowel injury during surgery. RESULTS During the first 12-year period, six operations were pelvic exenterations for primary gynecological malignancies or recurrences. One hundred and one patients received stomas during their first operation. Twenty-five patients encountered various complications. Postoperative death occurred in five patients. During the second 12-year period, 12 operations were pelvic exenterations for primary gynecological malignancies or recurrences. Eighty-seven patients received stomas during their first operation. Thirty-seven patients encountered various complications. Postoperative death occurred in six patients. CONCLUSION Gynecological problems frequently involve the colon or rectum. Cervical cancer related problems remain the most common type necessitating help from a colorectal surgeon. In spite of advances in surgical management, stomas are still frequently unavoidable in order to cure a patient or improve the patient's quality of life. Appropriate management of problems by a colorectal surgeon in relation to gynecology is important and in the best interests of the patient.
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Jongen J, Kahlke V, Petersen S. Letter to the Editor concerning "Gene expression analysis in chronic postradiation proctopathy" by Traub et al. (Int J Colorectal Dis 27:879-884, 2012). Int J Colorectal Dis 2012; 27:1689. [PMID: 22875488 DOI: 10.1007/s00384-012-1555-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/26/2012] [Indexed: 02/04/2023]
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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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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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Histopathologic Analysis of the Anal Sphincter after Chemoradiation for Low Rectal Cancer. ACTA ACUST UNITED AC 2011. [DOI: 10.1016/j.jecm.2011.10.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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Halkett G, Aoun S, Hayne D, Lund JA, Gruen A, Villa J, Livi L, Arcangeli S, Velikova G, Spry N. EORTC radiation proctitis-specific quality of life module – Pretesting in four European countries. Radiother Oncol 2010; 97:294-300. [DOI: 10.1016/j.radonc.2010.04.001] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2010] [Revised: 03/11/2010] [Accepted: 04/05/2010] [Indexed: 11/12/2022]
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Brændengen M, Tveit KM, Bruheim K, Cvancarova M, Berglund Å, Glimelius B. Late patient-reported toxicity after preoperative radiotherapy or chemoradiotherapy in nonresectable rectal cancer: results from a randomized Phase III study. Int J Radiat Oncol Biol Phys 2010; 81:1017-24. [PMID: 20932687 DOI: 10.1016/j.ijrobp.2010.07.007] [Citation(s) in RCA: 66] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2010] [Revised: 06/25/2010] [Accepted: 07/02/2010] [Indexed: 12/17/2022]
Abstract
PURPOSE Preoperative chemoradiotherapy (CRT) is superior to radiotherapy (RT) in locally advanced rectal cancer, but the survival gain is limited. Late toxicity is, therefore, important. The aim was to compare late bowel, urinary, and sexual functions after CRT or RT. METHODS AND MATERIALS Patients (N = 207) with nonresectable rectal cancer were randomized to preoperative CRT or RT (2 Gy × 25 ± 5-fluorouracil/leucovorin). Extended surgery was often required. Self-reported late toxicity was scored according to the LENT SOMA criteria in a structured telephone interview and with questionnaires European Organisation for Research and Treatment of Cancer (EORTC) Quality of Life Questionnaire (QLQ-C30), International Index of Erectile Function (IIEF), and sexual function-vaginal changes questionnaire (SVQ). RESULTS Of the 105 patients alive in Norway and Sweden after 4 to 12 years of follow-up, 78 (74%) responded. More patients in the CRT group had received a stoma (73% vs. 52%, p = 0.09). Most patients without a stoma (7 of 12 in CRT group and 9 of 16 in RT group) had incontinence for liquid stools or gas. No stoma and good anal function were seen in 5 patients (11%) in the CRT group and in 11 (30%) in the RT group (p = 0.046). Of 44 patients in the CRT group, 12 (28%) had had bowel obstruction compared with 5 of 33 (15%) in the RT group (p = 0.27). One-quarter of the patients reported urinary incontinence. The majority of men had severe erectile dysfunction. Few women reported sexual activity during the previous month. However, the majority did not have concerns about their sex life. CONCLUSIONS Fecal incontinence and erectile dysfunction are frequent after combined treatment for locally advanced rectal cancer. There was a clear tendency for the problems to be more common after CRT than after RT.
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Abstract
Radiation therapy is commonly utilized as a major component in the treatment of pelvic malignancy. Unfortunately, secondary toxicity to the lower gastrointestinal tract can occur. This most commonly affects the rectum, although injuries to the colon and small intestine are not uncommon. The presentation can be acute or chronic, and different mechanisms are responsible for each. Symptomatology is quite variable but can result in significant compromise for the patient. Numerous preventive and treatment strategies have been applied to this disease process. This article presents a summary of the current knowledge regarding radiation injury to the lower gastrointestinal tract with special emphasis on treatment options for radiation proctitis.
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Affiliation(s)
- Gregory D Kennedy
- Department of Surgery, University of Wisconsin Hospital and Clinics, Madison, Wisconsin 53792-7375, USA
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Lange MM, van de Velde CJ. Long-Term Anorectal and Urogenital Dysfunction After Rectal Cancer Treatment. SEMINARS IN COLON AND RECTAL SURGERY 2010. [DOI: 10.1053/j.scrs.2010.01.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
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Moreau-Claeys MV, Peiffert D. [Normal tissue tolerance to external beam radiation therapy: anal canal]. Cancer Radiother 2010; 14:359-62. [PMID: 20418146 DOI: 10.1016/j.canrad.2010.01.009] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2010] [Accepted: 01/29/2010] [Indexed: 11/24/2022]
Abstract
The anal canal is regarded as an organ at risk more often in pelvis radiation, but also in brachytherapy. Acute or chronic complications depend on its different components and are different from the anal margin or the rectum. The toxicity scale can be the NCI CT C version 3, completed by the tardive toxicity SOMALENT scale. The mean dose and maximal dose are recognized as predictors of complications. The maximum recommended dose despite the paucity of literature is 55 Gy.
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Affiliation(s)
- M-V Moreau-Claeys
- Département de Radiothérapie, Centre Alexis-Vautrin, 6 Avenue de Bourgogne, 54511 Vandoeuvre-les-Nancy, France.
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A murine model for the study of molecular pathogenesis of radiation proctitis. Int J Radiat Oncol Biol Phys 2010; 76:242-50. [PMID: 20005457 DOI: 10.1016/j.ijrobp.2009.07.1736] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2009] [Revised: 06/24/2009] [Accepted: 07/27/2009] [Indexed: 12/30/2022]
Abstract
PURPOSE To establish a novel mouse brachytherapy model with which to study the role of inflammation in the pathogenesis of radiation proctitis. METHODS AND MATERIALS The distal rectums of BALB/c and C57BL/6 mice were irradiated with three to five fractions of 5.5 to 8 Gy. Tissues were harvested and evaluated for histopathology, using the radiation injury score (RIS). Cytokine mRNA expression was assessed using real-time PCR. RESULTS Fifty percent of the mice treated with 22 Gy delivered in four fractions of 5.5 Gy died as a result of anorectal stenosis and distal bowel obstruction prior to the time of scheduled sacrifice, with a latency period of 4 to 10 weeks for the BALB/c and 3 to 4 weeks for the C57BL/6 mice. The RISs were 7, 12, and 8 at 2, 6, and 11 weeks, respectively, in the BALB/c mice and was 8.7 in the C57BL/6 mice on week 6. A 100- to 300-fold increase in interleukin-1beta (IL-1beta) (p = 0.04) and IL-6 mRNA (p = 0.07) and a 5- to 6-fold increase in transforming growth factor (TGF) and tumor necrosis factor-alpha mRNA expression levels (p < 0.001 and p = 0.01) were observed at 2 to 6 weeks after radiation. Cytokine mRNA tissue expression correlated positively with radiation dose (p < 0.0001). The RIS correlated well with IL-1beta and IL-6 mRNA levels in the BALB/c mice and with IL-1beta, IL-6, and TGF mRNA levels in C57BL/6 mice. Analysis of receiver operating characteristic curve showed that IL-1beta and IL-6 have the largest area under the curve and therefore are good markers of radiation proctitis (p < 0.001). CONCLUSIONS Radiation-induced proctitis was associated with a dose-dependent, characteristic proinflammatory cytokine response pattern in a novel mouse model suitable for interventional studies.
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Patel P, Subhas G, Gupta A, Chang YJ, Mittal VK, McKendrick A. Oral vitamin A enhances the effectiveness of formalin 8% in treating chronic hemorrhagic radiation proctopathy. Dis Colon Rectum 2009; 52:1605-9. [PMID: 19690489 DOI: 10.1007/dcr.0b013e3181afbe3a] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
PURPOSE Chronic radiation proctopathy occurs in 5 to 20% of patients receiving radiation therapy, with rectal bleeding as its most common presentation. Although formalin treatment for rectal bleeding is promising, improvement is possible. Given the success of vitamin A in other radiation-induced treatments, we studied the efficacy of combining formalin with vitamin A in controlling bleeding symptoms of chronic radiation proctopathy. METHODS A retrospective review (1993-2007) was performed of patients presenting with features of chronic radiation proctopathy. Formalin 8% in a buffered solution was applied to the affected mucosa with use a tip applicator, and 10,000 units of vitamin A were given orally on a daily basis. Formalin treatments were repeated at three-week to four-week intervals until symptoms resolved. RESULTS A comparison was made between patients who received formalin alone (n = 30) and those who received formalin in combination with vitamin A (n = 34). The 64 patients had a mean age of 79 years (range, 54-90 years). The combination group required fewer treatments (mean, 1.9) and a shorter time (11 weeks) for resolution of symptoms compared with the formalin-alone group (mean, 5.2 and 31 weeks, respectively) (P < 0.001). The overall success rate in controlling bleeding was only 64% in the formalin-alone group when compared with 94% in the combination group. CONCLUSIONS When vitamin A was added to the regimen, a significant reduction was observed in the number of treatments and the time needed for resolution of symptoms, and there was an increased overall success rate. This combination represents a simple, effective, and well tolerated method of controlling hemorrhagic chronic radiation proctopathy.
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Affiliation(s)
- Purnal Patel
- Department of Surgery, Providence Hospital and Medical Centers, Southfield, Michigan 48075, USA
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Sheth S, Bleibel W, Thukral C, A-Rahim Y, Beldi G, Csizmadia E, Robson SC. Heightened NTPDase-1/CD39 expression and angiogenesis in radiation proctitis. Purinergic Signal 2009; 5:321-6. [PMID: 19337853 DOI: 10.1007/s11302-009-9154-2] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2008] [Accepted: 03/05/2009] [Indexed: 10/20/2022] Open
Abstract
Radiation proctitis is an inflammatory process associated with persistent and refractory lower gastrointestinal bleeding. Purinergic signaling regulates hemostasis, inflammation, and angiogenesis. For example, CD39, the vascular ectonucleotidase, blocks platelet activation and is required for angiogenesis. Whether CD39 expression is affected by radiation injury is unknown. The aim of this work was to study CD39 expression patterns after clinical radiation injury to the rectum. We prospectively enrolled eight patients with radiation proctitis and five gender-matched controls. Biopsies were taken from normal-appearing rectal mucosa of controls and from the normal sigmoid and abnormal rectum of patients. Expression patterns of CD39, P2Y2 receptor, CD31, CD61 integrin, and vascular endothelial growth factor receptor 2 were examined by immunostaining; levels of CD39 were further evaluated by Western blots. Chronic inflammatory lesions of radiation proctitis were associated with heightened levels of angiogenesis. Immunohistochemical stains showed increased vascular expression of CD39, as confirmed by Western blots. CD39 was co-localized with vascular endothelial markers CD31 and CD61 integrin, as well as expressed by stromal tissues. Development of neovasculature and associated CD39 expression in radiation proctitis may be associated with the chronic, refractory bleeding observed in this condition.
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Affiliation(s)
- Sunil Sheth
- Division of Gastroenterology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, 02215, USA
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Yuan G, Ke Q, Su X, Yang J, Xu X. Qing Dai, a traditional Chinese medicine for the treatment of chronic hemorrhagic radiation proctitis. ACTA ACUST UNITED AC 2009. [DOI: 10.1007/s10330-008-0141-9] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Hayne D, Smith AE. Hyperbaric oxygen treatment of chronic refractory radiation proctitis: a randomized and controlled double-blind crossover trial with long-term follow-up: in regard to Clarke et al. (Int J Radiat Oncol Biol Phys 2008 Mar 12). Int J Radiat Oncol Biol Phys 2008; 72:1621; author reply 1621. [PMID: 19028292 DOI: 10.1016/j.ijrobp.2008.08.027] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2008] [Accepted: 08/06/2008] [Indexed: 02/08/2023]
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