Pelvic radiation therapy: Between delight and disaster

Development and refinement of patient care recommendations in brachytherapy for locally advanced cervical cancer using nominal group technique workshops

PURPOSE

Patient experiences of brachytherapy for locally advanced cervical cancer (LACC) are widely variable, with reports of difficult and traumatic experiences and aspects of care requiring improvement. The aim of this study was to develop patient care recommendations and consult with key stakeholders to review, refine and prioritise recommendations.

METHODS

Phase 1: Patient care recommendations were developed from qualitative exploratory study data. Phase 2: Service users and providers with recent experience of brachytherapy for LACC were recruited to online nominal group technique (NGT) workshops. Four NGT stages were followed: (1) initial voting and silent generation; (2) round robin; (3) clarification; and (4) prioritisation. Voting data were summed across the workshops, deriving inter-group scores. Qualitative data were analysed through content analysis.

RESULTS

Phase 1: Fifty-one patient care recommendations were developed. Phase 2: Thirteen participants took part in three online NGT workshops, with a combination of service users and providers. Initial recommendations were voted on; four new recommendations were added; minor changes were made and second voting was undertaken. Recommendations were positively received with 25 recommendations scoring maximum points from all participants. An importance score above 90% was given to 46 recommendations. The remaining recommendations received scores between 74 and 90%.

CONCLUSIONS

NGT workshops facilitated collaboration between key stakeholders, discussing, refining and prioritising patient care recommendations, leading to verification of achievable and relevant recommendations. These provide a foundation for future development of guidelines and subsequent implementation into clinical practice, aiming to improve consistency of care and patient experiences of brachytherapy for LACC.

Malignant Small Bowel Obstruction from Hernia Mesh Invasion by Jejunal Adenocarcinoma: A Report of a Rare Case

BACKGROUND Small bowel obstructions (SBO) are common and can be caused by various pathologies including intra-abdominal adhesions and hernias. Less frequently, these obstructions are caused by malignancy. The following article will review the etiology and treatment of SBOs, discuss complications of hernia repair with mesh, and examine if there is an association between mesh and cancer. CASE REPORT We present the case of a man who was over 89 years old who presented with an SBO that failed non-operative management. He previously had bilateral inguinal hernia repairs with mesh and pelvic radiation for prostate cancer. Imaging obtained during the workup was concerning for malignancy. Exploratory laparotomy revealed an ascending colon adenocarcinoma and small bowel obstruction secondary to jejunal adenocarcinoma. The jejunal adenocarcinoma was adhered to and invaded into the mesh from a previous hernia repair. He underwent successful resection and anastomosis, had an uneventful postoperative course, and was discharged. Given his advanced age, he refused further workup or treatment. CONCLUSIONS The etiology and management of small bowel obstructions is multifactorial. Small bowel obstructions affect a large portion of the population worldwide and the subsequent management accounts for significant health care spending. This case shows an exceedingly rare and possibly novel case of jejunal adenocarcinoma that invaded into the hernia mesh, leading to a malignant small bowel obstruction. While there is not a clear explanation behind this patients' pathology, we hypothesize that his prior hernia surgery led to an intra-abdominal adhesion, and subsequent pelvic radiation may have facilitated the malignancy invading the mesh and causing a high-grade small bowel obstruction.

Management of Ureteral Stricture Disease After Radiation Therapy for Pelvic Malignancies: A Retrospective, Multi-Institutional Analysis

OBJECTIVES

A radiation-induced ureteral stricture (RIUS) is a challenging condition in urologic surgery, and the optimal surgical strategy is still a matter of debate. The aim of this study was to report post-operative outcomes of minimally invasive management of this condition from a multi-institutional cohort.

METHODS

Data of patients with diagnoses of RIUS at five referral robotic centers between January 2017 and December 2022 were retrospectively analyzed. Pre-, intra- and post-operative variables were collected. Recurrence was defined as the presence of flank pain combined with imaging findings for obstruction, and requiring further management. Univariate and multivariate logistic regression models were built to identify predictors of ureteral stricture recurrence.

RESULTS

Fifty-three patients with a diagnosis of an RIUS were included. Primary pelvic malignancy was mostly cervical (42%). In 72% of cases (mostly mid-proximal and short strictures) endourological management was attempted, which was deemed successful in 74% of patients at stent removal. The endourology success rate at a median follow-up of 12 months was 59%. Twenty-five patients (47%) were scheduled for robotic surgery. The reconstructive techniques most often performed were end-to-end anastomosis (44%) and ureteral reimplantation (52%). Three low-grade Clavien-Dindo post-operative complications (12%) occurred. Robotic surgery was successful in all cases except one. Considering the entire cohort, eight patients (15%) developed recurrence at a median follow-up of 5 months. All patients with recurrence were managed by permanent drainage. A statistically significant improvement in eGFR with respect to baseline was found at a median follow-up of 12 months (p = 0.007). The univariate logistic regression model identified ureteral stricture length >2 cm (OR 6.4, 95% C.I. 1.1-36.9, p = 0.04) and concomitant chemotherapy (OR 8.9, 95% C.I. 1.6-49.9, p = 0.01) as predictors of recurrence. At multivariate analysis concomitant chemotherapy was confirmed as an independent predictor of recurrence (OR 7.8, 95% C.I. 1.3-49.0, p = 0.03).

CONCLUSIONS

Endourological management of an RIUS is reasonable for short and mid-proximal ureteral strictures, while robotics is required in almost all the remaining cases. Up to 15% of recurrence develops within 6 months. Re-do reconstructive surgery is rarely performed, even in referral centers.

Surgical Innovations to Protect Fertility from Oncologic Pelvic Radiation Therapy: Ovarian Transposition and Uterine Fixation

As oncologic therapy continues to advance, survivorship care has widened the realm of possibilities for quality-of-life improvements, including fertility preservation and restoration. We aim to summarize the current and future directions of fertility preservation techniques for patients facing gonadotoxic medical therapies who desire pregnancy after their condition is treated. This review of both ovarian and uterine transposition highlights the present roles, techniques, and fertility outcomes of the two fertility preservation treatment modalities designed to protect reproductive organs from harmful pelvic radiation. Current evidence shows that ovarian transposition preserves ovarian function for patients with localized pelvic radiation demonstrating the most successful return of fertility. Uterine transposition holds great promise for patients desiring to conceive and carry a full-term pregnancy after radiation therapy. With ongoing advancements in oncologic treatments leading to increased survival rates, fertility is increasingly becoming a key survivorship issue. Patients can anticipate counseling about these fertility preservation surgical techniques that protect both the ovaries as well as the uterus from harmful pelvic radiation.

Pelvic Radiation Therapy Increases Risk of Pouch Failure in Patients with Inflammatory Bowel Disease and Ileal Pouch

BACKGROUND

The effect of radiation on the ileal pouch is less well studied in patients with inflammatory bowel disease (IBD) and ileal pouch-anal anastomosis.

AIMS

This retrospective study investigates the impact of external radiation therapy on the outcomes of ileal pouches.

METHODS

The study included 82 patients with IBD and ileal pouches, of whom 12 received pelvic radiation, 16 abdominal radiation, 14 radiation in other fields, and 40 served as controls with no radiation. Pouch-related outcomes, including pouch failure, worsening of symptoms, pouchitis, and development of strictures, along with changes in Pouch Disease Activity Index (PDAI) scores pre- and post-radiation were assessed.

RESULTS

The pelvic radiation group exhibited a significantly higher rate of pouch failure (25%, p < 0.004) and worsening pouch-related symptoms (75%, p = 0.012) compared to other groups. Although not statistically significant, a higher incidence of pouchitis was observed in the pelvic radiation group (45.5%, p = 0.071). Strictures were more common in the pelvic radiation group (25%, p = 0.043). Logistic regression analysis revealed that pelvic radiation significantly increased the odds of pouch-related adverse outcomes (OR 5.66; 95% confidence interval: 1.61-21.5).

CONCLUSION

Pelvic radiation significantly impacts the outcomes of ileal pouches in patients with IBD, increasing the risk of pouch failure, symptom exacerbation, and structural complications. These findings underscore the need for careful consideration of radiation therapy in this patient population and highlight the importance of closely monitoring and managing radiation-induced pouch dysfunction.

Point/Counterpoint #1: Chemotherapy Alone Is a Sufficient Preoperative Treatment for Rectal cancer

ABSTRACT

For decades, the standard neoadjuvant therapy regimen for locally advanced rectal cancer consisted of chemoradiation, surgical resection, and consideration of adjuvant systemic therapy. Additional data have emerged suggesting neoadjuvant systemic therapy as a reasonable alternative to chemoradiation in selected patients. In addition, a total neoadjuvant therapy approach integrating both chemotherapy and chemoradiation results in superior cancer outcomes and the potential for consideration of nonoperative management in patients with a clinical complete response. Despite a multitude of therapeutic pathways for the management of rectal cancer, what is clear, however, is the importance of a multidisciplinary approach with shared patient and provider decision-making.

Risk of Secondary Malignancies After Pelvic Radiation: A Population-based Analysis

Background and objective

Radiation therapy has increasingly been used in the management of pelvic malignancies. However, the use of radiation continues to pose a risk of a secondary malignancy to its recipients. This study investigates the risk of secondary malignancy development following radiation for primary pelvic malignancies.

Methods

A retrospective cohort review of the Surveillance, Epidemiology, and End Results database from 1975 to 2016 was performed. Primary pelvic malignancies were subdivided based on the receipt of radiation, and secondary malignancies were stratified as pelvic or nonpelvic to investigate the local effect of radiation.

Key findings and limitations

A total of 2 102 192 patients were analyzed (1 189 108 with prostate, 315 026 with bladder, 88 809 with cervical, 249 535 with uterine, and 259 714 with rectal/anal cancer). The incidence rate (defined as cases per 1000 person years) of any secondary malignancies (including but not limited to secondary pelvic malignancies) was higher in radiation patients than in nonradiation patients (incidence rate ratio [IRR] 1.04, confidence interval [CI] 1.03-1.05), with significantly greater rates noted in radiation patients with prostate (IRR 1.22, CI 1.21-1.24), uterine (IRR 1.34), and cervical (IRR 1.80, CI 1.72-1.88) cancer. While the overall incidence rate of any secondary pelvic malignancy was lower in radiation patients (IRR 0.79, CI 0.78-0.81), a greater incidence was still noted in the same cohorts including radiation patients with prostate (IRR 1.42, CI 1.39-1.45), uterine (IRR 1.15, CI 1.08-1.21), and cervical (IRR 1.72, CI 1.59-1.86) cancer.

Conclusions and clinical implications

Except for localized cervical cancer, when put in the context of median overall survival, the impact of radiation likely does not carry enough weight to change practice patterns. Radiation for pelvic malignancies increases the risk for several secondary malignancies, and more specifically, secondary pelvic malignancies, but with a relatively low absolute risk of secondary malignancies, the benefits of radiation warrant continued use for most pelvic malignancies. Practice changes should be considered for radiation utilization in malignancies with excellent cancer-specific survival such as cervical cancer.

Patient summary

The use of radiation for the management of pelvic malignancies induces a risk of secondary malignancies to its recipients. However, the absolute risk being low, the benefits of radiation warrant its continued use, and a change in practice patterns is unlikely.

Chronic abdominal aortic occlusion in a patient with an underdeveloped, irradiated pelvis after childhood treatment of Ewing Sarcoma

Chronic radiation-induced arterial injury is generally predictable by known tumor types and anatomic location. We present the first case of radiation-induced chronic aortic occlusion associated with a small pelvis secondary to the treatment of childhood Ewing sarcoma. The patient presented with profound claudication and accelerated atherosclerosis obliterans of the aortoiliac system and failed endovascular treatment. Successful aortic reconstruction was performed. This case highlights the long-term effects of chemoradiation to the aortoiliac segment and pelvic bones in a child, and the technical challenges of vascular reconstruction in an underdeveloped irradiated pelvis.

Adverse Effects of Cancer Treatment in Patients With Cervical Cancer

BACKGROUND

In lower- to middle-income countries such as India, the literature on the adverse effects (AEs) of cancer treatment in patients with cervical cancer is very limited. This knowledge gap provides an opportunity to investigate and improve the quality of life for women with cervical cancer.

OBJECTIVE

The purpose of this study was to assess the AEs of various cancer treatment combinations in patients with cervical cancer.

METHODS

This observational, retrospective study analysed 1,030 women with cervical cancer, with a descriptive cross-sectional design, based on a review of medical records from patients who were followed up during the morbidity consultation conducted by a multidisciplinary team of doctors. The AEs of cancer treatment for women with cervical cancer were recorded in these medical records between October 14, 2019, and November 21, 2022, at 10 major public tertiary hospitals in India.

RESULTS

This study analysed 1,030 women with cervical cancer aged between 21 and 80 years (mean age: 48.8 ± 13.9 years; p=0.30). Patients between the ages of 36-50 years reported the most AEs (30.2%; 95% confidence interval (CI): 29.1-32.8) among other age groups. Combined radiation therapy and chemotherapy (CT) was the type of cancer treatment in which there were more AEs, presenting in 56.0% (95% CI: 55-60.1) of patients. Adverse effects associated with the gastrointestinal system were observed in the majority (92.5%, 95% CI: 90.2-96.9) of cervical cancer patients.

CONCLUSION

Exposure to different cancer treatments, particularly combination therapy, induces AEs in patients during and after cervical cancer treatment.

Outcomes Following Recent and Distant Neoadjuvant Radiation in Rectal Cancer: An Institutional Retrospective Review and Analysis of NSQIP

BACKGROUND

Neoadjuvant chemoradiotherapy (nCRT) is the standard of care in locally advanced rectal cancer (LARC). However, radiation therapy is thought to increase operative difficulty due to induction of fibrosis. Total neoadjuvant therapy (TNT) protocols increase the time between completion of radiation and surgical resection which may lead to increased operative difficulty and complications.

METHODS

A single institution retrospective review of patients ≥18 years with LARC undergoing nCRT from 2015 to 2022. Patients were dichotomized in 2 cohorts: <90 days from radiation to surgery (recent radiation), and ≥90 days from radiation to surgery (distant radiation). Institutional data was compared to National Surgical Quality Improvement Program (NSQIP) rectal cancer data from 2016 to 2020. Outcomes included intraoperative complications, 30-day morbidity, and oncologic outcomes.

RESULTS

One hundred forty-six institutional patients included, 120 had recent radiation, 26 had distant radiation. Thirty-day morbidity and intraoperative complications did not differ. There was greater radial margin positivity (7% vs. 24%), fewer lymph nodes harvested (17 ± 5 vs. 15 ± 6), and a lower rate of complete mesorectal dissection (88% vs. 65%,) in distant radiation patients 3059 patients were included in NSQIP analysis, 2029 completed radiation <90 days before surgery and 1030 without radiation 90 days before surgery. Patients without radiation 90 days preoperatively had more radial margin positivity (9.2% vs. 4.6%), organ space infection (8.6% vs. 6.4%), and pneumonia (2.2% vs. 0.9%).

CONCLUSION

The present study suggests that increased time between radiation and surgery results in more challenging dissection with less complete mesorectal dissection and increased radial margin positivity without increasing technical complications.

Co-occurrence of symptoms after radiochemotherapy in locally advanced cervix cancer patients: a cluster analysis

BACKGROUND

State of the art combined radiochemotherapy and image-guided brachytherapy for locally advanced cervical cancer (LACC) has shown improved disease control and survival as well as a significant reduction of organ related morbidity. However, LACC cancer survivors are still experiencing a spectrum of symptoms. The aim of this study was to identify co-occurring symptoms in cervix cancer survivors by using patient-reported outcome and physician assessed morbidity.

MATERIALS AND METHOD

EMBRACE I is a multicenter prospective observational study with 1416 LACC patients (2008-2015). Information on physician-assessed morbidity and patient-reported outcome was assessed at baseline and at regular follow-ups up with the CTCAE v.3 and EORTC-C30/CX24, respectively. Patients with at least 2 years of follow-up were included and data from 3 months to 2 years was used in the analysis. Factor analysis was used on both EORTC and CTCAE data with symptoms and follow-ups as observations. The extracted factors represent clusters of symptoms. Subsequently, regression models were built to investigate associations between the symptom clusters and QOL.

RESULTS

The analysis included 742 patients. Despite the differences in the definition of physician-assessed and patient-reported symptoms, similar clusters are identified by the two assessment methods. Three main organ-related clusters are recognized for urinary, gastro-intestinal and vaginal morbidity. Furthermore, a general symptoms cluster where fatigue, pain, insomnia, neuropathy, and hot flashes have large weights is found. Lastly, a cluster with nausea, vomit and lack of appetite is also identified. The general, gastrointestinal and nausea clusters show significant associations with general QOL.

CONCLUSIONS

This analysis on both PRO and physician-assessed morbidity found a cluster associated with general symptoms and organ-related symptom clusters (urinary, gastrointestinal, vaginal). This shows that LACC survivors experience a variety of co-occurring symptoms. Our analysis also shows that the cluster of general symptoms is associated with a decrease in QOL.

Mitigative and anti-inflammatory effects of Trichostatin A against radiation-induced gastrointestinal toxicity and gut microbiota alteration in mice

PURPOSE

Radiation-induced gastrointestinal injury (RIGI) is a serious side effect of abdominal and pelvic radiotherapy, which often limits the treatment of gastrointestinal and gynaecological cancers. RIGI is also observed during accidental radiological or nuclear scenarios with no approved agents available till date to prevent or mitigate RIGI in humans. Trichostatin A (TSA), an epigenetic modulator, has been currently in clinical trials for cancer treatment and is also well known for its antibiotic and antifungal properties.

METHODS

In this study, partial body (abdominal) irradiation mice model was used to investigate the mitigative effect of TSA against gastrointestinal toxicity caused by gamma radiation. Mice were checked for alterations in mean body weight, diarrheal incidence, disease activity index and survival against 15 Gy radiation. Structural abnormalities in intestine and changes in microbiota composition were studied by histopathology and 16S rRNA sequencing of fecal samples respectively. Immunoblotting and biochemical assays were performed to check protein nitrosylation, expression of inflammatory mediators, infiltration of inflammatory cells and changes in pro-inflammatory cytokine.

RESULTS

TSA administration to C57Bl/6 mice improved radiation induced mean body weight loss, maintained better health score, reduced disease activity index and promoted survival. The 16S rRNA sequencing of fecal DNA demonstrated that TSA influenced the fecal microbiota dynamics with significant alterations in the Firmicutes/Bacteriodetes ratio. TSA effectively mitigated intestinal injury, down-regulated NF-κB, Cox-2, iNOS expression, inhibited PGE2 and protein nitrosylation levels in irradiated intestine. The upregulation of NLRP3-inflammasome complex and infiltrations of inflammatory cells in the inflamed intestine were also prevented by TSA. Subsequently, the myeloperoxidase activity in intestine alongwith serum IL-18 levels was found reduced.

CONCLUSION

These findings provide evidence that TSA inhibits inflammatory mediators, alleviates gut dysbiosis, and promotes structural restoration of the irradiated intestine. TSA, therefore, can be considered as a potential agent for mitigation of RIGI in humans.

Low-grade intestinal inflammation two decades after pelvic radiotherapy

BACKGROUND

Radiotherapy is effective in the treatment of cancer but also causes damage to non-cancerous tissue. Pelvic radiotherapy may produce chronic and debilitating bowel symptoms, yet the underlying pathophysiology is still undefined. Most notably, although pelvic radiotherapy causes an acute intestinal inflammation there is no consensus on whether the late-phase pathophysiology contains an inflammatory component or not. To address this knowledge gap, we examined the potential presence of a chronic inflammation in mucosal biopsies from irradiated pelvic cancer survivors.

METHODS

We biopsied 24 cancer survivors two to 20 years after pelvic radiotherapy, and four non-irradiated controls. Using tandem mass tag (TMT) mass spectrometry and mRNA sequencing (mRNA-seq), we charted proteomic and transcriptomic profiles of the mucosal tissue previously exposed to a high or a low/no dose of radiation. Changes in the immune cell populations were determined with flow cytometry. The integrity of the protective mucus layers were determined by permeability analysis and 16S rRNA bacterial detection.

FINDINGS

942 proteins were differentially expressed in mucosa previously exposed to a high radiation dose compared to a low radiation dose. The data suggested a chronic low-grade inflammation with neutrophil activity, which was confirmed by mRNA-seq and flow cytometry and further supported by findings of a weakened mucus barrier with bacterial infiltration.

INTERPRETATION

Our results challenge the idea that pelvic radiotherapy causes an acute intestinal inflammation that either heals or turns fibrotic without progression to chronic inflammation. This provides a rationale for exploring novel strategies to mitigate chronic bowel symptoms in pelvic cancer survivors.

FUNDING

This study was supported by the King Gustav V Jubilee Clinic Cancer Foundation (CB), The Adlerbertska Research Foundation (CB), The Swedish Cancer Society (GS), The Swedish State under the ALF agreement (GS and CB), Mary von Sydow's foundation (MA and VP).

The effect of nutritional interventions in acute radiation-induced diarrhoea in patients with primary pelvic cancer: A systematic review

Acute radiation-induced diarrhoea (RID) is a well-known side effect of external radiation therapy for pelvic cancer. Acute RID is an unresolved clinical problem in approximately 80% of patients. We investigated the effect of nutritional interventions on acute RID in patients with pelvic cancer treated with curative radiotherapy. A search was conducted using PubMed, Embase.com, CINAHL, and Cochrane Library, from 1 January 2005 until 10 October 2022. We included randomised controlled trials or prospective observational studies. Eleven of the 21 identified studies had low quality of evidence, mainly because of low patient numbers distributed among several cancer diagnoses, and non-systematic assessment of acute RID. Interventions included probiotics (n = 6), prebiotics (n = 6), glutamine (n = 4), and others (n = 5). Five studies, of which two provided high quality evidence, showed that probiotics improved acute RID. Future well-designed studies investigating the effects of probiotics on acute RID are warranted. PROSPERO ID: CRD42020209499).

Radiobiological modeling of radiation-induced acute proctitis: A single-institutional study of prostate carcinoma

Purpose

To estimate the fitting parameters of the sigmoidal dose response (SDR) curve of radiation-induced acute proctitis in prostate cancer patients treated with intensity modulated radiation therapy (IMRT) for the calculation of normal tissue complication probability (NTCP).

Materials and Methods

Twenty-five prostate cancer patients were enrolled and evaluated weekly for acute radiation-induced (ARI) proctitis toxicity. Their scoring was performed as per common terminology criteria for adverse events version 5.0. The radiobiological parameters namely n, m, TD50, and γ50 were calculated from the fitted SDR curve obtained from the clinical data of prostate cancer patients.

Results

ARI toxicity for rectum in carcinoma of prostate patients was calculated for the endpoint of acute proctitis. The n, m, TD50, and γ50 parameters from the SDR curve of Grade 1 and Grade 2 acute proctitis are found to be 0.13, 0.10, 30.48 ± 1.52 (confidence interval [CI] 95%), 3.18 and 0.08, 0.10, 44.37 ± 2.21 (CI 95%), 4.76 respectively.

Conclusion

This study presents the fitting parameters for NTCP calculation of Grade-1 and Grade-2 ARI rectum toxicity for the endpoint of acute proctitis. The provided nomograms of volume versus complication and dose versus complication for different grades of acute proctitis in the rectum help radiation oncologists to decide the limiting dose to reduce the acute toxicities.

Online Symptom Monitoring During Pelvic Radiation Therapy: Randomized Pilot Trial of the eRAPID Intervention

PURPOSE

Radiation therapy (RT) and chemoRT for pelvic cancers increase survival but are associated with serious treatment-related symptoms. Electronic-patient self-Reporting of Adverse-events: Patient Information and aDvice (eRAPID) is a secure online system for patients to self-report symptoms, generating immediate advice for hospital contact or self-management. This pilot study aimed to establish feasibility and acceptability of the system.

METHODS AND MATERIALS

In a prospective 2-center randomized parallel-group pilot study, patients undergoing radical pelvic RT for prostate cancer (prostateRT) or chemoRT for lower gastrointestinal and gynecological cancers were randomized to usual care (UC) or eRAPID (weekly online symptom reporting for 12, 18, and 24 weeks). Primary outcomes were recruitment/attrition, study completion, and patient adherence. Secondary outcomes were effect on hospital services and performance of patient outcome measures. Missing data, floor/ceiling effects, and mean change scores were examined for Functional Assessment of Cancer Therapy (FACT-G), European Organisation for Research and Treatment of Cancer, Quality of Life (EORTC QLQ C-30), self-efficacy, and EuroQol (EQ5D).

RESULTS

From 228 patients approached, 167 (73.2%) were consented and randomized (83, eRAPID; 84, UC; 87, prostateRT; 80, chemoRT); 150 of 167 completed 24 study weeks. Only 16 patients (9.6%) withdrew (10, eRAPID; 6, UC). In the eRAPID arm, completion rates were higher in patients treated with prostateRT compared with chemoRT (week 1, 93% vs 69%; week 2, 93% vs 68%; week 12, 69% vs 55%). Overall, over 50% of online reports triggered self-management advice for milder adverse events. Unscheduled hospital contact was low, with no difference between eRAPID and UC. Return rates for outcome measures were excellent in prostateRT (97%-91%; 6-24 weeks) but lower in chemoRT (95%-55%; 6-24 weeks). Missing data were low (1%-4.1%), ceiling effects were evident in EQ5D-5L, self-efficacy-scale, and FACT-Physical Wellbeing. At 6 weeks, the chemoRT-eRAPID group showed less deterioration in FACT-G, EORTC QLQ-C30, and EQ5D-Visual Analogue Scale than UC, after baseline adjustment.

CONCLUSIONS

eRAPID was successfully added to UC at 2 cancer centers in different patient populations. Acceptability and feasibility were confirmed with excellent adherence by prostate patients, but lower by those undergoing chemoRT for gynecological cancers.

A Retrospective Single-Arm Cohort Study in a Single Center of Radiofrequency Ablation in Treatment of Chronic Radiation Proctitis

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.

Treatment strategy and clinical characteristics of patients with cervical cancer as prognostic parameters of survival

Background. Cervical cancer (CRC) ranks second in the world among all malignant neoplasms of the female genital organs. According to the WHO, more than 500000 new cases of CRC are detected annually in the world. In 2021, 3398 new cases of the disease were registered in Ukraine. Currently a number of factors that have a rather high individual prognostic significance influences the CRC development. Among these factors are those which are associated with an adverse outcome: heavy hereditary anamnesis, growth form of tumor and its localization, variant of spread, depth of invasion into the stroma, morphological structure, methods of treatment, etc. Over the last decade, there has been an unfavorable trend towards an increase in the number of young patients who have an advanced tumor process, which significantly restricts methods and reduces the chances of the successful treatment. Thereby, the high level of morbidity and mortality from CRC, especially among young patients, as well as the unsatisfactory results of 5-year survival after traditional methods of treatment, indicate that the cancer of this type is the prior problem in domestic oncology. Purpose. To make scientific analysis of modern treatment strategies and characteristics of CRC as prognostic survival parameters. Materials and methods. The literature review included available full-text publications, which were obtained as a result of an in-depth analysis of foreign and domestic scientific publications. Results. Authors gave analysis of modern domestic and foreign literature on the evaluation of the effectiveness of treatment of cervical cancer patients; namely, how treatment strategies, individual characteristics of patients and characteristics of the tumor affect the results of treatment and prognosis of patient survival. It is shown which parameters, factors and important nuances of the disease should be taken into account, which is decisive in choosing treatment tactics and preventing complications. Conclusions. Knowing and taking into account the prognostic parameters of the survival of cervical cancer patients is important for the assessment of treatment standards, as well as the development of personalized tactics for the treatment and monitoring of this disease.

Exploiting dietary fibre and the gut microbiota in pelvic radiotherapy patients

With an ageing population, there is an urgent need to find alternatives to current standard-of-care chemoradiation schedules in the treatment of pelvic malignancies. The gut microbiota may be exploitable, having shown a valuable role in improving patient outcomes in anticancer immunotherapy. These bacteria feed on dietary fibres, which reach the large intestine intact, resulting in the production of beneficial metabolites, including short-chain fatty acids. The gut microbiota can impact radiotherapy (RT) treatment responses and itself be altered by the radiation. Evidence is emerging that manipulation of the gut microbiota by dietary fibre supplementation can improve tumour responses and reduce normal tissue side effects following RT, although data on tumour response are limited to date. Both may be mediated by immune and non-immune effects of gut microbiota and their metabolites. Alternative approaches include use of probiotics and faecal microbiota transplantation (FMT). Current evidence will be reviewed regarding the use of dietary fibre interventions and gut microbiota modification in improving outcomes for pelvic RT patients. However, data regarding baseline (pre-RT) gut microbiota of RT patients and timing of dietary fibre manipulation (before or during RT) is limited, heterogenous and inconclusive, thus more robust clinical studies are required before these strategies can be applied clinically.

Chologene Diarrhö, Stiefkind der chronischen Diarrhö – Prävalenz, Diagnostik und Therapie

Die chologene Diarrhö ist eine der häufigsten nicht diagnostizierten Ursachen der chronischen Diarrhö, der zahlreiche verschiedene Pathophysiologien zugrunde liegen können. Auch nach Ausschlussdiagnostik der häufigeren Ursachen verbleiben bis zu 5% der Bevölkerung von einer ungeklärten chronischen Diarrhö betroffen. In diesem Kollektiv findet sich in bis zu 50% als Ursache eine chologene Diarrhö.

Multiparametric MRI-based radiomics model to predict pelvic lymph node invasion for patients with prostate cancer

OBJECTIVE

To identify which patient with prostate cancer (PCa) could safely avoid extended pelvic lymph node dissection (ePLND) by predicting lymph node invasion (LNI), via a radiomics-based machine learning approach.

METHODS

An integrative radiomics model (IRM) was proposed to predict LNI, confirmed by the histopathologic examination, integrating radiomics features, extracted from prostatic index lesion regions on MRI images, and clinical features via SVM. The study cohort comprised 244 PCa patients with MRI and followed by radical prostatectomy (RP) and ePLND within 6 months between 2010 and 2019. The proposed IRM was trained in training/validation set and evaluated in an internal independent testing set. The model's performance was measured by area under the curve (AUC), sensitivity, specificity, negative predictive value (NPV), and positive predictive value (PPV). AUCs were compared via Delong test with 95% confidence interval (CI), and the rest measurements were compared via chi-squared test or Fisher's exact test.

RESULTS

Overall, 17 (10.6%) and 14 (16.7%) patients with LNI were included in training/validation set and testing set, respectively. Shape and first-order radiomics features showed usefulness in building the IRM. The proposed IRM achieved an AUC of 0.915 (95% CI: 0.846-0.984) in the testing set, superior to pre-existing nomograms whose AUCs were from 0.698 to 0.724 (p < 0.05).

CONCLUSION

The proposed IRM could be potentially feasible to predict the risk of having LNI for patients with PCa. With the improved predictability, it could be utilized to assess which patients with PCa could safely avoid ePLND, thus reduce the number of unnecessary ePLND.

KEY POINTS

• The combination of MRI-based radiomics features with clinical information improved the prediction of lymph node invasion, compared with the model using only radiomics features or clinical features. • With improved prediction performance on predicting lymph node invasion, the number of extended pelvic lymph node dissection (ePLND) could be reduced by the proposed integrative radiomics model (IRM), compared with the existing nomograms.

Pitfalls in the reporting of neoplastic and pseudo neoplastic lesions in the colon and rectum

INTRODUCTION

Colonic biopsies comprise large portion of pathologists' daily work. Within various pathological entities, there are histological ranges and variations. Unawareness of all of these variabilities might lead to misdiagnosis by an inexperienced pathologist and, accordingly, to mismanagement.

Irradiation Induces Tuft Cell Hyperplasia and Myenteric Neuronal Loss in the Absence of Dietary Fiber in a Mouse Model of Pelvic Radiotherapy

Pelvic radiotherapy is associated with chronic intestinal dysfunction. Dietary approaches, such as fiber enrichment during and after pelvic radiotherapy, have been suggested to prevent or reduce dysfunctions. In the present paper, we aimed to investigate whether a diet rich in fermentable fiber could have a positive effect on radiation-induced intestinal damage, especially focusing on tuft cells and enteric neurons. Male C57BL/6 mice were fed either a purified non-fiber diet or the same purified diet with 5% or 15% oat fiber added, starting two weeks prior to sham-irradiation or irradiation with four fractions of 8 Gray. The animals continued on the diets for 1, 6 or 18 weeks, after which the gross morphology of the colorectum was assessed together with the numbers of enteric neurons, tuft cells and crypt-surface units. The results showed that dietary fiber significantly affected the intestinal morphometrics, both in the short and long-term. The presence of dietary fiber stimulated the re-emergence of crypt-surface unit structures after irradiation. At 18 weeks, the animals fed with the non-fiber diet displayed more myenteric neurons than the animals fed with the dietary fibers, but irradiation resulted in a loss of neurons in the non-fiber fed animals. Irradiation, but not diet, affected the tuft cell numbers, and a significant increase in tuft cells was found 6 and 18 weeks after irradiation. In conclusion, dietary fiber intake has the potential to modify neuronal pathogenesis in the colorectum after irradiation. The long-lasting increase in tuft cells induced by irradiation may reflect an as yet unknown role in the mucosal pathophysiology after pelvic irradiation.

Gut Microbiome and Its Associations With Acute and Chronic Gastrointestinal Toxicities in Cancer Patients With Pelvic Radiation Therapy: A Systematic Review

Aim

Pelvic radiation therapy (RT) can impact the gut microbiome in patients with cancer and result in gastrointestinal (GI) toxicities. The purpose of this systematic review was to describe the effects of RT on the gut microbiome and the associations between the gut microbiome and GI toxicities in patients treated with pelvic RT.

Methods

PubMed, Embase, and Web of Science databases were searched from their earliest records to August 2020. The articles screening process adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The Mixed Method Assessment Tool was used to assess the methodological quality for each included study. All study findings were synthesized and presented in narrative format. Thirteen studies were included. The gut microbiome of fecal samples was analyzed using 16S rRNA sequencing approaches.

Results

There were disparities in alpha and beta diversities that existed across the studies. Divergent results were found among various phyla, including Firmicutes, Bacteroidetes, Proteobacteria, Actinobacteria, Cyanobacteria, Fusobacteria, and Deinococcus-Thermus. Moreover, alteration in the gut microbiome diversity and abundance related to cancer treatment was associated with pelvic toxicities, specifically diarrhea. Following treatment, increases in the abundance of Bacteroides was associated with diarrhea and radiation enteritis.

Conclusions

Pelvic RT can disrupt the diversity and abundance of commensal gut microorganisms. A dysbiotic gut microbiome showed a promising association with radiation enteritis through alterations of the intestinal barrier function, innate immunity, and intestinal repair mechanisms; however, confounders, such as diet, were not thoroughly addressed.

Radiation Proctitis and Management Strategies

Radiotherapy (RT) is a treatment modality that uses high-energy rays or radioactive agents to generate ionizing radiation against rapidly dividing cells. The main objective of using radiation in cancer therapy is to impair or halt the division of the tumor cells. Over the past few decades, advancements in technology, the introduction of newer methods of RT, and a better understanding of the pathophysiology of cancers have enabled physicians to deliver doses of radiation that match the exact dimensions of the tumor for greater efficacy, with minimal exposure of the surrounding tissues. However, RT has numerous complications, the most common being radiation proctitis (RP). It is characterized by damage to the rectal epithelium by secondary ionizing radiation. Based on the onset of signs and symptoms, post-radiotherapy RP can be classified as acute or chronic, each with varying levels of severity and complication rates. The treatment options available for RP are limited, with most of the data on treatment available from case reports or small studies. Here, we describe the types of RT used in modern-day medicine and radiation-mediated tissue injury. We have primarily focused on the classification, epidemiology, pathogenesis, clinical features, treatment strategies, complications, and prognosis of RP.

Sexual function in reproductive-aged women following radiotherapy: a cross sectional study

Background While female sexual dysfunction post-radiation therapy has been previously described, much of the literature is focused on older, often postmenopausal, women; and neglects the experiences of younger populations. Our study aims to describe the changes in sexual functioning following radiotherapy among women of a reproductive age. Methods A cross-sectional survey was conducted on reproductive-aged women post-radiation therapy. Information on sexual frequency, pleasure, discomfort and habit was collected and compared to responses from healthy women of comparable ages. Results Reproductive-aged women post-radiotherapy experienced decreased pleasure, more discomfort and had less sexual activity than healthy controls. However, sexual habit was comparable. Conclusions Our findings illustrated that most domains of sexual function are negatively affected in our study population. Understanding the sexual sequelae of radiation therapy may help guide clinicians in counselling their patients and planning their future needs.

Neoadjuvant chemotherapy without radiation as a potential alternative treatment for locally advanced rectal cancer: A meta-analysis

BACKGROUND

Neoadjuvant chemoradiotherapy (Neo-CRT) is the current standard strategy for treating locally advanced rectal cancer. However, it delays the administration of optimal chemotherapy and increases toxicity.

AIM

To compare the feasibility and efficacy of neoadjuvant chemotherapy (Neo-CT) and Neo-CRT for patients with locally advanced rectal cancer.

METHODS

The Cochrane, EMBASE, and PubMed databases were searched for relevant articles using MESH terms and free words. The hazard ratio of overall survival and the risk ratio (RR) for the pathological complete response, the sphincter preservation rate, and treatment-related adverse events were analyzed.

RESULTS

A total of 19 studies of 60870 patients were included in the meta-analysis. There was no significant difference in overall survival [hazard ratio = 1.09, 95% confidence interval (CI) = 0.93–1.24; P = 0.19] or the pathological complete response (RR = 0.79, 95%CI = 0.61–1.03; P = 0.086) between the Neo-CT and Neo-CRT groups. As compared to the Neo-CRT group, the incidences of anastomotic fistula (RR = 0.49, 95%CI = 0.35–0.68; P = 0.000) and temporary colostomy (RR = 0.69, 95%CI = 0.58–0.83; P = 0.000) were significantly lower in the Neo-CT group, with a simultaneous increase in the sphincter preservation rate (RR = 1.07, 95%CI = 1.01–1.13; P = 0.029). However, there was no significant difference in the tumor downstaging rate, overall complications, and urinary complications.

CONCLUSION

Neo-CT administration can lower the incidences of anastomotic fistula and temporary colostomy and increase the sphincter preservation rate as to compared to Neo-CRT and could provide an alternative to chemoradiotherapy for locally advanced rectal cancer.

Perioperative therapy in muscle invasive bladder cancer

Radical cystectomy with bilateral pelvic lymph node dissection is the standard of care for muscle invasive bladder cancer (MIBC). The role of neoadjuvant and adjuvant therapy has evolved over the last 3–4 decades, and neoadjuvant chemotherapy (NACT) has now become the standard recommended treatment. However, there are many nuances to this and the utilization of chemotherapy has not been universal. The optimum chemotherapy regimen is still debated. Adjuvant radiation has a role in high-risk patients although not established and immunotherapy has shown promising results. We reviewed the evidence on NACT and adjuvant chemotherapy (ACT) regimens, NACT versus ACT, and the role of adjuvant radiotherapy and immunotherapy in MIBC.

Role of dietary fiber in safeguarding intestinal health after pelvic radiotherapy

PURPOSE OF REVIEW

Damage to healthy bowel tissue during pelvic radiotherapy can produce devastating and life-long changes in bowel function. The surging interest in microbiota and its importance for our wellbeing has generated a bulk of research highlighting how the food we consume impacts bowel health and disease. Dietary fiber is known to promote bowel health, yet there is a limited number of studies on dietary fiber in connection to pelvic radiotherapy. Here, we review some of the literature on the subject and present the most recent publications in the field.

RECENT FINDINGS

Advice given concerning dietary fiber intake during and after pelvic radiotherapy are inconsistent, with some clinics suggesting a decrease in intake and others an increase. Recent animal studies provide a solid support for a protective role of dietary fiber with regards to intestinal health after pelvic radiotherapy, mainly through its impact on the microbiota. No clinical study has yet provided unambiguous evidence for a similar function of dietary fiber in humans undergoing pelvic radiotherapy.

SUMMARY

There is a lack of evidence behind the dietary advice given to cancer survivors suffering from radiation-induced bowel dysfunction, and high-quality and well powered studies with long follow-up times are needed.

Cohort profile: an observational longitudinal data collection of health aspects in a cohort of female cancer survivors with a history of pelvic radiotherapy-a population-based cohort in the western region of Sweden

PURPOSE

The study 'Health among women after pelvic radiotherapy' was conducted in response to the need for more advanced and longitudinal data concerning long-term radiotherapy-induced late effects and chronic states among female cancer survivors. The objective of this paper is to detail the cohort profile and the study procedure in order to provide a sound basis for future analyses of the study cohort.

PARTICIPANTS

Since 2011, and still currently ongoing, participants have been recruited from a population-based study cohort including all female patients with cancer, over 18 years of age, treated with pelvic radiotherapy with curative intent at Sahlgrenska University Hospital in Gothenburg, in the western region of Sweden, which covers 1.7 million of the Swedish population. The dataset presented here consists of baseline data provided by 605 female cancer survivors and 3-month follow-up data from 260 individuals with gynaecological, rectal or anal cancer, collected over a 6-year period.

FINDINGS TO DATE

Data have been collected from 2011 onwards. To date, three studies have been published using the dataset reporting long-term radiation-induced intestinal syndromes and late adverse effects affecting sexuality, the urinary tract, the lymphatic system and physical activity. These projects include the evaluation of interventions developed by and provided in a nurse-led clinic.

FUTURE PLANS

This large prospective cohort offers the possibility to study health outcomes in female pelvic cancer survivors undergoing a rehabilitation intervention in a nurse-led clinic, and to study associations between demographics, clinical aspects and long-term late effects. Analysis focusing on the effect of the interventions on sexual health aspects, preinterventions and postinterventions, is currently ongoing. The cohort will be expanded to comprise the entire data collection from 2011 to 2020, including baseline data and data from 3-month and 1-year follow-ups after interventions. The data will be used to study conditions and treatment-induced late effects preintervention and postintervention.

Dose-Volume Predictors for Patient-reported Late Diarrhoea, Faecal Incontinence and Urgency after Pelvic Radiotherapy

AIMS

Pelvic radiotherapy adds significantly to the curative treatment of many pelvic malignancies. However, this cure comes at a cost for many patients, where late bowel toxicities, such as faecal incontinence, urgency and diarrhoea, adversely affect quality of life. Despite the implementation of advanced radiotherapy techniques in many centres, there are deficiencies in our knowledge of how to make best use of these techniques to minimise these late toxicities, with dose-volume constraints specifically for late effects needing definition. The aims of this study were to establish dose-volume predictors for patient-reported late bowel toxicities and derive constraints for clinical use to reduce the risk of these toxicities.

MATERIALS AND METHODS

All radiotherapy patients treated in our institution between 2012 and 2014 for gynaecological and urological cancers (bladder, prostate where pelvic nodes are treated) were identified. Patients were sent patient-reported toxicity questionnaires at 12 and 24 months after treatment. Planning computed tomography scans were retrospectively contoured with different definitions of bowel as organs at risk (OARs). Dose-volume data for each OAR were collected and predictors of these toxicities found using multivariate analysis. For those dose-volume predictors found to be significant on multivariate analysis, statistically significant and clinically relevant dose-volume constraints were derived. Furthermore, data collected were used to validate constraints from published studies.

RESULTS

Faecal urgency, incontinence and diarrhoea rates were found in 52, 23.5 and 18.7% of the 203 patients included at 12 months following radiotherapy. Dose-volume parameters for sigmoid colon and large bowel were significant for these toxicities, and constraints for these OARs were derived, which are promising. A previously published constraint for bowel loops was validated with our data.

CONCLUSIONS

The sigmoid colon and large bowel are important OARs for the development of faecal urgency, incontinence and diarrhoea. Promising constraints for these OARs were derived, which require further validation before prospective clinical use.

2D exfoliated black phosphorus influences healthy and cancer prostate cell behaviors

Nowadays, prostate cancer is the most widespread tumour in worldwide male population. Actually, brachytherapy is the most advanced radiotherapy strategy for the local treatment of prostate cancer. It consists in the placing of radioactive sources closed to the tumour side thus killing cancer cells. However, brachytherapy causes the same adverse effects of external-beam radiotherapy. Therefore, alternative treatment approaches are required for enhancing radiotherapy effectiveness and reducing toxic symptoms. Nanostructured exfoliated black phosphorus (2D BP) may represent a strategic tool for local cancer therapy because of its capability to induce singlet oxygen production and act as photosensitizer. Hence, we investigated 2D BP in vitro effect on healthy and cancer prostate cell behavior. 2D BP was obtained through liquid exfoliation. 2D BP effect on healthy and cancer prostate cell behaviors was analyzed by investigating cell viability, oxidative stress and inflammatory marker expression. 2D BP inhibited prostate cancer cell survival, meanwhile promoted healthy prostate cell survival in vitro by modulating oxidative stress and immune response with and without near-infrared light (NIR)-irradiation. Nanostructured 2D BP is able to inhibit in vitro prostate cancer cells survival and preserve healthy prostate cell vitality through the control of oxidative stress and immune response, respectively.

Effect of Kegel exercises on the prevention of urinary and fecal incontinence in patients with prostate cancer undergoing radiotherapy

PURPOSE

This is a nonrandomized experimental study conducted to evaluate the effect of Kegel exercises on the prevention of urinary and fecal incontinence in prostate cancer patients undergoing radiotherapy.

METHOD

The study was conducted with 30 patients in the intervention group (IG) and 30 patients in the control group (CG). Data were collected using a patient information form, CTCAE, EORTC QLQ-C30, and a follow-up form reporting weekly Kegel exercises. Before radiotherapy, the IG was provided with Kegel exercise training via visual training material; exercises were performed under the supervision of the researcher, and the exercise pamphlet was handed out. During radiotherapy, weekly follow-ups were performed by face-to-face contact or phone calls. No similar application was provided to the CG. CTCAE and EORTC QLQ-C30 were evaluated three times (baseline, 4th and 8th weeks of exercises).

RESULTS

At the end of the 4th week of exercises, 1st-grade urinary incontinence (UI) developed in the IG (10%) and in the CG (13.3%). At the end of the 8th week, 2nd-grade UI (3.3%) developed in the IG and 1st-grade (10%) and 2nd-grade UI (6.7%) developed in the CG. Fecal incontinence developed in neither group. At the end of the intervention, there was a significant improvement in Role, Social function and Global Health Status in the IG compared with the 4th week scores. In addition, less Fatigue, Diarrhea, Anorexia and Constipation scores were found compared with the baseline.

CONCLUSION

Kegel exercises can be recommended as an approach in the prevention of urinary incontinence and to improve quality of life.

[Bile acid diarrhea, stepchild of chronic diarrhea - prevalence, diagnosis and treatment. Update 2021]

Bile acid diarrhea is one of the most frequently undiagnosed causes of chronic diarrhea. A variety of different pathophysiologic causes can underlie chronic diarrhea. Even after exclusion of the more frequent causes, up to 5 % of the population remains affected by unexplained chronic diarrhea. In up to 50 % within this cohort, bile acid diarrhea is the underlying cause.The various pathophysiologies leading to bile acid diarrhea are well characterized. In this way, bile acid diarrhea can be divided into primary, secondary and tertiary subtypes. Common to all causes is the increased amount of bile acids in the colon and in the faeces and the resulting secretory-osmotic diarrhea, in more severe forms in combination with steatorrhea. The diagnosis of bile acid diarrhea follows a clear algorithm which, in addition to the search for the cause and possibly a therapeutic trial, recognizes the 75SeHCAT test as the reference method for the detection of an increased loss of bile acids. In view of the chronic nature of the symptoms and the need for permanent, lifelong therapy, the use of a one-time, reliable diagnostic test is justified, though the test is currently only available at a few centers. In addition to the treatment of identifiable underlying diseases, the current treatment includes the use of drugs that bind bile acids, with additional nutritional recommendations and vitamin substitutions.The present review article summarizes the pathophysiology and importance of bile acid diarrhea and discusses the current approach towards diagnosis and treatment.

Lower Urinary Tract Symptoms in Prostate Cancer Patients Treated With Radiation Therapy: Past and Present

The incidence of prostate cancer (PCa) is increasing concomitantly with population aging. Accordingly, interest in radiation therapy (RT) and the frequency of RT are also increasing. The types of RT can be broadly divided into external beam RT (EBRT), brachytherapy (BT), and combination therapy (EBRT+BT). Lower urinary tract symptoms (LUTS) after RT for the treatment of PCa are common; however, there are few reviews on the relationship between RT and LUTS. Herein, we review the causes and incidence of LUTS, as well as the evaluation and treatment options. Because of the reported risks of RT, patients undergoing RT should be counseled regarding the challenges of treatment and informed that they may have higher failure rates than nonirradiated patients. Moreover, thorough evaluation and treatment strategies are needed to support treatment recommendations. With a review of the existing literature, this narrative article provides an overview to aid urologists in treating patients presenting with complications associated with RT for the treatment of PCa. Further research is required to provide evidence of the effectiveness and feasibility of the management approach to the care of patients with LUTS after RT for the treatment of PCa.

Metformin as a radiosensitiser for pelvic malignancy: A systematic review of the literature

BACKGROUND

The treatment of pelvic malignancies has continued to improve over recent years, with neoadjuvant radiotherapy often considered the gold standard to downstage disease. Radiosensitisers are routinely employed in an attempt to improve response of cancers to radiotherapy. Previous preclinical evidence has suggested a role for metformin, a commonly used drug for type 2 diabetes.

METHOD

A literature search was performed for published full text articles using the PubMed, Cochrane and Scopus databases using the search criteria string 'Metformin' AND ('Radiosensitivity' OR 'radiosensitising' OR 'radiosensitising'). Additional papers were detected by scanning the references of relevant papers. Data were extracted from each study by two authors onto a dedicated proforma. The review was registered on the PROSPERO database (ID: CRD42020199066).

RESULTS

A total of 242 papers were identified, 11 of which were included in this review; an additional 5 papers were obtained from reference searches. Metformin has been demonstrated to reduce cell-viability post-radiotherapy in both rectal and prostate cancer cell lines, with an enhanced effect in tumours with a p53 mutation and increased apoptosis post-radiotherapy for cervical cancer. Clinical trials demonstrate improved tumour and nodal downstaging and pCR rates for rectal cancer using metformin as a radiosensitiser.

CONCLUSION

With an increasing understanding of the underlying mechanism of the effects on metformin prospective studies are required to assess the effect of routine use on cancer related outcomes. Progressive future studies may be better served by the use of predictive biomarker guided treatment to enable identification of the appropriate cohort to target.

Radiation-induced damage in the lower gastrointestinal tract: Clinical presentation, diagnostic tests and treatment options

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.

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSION

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

BILATERAL AVASCULAR NECROSIS OF SACRAL LATERAL MASSES AFTER A COMPLETE RADIOLOGICAL RESPONSE OF LOCALLY ADVANCED RECTAL CANCER TREATED WITH NEOADJUVANT CHEMORADIATION THERAPY. CASE REPORT

We present a rare case report of a bilateral avascular necrosis of lateral sacral masses in a patient who developed a sustainable complete clinical and radiological response after chemoradiotherapy for locally advanced rectal cancer. It is shown that despite the standardized and precise planning and fractioning for neoadjuvant chemoradiation therapy for locally advanced rectal cancer, the biological effects of ionizing radiation on critical organs can be va- ried both in time of occurrence and in structure. Evaluating the effect of neoadjuvant chemoradiation therapy, one should take into account the possibility of the development of even very rare effects of ionizing radiation on criti- cal organs and include their early detection in the diagnostic algorithm.

Dietary Oat Bran Reduces Systemic Inflammation in Mice Subjected to Pelvic Irradiation

Patients undergoing radiotherapy to treat pelvic-organ cancer are commonly advised to follow a restricted fiber diet. However, reducing dietary fiber may promote gastrointestinal inflammation, eventually leading to deteriorated intestinal health. The goal of this study was to evaluate the influence of dietary fiber on radiation-induced inflammation. C57BL/6J male mice were fed a High-oat bran diet (15% fiber) or a No-fiber diet (0% fiber) and were either irradiated (32 Gy delivered in four fractions) to the colorectal region or only sedated (controls). The dietary intervention started at 2 weeks before irradiation and lasted for 1, 6, and 18 weeks after irradiation, at which time points mice were sacrificed and their serum samples were assayed for 23 cytokines and chemokines. Our analyses show that irradiation increased the serum cytokine levels at all the time points analyzed. The No-fiber irradiated mice had significantly higher levels of pro-inflammatory cytokines than the High-oat irradiated mice at all time points. The results indicate that a fiber-rich oat bran diet reduces the intensity of radiation-induced inflammation, both at an early and late stage. Based on the results, it seems that the advice to follow a low-fiber diet during radiotherapy may increase the risk of decreased intestinal health in cancer survivors.

Stiff to Dilate and Risky to Cut Through: Iliac Radiation Arteritis

Radiation arteritis is not an uncommon clinical situation, given that almost 50% of patients with cancer receive radiotherapy in the course of treatment. Radiation effects are non-specific, and late radiation tissue injury presentation can be very variable. However, radiation arteritis has some unique clinical and radiological features, with consequent special therapeutic considerations. Iliac radiation arteritis may be accompanied by radiation-associated iliac vein disease and small vessel disease. Therefore, diagnostic and therapeutic plans should be directed toward all possible late radiation effects as relevant. Despite the complexity of the disease process and diagnostic challenges, treatment can be very straightforward if adequately planned. Otherwise, limb loss and/or life-threatening complications can rapidly ensue. This article highlights the natural history of radiation arteritis, with a particular emphasis on the iliac segment, and discusses the risk potentials of this condition, given that limb loss may be multifactorial, not merely because of the iliac arterial flow interruption. The main lines of management are also briefly discussed.

The Effects of Hyperbaric Oxygen Therapy on Pelvic Radiation Induced Gastrointestinal Complications (Rectal Bleeding, Diarrhea, and Pain): A Meta-Analysis

Background: Radiotherapy is a routine treatment for pelvic cancer patients. While it had been proven effective, gastrointestinal side effects remain a concern, impairing the quality of life. A few studies focused on the effects of hyperbaric oxygen (HBO) treatment to alleviate radiation-induced gastrointestinal complications. This meta-analysis aimed to critically review and summarize existing literature, assessing the effectiveness of HBO therapy for the treatment of radiation-induced gastrointestinal side effects. Methods: Medical literature search was performed with PubMed, Cochrane Library, and EMBASE up to March 14, 2019. Literatures about HBO treatment upon patients undergoing pelvic cancer (endometrial, cervix, rectum, or prostate cancers) radiotherapy were collected, and the effects of HBO treatment on radiotherapy-induced gastrointestinal complications were evaluated. A random-effects model was used to calculate the pooled effect size. Subgroup analyses were performed to search for sources of heterogeneity. Publication bias was detected with Funnel plots and Egger's test. Results: Three different radiotherapy-related gastrointestinal complications, including rectal bleeding, diarrhea, and pain, were analyzed after screening. It was revealed that the improvement rates were considerable in rectal bleeding (0.81, 95% CI: 0.74-0.89) and diarrhea (0.75, 95% CI: 0.61-0.90) and slightly in pain (0.58, 95% CI: 0.38-0.79). Subgroup analysis revealed factors that significantly influenced the heterogeneity of rectal bleeding, diarrhea, and pain (evaluation criteria, follow-up time, and scoring system, respectively). No significant publication bias was detected. Conclusion: HBO treatment might have the potential to alleviate radiotherapy-related gastrointestinal complications, including rectal bleeding, diarrhea, and pain, but more data are needed for further conclusions. Other symptoms were not further analyzed, as the number of studies was insufficient. More large-scale and prospective studies are needed for better evaluation of HBO's therapeutic values.

Trends and Outcomes with Kidney Failure from Antineoplastic Treatments and Urinary Tract Cancer in France

BACKGROUND AND OBJECTIVES

Cancer survival is improving along with an increase in the potential for adverse kidney effects from antineoplastic treatments or nephrectomy. We sought to describe recent trends in the incidence of kidney failure related to antineoplastic treatments and urinary tract cancers and evaluate patient survival and kidney transplantation access.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

We used the French Renal Epidemiology and Information Network registry to identify patients with kidney failure related to antineoplastic treatments or urinary tract cancer from 2003 to 2015. We identified 287 and 1157 cases with nephrotoxin- and urinary tract cancer-related kidney failure, respectively. The main study outcomes were death and kidney transplantation. After matching cases to two to ten controls (n=11,678) with other kidney failure causes for age, sex, year of dialysis initiation, and diabetes status, we estimated subdistribution hazard ratios (SHR) of each outcome separately for patients with and without active malignancy.

RESULTS

The mean age- and sex-adjusted incidence of nephrotoxin-related kidney failure was 0.43 (95% CI, 0.38 to 0.49) per million inhabitants and 1.80 (95% CI, 1.68 to 1.90) for urinary tract cancer-related kidney failure; they increased significantly by 5% and 2% annually, respectively, during 2006-2015. Compared with matched controls, age-, sex-, and comorbidity-adjusted SHRs for mortality in patients with nephrotoxin-related kidney failure were 4.2 (95% CI, 3.2 to 5.5) and 1.4 (95% CI, 1.0 to 2.0) for those with and without active malignancy, respectively; for those with urinary tract cancer, SHRs were 2.0 (95% CI, 1.7 to 2.2) and 1.1 (95% CI, 0.9 to 1.2). The corresponding SHRs for transplant wait-listing were 0.19 (95% CI, 0.11 to 0.32) and 0.62 (95% CI, 0.43 to 0.88) for nephrotoxin-related kidney failure cases and 0.28 (95% CI, 0.21 to 0.37) and 0.47 (95% CI, 0.36 to 0.60) for urinary tract cancer cases. Once on the waiting list, access to transplantation did not differ significantly between cases and controls.

CONCLUSIONS

Cancer-related kidney failure is slowly but steadily increasing. Mortality does not appear to be increased among patients without active malignancy at dialysis start, but their access to kidney transplant remains limited.

A New Assay to Measure Intestinal Crypt Survival after Irradiation: Challenges and Opportunities

Radiotherapy is a critical component of many current, curative cancer treatments, yet it is accompanied by unavoidable irradiation of normal tissues. Abdominal and pelvic radiation almost always results in some dose delivered to the bowel with deleterious effects to the small and large intestines. While the likelihood of enteritis is dose dependent, there is also considerable variation between patients in both the extent of symptoms of enteritis as well as their duration. In this article, Martin and colleagues hypothesized that the radiation sensitivity of intestinal organoids could predict the sensitivity of individual patients to enteritis and have taken the first steps to develop such an assay.See related article by Martin et al., p. 1219.

The Cancer Microbiome: Distinguishing Direct and Indirect Effects Requires a Systemic View

The collection of microbes that live in and on the human body - the human microbiome - can impact on cancer initiation, progression, and response to therapy, including cancer immunotherapy. The mechanisms by which microbiomes impact on cancers can yield new diagnostics and treatments, but much remains unknown. The interactions between microbes, diet, host factors, drugs, and cell-cell interactions within the cancer itself likely involve intricate feedbacks, and no single component can explain all the behavior of the system. Understanding the role of host-associated microbial communities in cancer systems will require a multidisciplinary approach combining microbial ecology, immunology, cancer cell biology, and computational biology - a systems biology approach.

Seminal Vesicle Adherent to Rectal Wall Following Neoadjuvant Chemoradiotherapy: A Potential False-Positive Diagnostic Pitfall

The standard of care for stage T3 and stage T4 rectal adenocarcinomas involves neoadjuvant chemoradiotherapy followed by either low anterior resection or abdominopelvic resection. The presence of residual adenocarcinoma or positive surgical margins provides useful prognostic information and can influence ongoing adjuvant therapy. Although uncommon, mimics of treated adenocarcinoma may be present in the surgical specimen. A high index of suspicion is critical in avoiding potential false-positive pitfalls, and the exclusion of mimics of treated adenocarcinoma is paramount to accurate diagnosis and treatment. Seminal vesicle epithelium has long been a challenge in differentiating prostatic adenocarcinoma from benign epithelium. However, the role of incidental seminal vesiculectomy in rectal resections due to fibrous adhesion to the rectal wall secondary to chemoradiation has not been studied. As the seminal vesicle epithelium can show markedly atypical nuclei with radiation-type effect at baseline, the potential risk of misinterpretation as residual adenocarcinoma is high. In this article, we present 2 case reports of rectal adenocarcinoma treated with neoadjuvant chemoradiotherapy followed by transabdominal resection (low anterior resection or abdominopelvic resection) with incidental seminal vesiculectomies mimicking either residual adenocarcinoma or residual adenocarcinoma at a margin of resection.

A Mouse Model for Skeletal Structure and Function Changes Caused by Radiation Therapy and Estrogen Deficiency

Radiation therapy and estrogen deficiency can damage healthy bone and lead to an increased fracture risk. The goal of this study is to develop a mouse model for radiation therapy using a fractionated biologically equivalent dose for cervical cancer treatment in both pre- and postmenopausal women. Thirty-two female C57BL/6 mice 13 weeks of age were divided into four groups: Sham + non-irradiated (SHAM + NR), Sham + irradiated (SHAM + IRR), ovariectomy + non-irradiated (OVX + NR) and ovariectomy + irradiated (OVX + IRR). The irradiated mice received a 6 Gy dose of X-rays to the hindlimbs at Day 2, Day 4 and Day 7 (18 Gy total). Tissues were collected at Day 35. DEXA, microCT analysis and FEA were used to quantify structural and functional changes at the proximal tibia, midshaft femur, proximal femur and L1 vertebra. There was a significant (p < 0.05) decline in proximal tibia trabecular BV/TV from (1) IRR compared to NR mice within Sham (- 46%) and OVX (- 41%); (2) OVX versus Sham within NR mice (- 36%) and IRR mice (- 30%). With homogenous material properties applied to the proximal tibia mesh using FEA, there was (1) an increase in whole bone (trabecular + cortical) structural stiffness from IRR compared to NR mice within Sham (+ 10%) and OVX (+ 15%); (2) a decrease in stiffness from OVX versus Sham within NR mice (- 18%) and IRR mice (- 14%). Fractionated irradiation and ovariectomy both had a negative effect on skeletal microarchitecture. Ovariectomy had a systemic effect, while skeletal radiation damage was largely specific to trabecular bone within the X-ray field.

Clinical Evaluation and Management of Cancer Survivors with Radiation Fibrosis Syndrome

OBJECTIVES

To define radiation fibrosis and radiation fibrosis syndrome; review the basics of radiotherapy, the pathophysiology of radiation injury, and the principles of clinical evaluation and management of the common late effects resulting from radiation therapy for cancer treatment.

DATA SOURCES

Peer-reviewed journal articles, book chapters, Internet.

CONCLUSION

There is no cure for radiation fibrosis syndrome, but supportive treatment of its clinical sequelae can potentially result in improved function and quality of life.

IMPLICATIONS FOR NURSING PRACTICE

The sequelae of radiation fibrosis syndrome can often be improved with early detection and supportive care by a multidisciplinary team including cancer rehabilitation physiatrists, oncologists, oncology nurses, nurse practitioners, physical therapists, occupational therapists, and speech and language pathologists.