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Dahiya DS, Pinnam BSM, Ishaya M, Chandan S, Gangwani MK, Singh S, Ali H, Sohail AH, Canakis A, Ramai D, Zelt C, Inamdar S, Al-Haddad M, Rojas-DeLeon M, Sharma NR. Early and Late Readmissions of Radiation Proctitis in the United States: Are We Getting Better? J Clin Med 2024; 13:423. [PMID: 38256557 PMCID: PMC10816733 DOI: 10.3390/jcm13020423] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2023] [Revised: 01/06/2024] [Accepted: 01/11/2024] [Indexed: 01/24/2024] Open
Abstract
Background/Aims: Radiation proctitis (RP), a well-known complication of pelvic radiation therapy, may lead to recurrent hospitalizations. We aimed to assess readmissions of RP in the United States. Methods: We analyzed the Nationwide Readmission Database from 2016 to 2020 to identify all 30-, 60-, and 90-day readmissions of RP in the United States. Hospitalization characteristics, predictors, clinical outcomes, and healthcare burdens were assessed. Results: From 2016 to 2020, we noted a declining trend of 30-, 60-, and 90-day readmissions of RP in the US. However, the all-cause 30-, 60-, and 90-day readmission rates of RP were still high at 13.7%, 19.4%, and 23.16%, respectively. On readmission, RP was identified as the admitting diagnosis in only 20.61%, 17.87%, and 15.76% of 30-, 60-, and 90-day readmissions, respectively. The mean age for all readmissions was 70 years with a significant male dominance. Lower endoscopy at index admission reduced the risk of readmissions within 90 days, but this was not statistically significant. However, the Charlson Comorbidity Index (CCI) score was an independent predictor of all readmissions. Furthermore, the mean length of stay was 5.57 (95% CI 5.15-6), 5.50 (95% CI 5.12-5.89), and 5.47 (95% CI 5.07-5.87) days and the mean hospitalization charge was USD 60,451 (95% CI USD 54,728-66,174), USD 62,671 (95% CI USD 57,326-68,015), and USD 62,144 (95% CI USD 57,144-67,144) for 30-, 60-, and 90-day readmissions. The all-cause inpatient mortality for 30-, 60-, and 90-day readmissions was 3.58%, 3.89%, and 3.46%, respectively. Conclusions: RP readmissions are a significant healthcare burden. Further efforts must be directed toward improving management strategies to reduce readmission rates.
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Affiliation(s)
- Dushyant Singh Dahiya
- Division of Gastroenterology, Hepatology & Motility, The University of Kansas School of Medicine, 2000 Olathe Blvd, Kansas City, KS 66160, USA
| | - Bhanu Siva Mohan Pinnam
- Department of Internal Medicine, John H. Stroger Jr. Hospital of Cook County, Chicago, IL 60612, USA
| | - Michelle Ishaya
- Department of Internal Medicine, John H. Stroger Jr. Hospital of Cook County, Chicago, IL 60612, USA
| | - Saurabh Chandan
- Division of Gastroenterology and Hepatology, CHI Creighton University Medical Center, Omaha, NE 68178, USA
| | | | - Sahib Singh
- Department of Internal Medicine, Sinai Hospital, Baltimore, MD 21215, USA
| | - Hassam Ali
- Division of Gastroenterology, Hepatology and Nutrition, East Carolina University/Brody School of Medicine, Greenville, NC 27858, USA
| | - Amir Humza Sohail
- Complex Surgical Oncology, Department of Surgery, University of New Mexico, Albuquerque, NM 87106, USA
| | - Andrew Canakis
- Division of Gastroenterology and Hepatology, University of Maryland School of Medicine, Baltimore, MD 21201, USA
| | - Daryl Ramai
- Division of Gastroenterology and Hepatology, The University of Utah School of Medicine, Salt Lake City, UT 84112, USA
| | - Christina Zelt
- Interventional Oncology & Surgical Endoscopy (IOSE) Division, GI Oncology Tumor Site Team, Parkview Cancer Institute, Parkview Health, Fort Wayne, IN 46845, USA
| | - Sumant Inamdar
- Division of Gastroenterology and Hepatology, University of Arkansas for Medical Sciences, Little Rock, AR 72205, USA
| | - Mohammad Al-Haddad
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, IN 46202, USA
| | - Mariajose Rojas-DeLeon
- Division of Gastroenterology and Hepatology, Parkview Health System, Fort Wayne, IN 46845, USA
| | - Neil R. Sharma
- Interventional Oncology & Surgical Endoscopy (IOSE) Division, GI Oncology Tumor Site Team, Parkview Cancer Institute, Parkview Health, Fort Wayne, IN 46845, USA
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Auyeung AB, Rayan MN, Tang X, Thomas S. Radiation proctitis with recurrent gastrointestinal bleeding complicated by cytomegalovirus. J R Coll Physicians Edinb 2023; 53:265-268. [PMID: 37905373 DOI: 10.1177/14782715231205916] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2023] Open
Abstract
Cytomegalovirus (CMV) usually causes infections with mild symptoms in immunocompetent individuals. However, in immunocompromised patients, these infections can be serious or life-threatening. Following initial infection, CMV typically becomes dormant but remains lifelong in the host. Reactivation of the latent virus can occur in many organ systems, including the gastrointestinal (GI) tract. Radiation proctitis is a known risk factor associated with prostate radiation, with complicating ulceration and GI bleeding. We present the first case report of an immunocompetent 81-year-old male with multiple episodes of life-threatening GI bleeding, secondary to a non-healing CMV-positive rectal ulcer and CMV colitis following radiation for prostate cancer. Multiple insults including prostate radiation, repeated blood transfusions and CMV infection likely contributed to the recurrent bleeding episodes.
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Affiliation(s)
- Austin B Auyeung
- University of Central Florida College of Medicine, Graduate Medical Education/HCA Florida North Florida Hospital, Internal Medicine Residency Program, Gainesville, FL, USA
| | - Melanie N Rayan
- University of Central Florida College of Medicine, Graduate Medical Education/HCA Florida North Florida Hospital, Internal Medicine Residency Program, Gainesville, FL, USA
| | - Xiaolan Tang
- University of Central Florida College of Medicine, Graduate Medical Education/HCA Florida North Florida Hospital, Internal Medicine Residency Program, Gainesville, FL, USA
| | - Sanil Thomas
- Infectious Diseases Department, HCA Florida North Florida Hospital, Gainesville, FL, USA
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3
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Skvortsova TE, Oganezova IA, Medvedeva OI. [Progressive radiation-induced rectal injury: is there an opportunity to get out of a vicious circle? A clinical case]. TERAPEVT ARKH 2023; 95:870-875. [PMID: 38159020 DOI: 10.26442/00403660.2023.10.202453] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2023] [Accepted: 11/22/2023] [Indexed: 01/03/2024]
Abstract
Radiation therapy is one of the main treatment option for prostate cancer used either independently or as a component of combined and complex treatment of the disease. Modern achievements make it possible to deliver doses of radiation that match the exact dimensions of the tumor for greater efficacy, with minimal exposure of the surrounding tissues, however, does not eliminate them. In most patients, clinical manifestations of chronic radiation proctitis occur during the first 2 years after radiation therapy. The article summarizes the current knowledge about pathophysiology, clinical manifestations, diagnostics and treatment options for this condition. In this paper, we present a case of complicated of chronic radiation proctitis.
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Moreira Monteiro A, Alpuim Costa D, Mareco V, Espiney Amaro C. The effectiveness of hyperbaric oxygen therapy for managing radiation-induced proctitis - results of a 10-year retrospective cohort study. Front Oncol 2023; 13:1235237. [PMID: 37637048 PMCID: PMC10450915 DOI: 10.3389/fonc.2023.1235237] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2023] [Accepted: 07/07/2023] [Indexed: 08/29/2023] Open
Abstract
Introduction Despite modern radiotherapy (RT) techniques, radiation-induced proctitis (RIP) remains a significant complication of RT for pelvic organ malignancies. Over the last decades, an enormous therapeutic armamentarium has been considered in RIP, including hyperbaric oxygen therapy (HBOT). However, the evidence regarding the impact of HBOT on RIP is conflicting. This study aims to evaluate the effectiveness and safety of HBOT in the treatment of RIP. Methods Ten-year (2013-2023) retrospective analysis of all consecutive patients with RIP treated with HBOT at Centro de Medicina Subaquática e Hiperbárica (CMSH) (Armed Forces Hospital - Lisbon, Portugal). Patients were exposed to 100% oxygen at 2.5 ATA, in a multiplace first-class hyperbaric chamber, for 70-min periods, once daily, five times per week. Fisher's exact test was performed using SPSS (version 23.0); p<0.05 was accepted as statistically significant. Results Of a total of 151 patients with RIP, 88 were included in the final analysis, of whom 38.6% evidenced other concurrent radiation-induced soft tissue lesions. The most reported primary pelvic tumor treated with RT was prostate cancer (77.3%), followed by cervical cancer (10.2%). Hematochezia was the most observed clinical manifestation (86.4%). After a median of 60 HBOT sessions (interquartile range [IQR]: 40-87.5), 62.5% and 31.8% of patients achieved a clinical complete and partial response, respectively, with a hematochezia resolution rate of 93.7% (complete or partial). While partial and complete responses require fewer than 70 sessions of HBOT in terms of overall RIP symptoms (p=0.069), isolated hematochezia tends to require at least 70 sessions (p=0.075). Individuals with at least two concurrent late radiation tissue injuries were associated with a complete response to HBOT (p=0.029). Only about 5.7% of patients did not respond to the treatment. Eighteen patients (20.5%) developed reversible ear barotrauma. The number of HBOT sessions was a predictor of HBOT side effects (odds ratio: 1.010; 95% confidence interval, 1.000-1.020; p=0.047). Conclusion The HBOT proved to be an effective and safe treatment for RIP refractory to medical and/or endoscopic treatments. This real-world evidence study adds value to published data on the management of RIP with HBOT.
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Affiliation(s)
| | - Diogo Alpuim Costa
- Faculdade de Medicina, Universidade de Lisboa, Lisbon, Portugal
- NOVA Medical School, Faculdade de Ciências Médicas, Lisbon, Portugal
- Centro de Medicina Subaquática e Hiperbárica (CMSH), Armed Forces Hospital, Lisbon, Portugal
- Medical Oncology Department, Hospital de Cascais Dr. José de Almeida, Alcabideche, Portugal
- Hematology and Oncology Department, CUF Oncologia, Lisbon, Portugal
| | - Virgínia Mareco
- Radiotherapy Department, Hospital de Santa Maria, Centro Hospitalar Universitário Lisboa Norte, Lisbon, Portugal
| | - Carla Espiney Amaro
- Centro de Medicina Subaquática e Hiperbárica (CMSH), Armed Forces Hospital, Lisbon, Portugal
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Polese L, Giugliano E, Cadrobbi R, Boemo DG. Diode Laser Therapy for Radiation-Induced Vascular Ectasia: Long-Term Results and Cost Analysis. Life (Basel) 2023; 13:life13041025. [PMID: 37109554 PMCID: PMC10144337 DOI: 10.3390/life13041025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2023] [Revised: 03/23/2023] [Accepted: 04/14/2023] [Indexed: 04/29/2023] Open
Abstract
BACKGROUND Collateral damage to surrounding healthy tissues has been reported in patients who undergo radiation therapy for pelvic malignancies. This study aimed to evaluate the safety, efficacy and cost efficiency of endoscopic diode laser therapy in patients diagnosed with chronic radiation proctitis (CRP). METHODS The data of 24 patients (median age 78, range 67-90 years) who presented rectal bleeding and were diagnosed with CRP after undergoing high-dose radiotherapy for prostatic cancer and underwent diode laser therapy were evaluated retrospectively. Non-contact fibers were used in the patients who underwent the procedure without sedation in an outpatient setting. RESULTS The patients underwent a median of two sessions; overall, a mean of 1591 J of laser energy per session was used. No complications were noted during or after the procedures. Bleeding was completely resolved in 21/24 (88%) patients, and two patients showed improvement (96%). It was not necessary to suspend antiplatelet (six patients) or anticoagulant (four patients) therapy during the treatment course. The mean cost per session was EUR 473.4. CONCLUSIONS The study findings demonstrated that endoscopic non-contact diode laser treatment in CRP patients is safe, effective and cost efficient. For this procedure, antiplatelet and anticoagulant therapy suspension, intraprocedural sedation and hospital admission are not required.
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Affiliation(s)
- Lino Polese
- First Surgical Unit, Department of Surgery, Oncology and Gastroenterology, University of Padova, 35128 Padova, Italy
| | - Emilia Giugliano
- First Surgical Unit, Department of Surgery, Oncology and Gastroenterology, University of Padova, 35128 Padova, Italy
| | - Roberto Cadrobbi
- First Surgical Unit, Department of Surgery, Oncology and Gastroenterology, University of Padova, 35128 Padova, Italy
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Jain N, Mohan JA, Ramita S, Kanchan S, Amandeep K, Meena S. Argon plasma coagulation therapy in hemorrhagic radiation proctitis following pelvic radiation in gynecological malignancies. J Cancer Res Ther 2023; 19:708-712. [PMID: 37470598 DOI: 10.4103/jcrt.jcrt_1364_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/21/2023]
Abstract
Introduction Chronic radiation proctitis is a common chronic complication of malignant pelvic diseases after pelvic radiation therapy. Although, the incidence has decreased after advent of intensity-modulated radiotherapy due to better control of radiation dose to rectum. In the era of conventional two-field radiotherapy to pelvis, this was a common complication usually presenting after 1-2 years of treatment completion. Rectal bleeding caused by radiation proctitis is difficult to manage. Argon plasma coagulation (APC) is an electrocoagulation technique that appears to be an effective and low-cost alternative to the use of lasers in gastrointestinal endoscopy. The aim of this study was to evaluate the efficacy of APC, as well as patients' tolerance of the procedure, in the treatment of bleeding radiation-induced proctitis. Materials and Methods Between January 2015 and August 2017, 29 patients of cancer cervix treated with definite radiotherapy both external and brachytherapy who suffered from rectal bleeding due to radiation proctitis were included for treatment with argon plasma laser (APC). Twenty-three patients suffered from anemia, 16 of whom required blood transfusion. APC was performed, applying the no-touch spotting technique at an electrical power of 40 Watt and an argon gas flow of 1.5-2.0 l/min. Pulse duration was <0.5 s. Treatment sessions were carried out at intervals of 3 weeks. Subjects received 2-4 treatment sessions. Results Twenty-eight out of 29 patients were accessible for effects and results. APC led to persistent clinical and endoscopic remission of rectal bleeding after a median of three sessions. No adverse effects were encountered after initial treatment. All the patients were in complete remission. Conclusions APC is an effective, safe, and well-tolerated treatment for rectal bleeding caused by chronic radiation proctitis. It should be considered as a first-line therapy for radiation proctitis.
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Affiliation(s)
- Neeraj Jain
- Department of Radiation Oncology, Sri Guru Ram Das University of Health Sciences, Amritsar, Punjab, India
| | - Jerath Amitabh Mohan
- Department of Gastroenterology, Sarvhit Gastrocity, Smt Parvati Devi Hospital, Amritsar, Punjab, India
| | - Sharma Ramita
- Department of Radiation Oncology, Sri Guru Ram Das University of Health Sciences, Amritsar, Punjab, India
| | - Sachdeva Kanchan
- Department of Medical Physics, Tata Memorial Hospital, Mumbai, Maharashtra, India
| | - Kaur Amandeep
- Department of Medical Physics, Gujrat Cancer Research Institute, Ahmedabad, Gujarat, India
| | - Sudan Meena
- Department of Radiation Oncology, Sri Guru Ram Das University of Health Sciences, Amritsar, Punjab, India
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7
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Wei C, Xiang X, Zhou X, Ren S, Zhou Q, Dong W, Lin H, Wang S, Zhang Y, Lin H, He Q, Lu Y, Jiang X, Shuai J, Jin X, Xie C. Development and validation of an interpretable radiomic nomogram for severe radiation proctitis prediction in postoperative cervical cancer patients. Front Microbiol 2023; 13:1090770. [PMID: 36713206 PMCID: PMC9877536 DOI: 10.3389/fmicb.2022.1090770] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2022] [Accepted: 12/28/2022] [Indexed: 01/13/2023] Open
Abstract
Background Radiation proctitis is a common complication after radiotherapy for cervical cancer. Unlike simple radiation damage to other organs, radiation proctitis is a complex disease closely related to the microbiota. However, analysis of the gut microbiota is time-consuming and expensive. This study aims to mine rectal information using radiomics and incorporate it into a nomogram model for cheap and fast prediction of severe radiation proctitis prediction in postoperative cervical cancer patients. Methods The severity of the patient's radiation proctitis was graded according to the RTOG/EORTC criteria. The toxicity grade of radiation proctitis over or equal to grade 2 was set as the model's target. A total of 178 patients with cervical cancer were divided into a training set (n = 124) and a validation set (n = 54). Multivariate logistic regression was used to build the radiomic and non-raidomic models. Results The radiomics model [AUC=0.6855(0.5174-0.8535)] showed better performance and more net benefit in the validation set than the non-radiomic model [AUC=0.6641(0.4904-0.8378)]. In particular, we applied SHapley Additive exPlanation (SHAP) method for the first time to a radiomics-based logistic regression model to further interpret the radiomic features from case-based and feature-based perspectives. The integrated radiomic model enables the first accurate quantitative assessment of the probability of radiation proctitis in postoperative cervical cancer patients, addressing the limitations of the current qualitative assessment of the plan through dose-volume parameters only. Conclusion We successfully developed and validated an integrated radiomic model containing rectal information. SHAP analysis of the model suggests that radiomic features have a supporting role in the quantitative assessment of the probability of radiation proctitis in postoperative cervical cancer patients.
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Affiliation(s)
- Chaoyi Wei
- Wenzhou Key Laboratory of Biophysics, Wenzhou Institute, University of Chinese Academy of Sciences, Wenzhou, Zhejiang Province, China
| | - Xinli Xiang
- The Second Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang Province, China
| | - Xiaobo Zhou
- Medical and Radiation Oncology, The Second Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang Province, China
| | - Siyan Ren
- Medical and Radiation Oncology, The Second Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang Province, China
| | - Qingyu Zhou
- Medical and Radiation Oncology, The Second Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang Province, China
| | - Wenjun Dong
- Medical and Radiation Oncology, The Second Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang Province, China
| | - Haizhen Lin
- Medical and Radiation Oncology, The Second Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang Province, China
| | - Saijun Wang
- Medical and Radiation Oncology, The Second Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang Province, China
| | - Yuyue Zhang
- Medical and Radiation Oncology, The Second Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang Province, China
| | - Hai Lin
- Wenzhou Key Laboratory of Biophysics, Wenzhou Institute, University of Chinese Academy of Sciences, Wenzhou, Zhejiang Province, China
| | - Qingzu He
- Wenzhou Key Laboratory of Biophysics, Wenzhou Institute, University of Chinese Academy of Sciences, Wenzhou, Zhejiang Province, China
| | - Yuer Lu
- Wenzhou Key Laboratory of Biophysics, Wenzhou Institute, University of Chinese Academy of Sciences, Wenzhou, Zhejiang Province, China
| | - Xiaoming Jiang
- Wenzhou Key Laboratory of Biophysics, Wenzhou Institute, University of Chinese Academy of Sciences, Wenzhou, Zhejiang Province, China
| | - Jianwei Shuai
- Wenzhou Key Laboratory of Biophysics, Wenzhou Institute, University of Chinese Academy of Sciences, Wenzhou, Zhejiang Province, China
| | - Xiance Jin
- Radiotherapy Center, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang Province, China,School of Basic Medical Sciences, Wenzhou Medical University, Wenzhou, Zhejiang Province, China,*Correspondence: Xiance Jin, ✉
| | - Congying Xie
- Medical and Radiation Oncology, The Second Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang Province, China,Congying Xie, ✉
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Xie H, Gong M, Zhang J, Li Q. Construction of a predictive model for radiation proctitis after radiotherapy for female pelvic tumors based on machine learning. Zhong Nan Da Xue Xue Bao Yi Xue Ban 2022; 47:1065-1074. [PMID: 36097774 PMCID: PMC10950104 DOI: 10.11817/j.issn.1672-7347.2022.220353] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Received: 06/27/2022] [Indexed: 06/15/2023]
Abstract
OBJECTIVES Radiation therapy is a main method for female pelvic malignancies, which can cause some adverse reactions, such as radiation proctitis (RP). The incidence of RP is highly positively correlated with radiation dose. There is an urgent need for a scientific method to accurately predict the occurrence of RP to help doctors make clinical decisions. In this study, based on the clinical data of female pelvic tumor patients and dosimetric parameters of radiotherapy, the random forest method was used to screen the hub features related to the occurrence of RP, and then a machine learning algorithm was used to construct a risk prediction model for the occurrence of RP, in order to provide technical support and theoretical basis for the prediction and prevention of RP. METHODS A total of 100 female patients with pelvic tumors, who received static three-dimensional conformal intensity-modulated radiation therapy in the Department of Radiation Oncology of the Affiliated Hospital of Xiangnan University from January 2019 to December 2020, were retrospectively collected, and their clinically relevant data and radiotherapy planning system data were collected. During radiotherapy and 18 months after radiotherapy, 35 cases developed RP (RP group), and the remaining 65 cases had no RP (non-RP group). The clinical and dosimetric characteristics of patients were ranked by the importance of random forest algorithm, and the independent prognostic characteristics associated with the occurrence of RP were selected for machine learning modeling. A total of 6 machine learning algorithms including support vector machines, random forests, logistic regression, lightweight gradient boosting machines, Gaussian naïve Bayes, and adaptive enhancement were used to build models. The performance of the model was evaluated by the area under the receiver operating characteristic curve (AUC), accuracy, sensitivity, specificity, positive predictive value, negative predictive value, and F1 score. Finally, the random forest model was determined as the prediction model, and the calibration curve and decision curve of the prediction model were drawn to evaluate the accuracy and clinical benefit of the model. RESULTS The parameters for random forest prediction model in the training set were as follow: AUC, 1.000, accuracy, 0.988, sensitivity, 1.000, specificity, 1.000, positive predictive value, 1.000, negative predictive value, 0.981, and F1 score, 1.000. In validation set, AUC was 0.713, accuracy was 0.640, sensitivity was 0.618, specificity was 0.822, positive predictive value was 0.500, negative predictive value was 0.656, and F1 score was 0.440. Random forest showed high predictive performance. Moreover, the Brief of the calibration curve for the prediction model was 0.178, the prediction accuracy was high, and the decision curve showed that the prediction model could benefit clinically. CONCLUSIONS Based on the clinical and dosimetric parameters for the female pelvic tumor patients, the prediction model of radiation proctitis constructed by random forest algorithm has high predictive ability and strong clinical usability.
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Affiliation(s)
- Hui Xie
- Department of Radiation Oncology, Affiliated Hospital of Xiangnan University, Chenzhou Hunan 423000.
- Key Laboratory of Medical Imaging and Artificial Intelligence of Hunan Province, Chenzhou Hunan 423000.
| | - Ming Gong
- Department of Radiation Oncology, Affiliated Hospital of Xiangnan University, Chenzhou Hunan 423000
- School of Nuclear Science and Techology, University of South China, Hengyang Hunan 421001
| | - Jianfang Zhang
- Department of Physical Examination, Beihu Centers for Disease Control and Prevention, Chenzhou Hunan 423000
| | - Qing Li
- Key Laboratory of Medical Imaging and Artificial Intelligence of Hunan Province, Chenzhou Hunan 423000.
- College of Medical Imaging Laboratory and Rehabilitation, Xiangnan University, Chenzhou Hunan 423000, China.
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Wu Y, Liu C, Wang W, Tian L, Xiao Z, Wang Y, Guo H, Xue X. Study on Appropriate Rectal Volume for External Irradiation in Patients With Cervical Cancer. Front Oncol 2022; 12:814414. [PMID: 35273913 PMCID: PMC8902035 DOI: 10.3389/fonc.2022.814414] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2021] [Accepted: 01/20/2022] [Indexed: 12/03/2022] Open
Abstract
Objective To investigate the appropriate rectal volume for external irradiation of cervical cancer. Methods A retrospective study of 143 patients with cervical cancer who underwent external radiotherapy from January 2017 to September 2020 was conducted. Average rectum volumes and the cumulative dose (V30, V40, V50, D2cc) to organs at risk (bladder, rectum, and small bowel) during radiotherapy were evaluated using the treatment planning system. Rates of radiation cystitis and radiation proctitis were assessed. Results The median follow-up was 48 months, and the included patients had a median age of 53 years. Patients were divided into 3 groups based on their average rectum volume: Group A: <40 ml; Group B: 40–70 ml; and Group C: ≥70 ml. V30 and V40 in the rectum bladder and small bowel were highest in Group A (mean ± SD standard deviation), but V50 and D2cc in the rectum and bladder were highest in Group C (mean ± SD). Patients in Group B had the lower incidence of both radiation cystitis and radiation proctitis. (p<0.05). Conclusions For external irradiation in patients with cervical cancer, a rectum volume of 40–70 ml seems most appropriate, whereas >70 ml increases the risk of severe radiation cystitis and radiation proctitis, and <40 ml increases the risk of mild radiation cystitis and mild radiation proctitis.
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Affiliation(s)
- Yanjiao Wu
- Department of Radiotherapy, The Second Hospital of Hebei Medical University, Shijiazhuang, China
| | - Chunmei Liu
- Department of Radiotherapy, The Second Hospital of Hebei Medical University, Shijiazhuang, China
| | - Wenyan Wang
- Department of Radiotherapy, The Second Hospital of Hebei Medical University, Shijiazhuang, China
| | - Lei Tian
- Department of Radiotherapy, The Second Hospital of Hebei Medical University, Shijiazhuang, China
| | - Zhiqing Xiao
- Department of Radiotherapy, The Second Hospital of Hebei Medical University, Shijiazhuang, China
| | - Yanqiang Wang
- Department of Radiotherapy, The Second Hospital of Hebei Medical University, Shijiazhuang, China
| | - Han Guo
- Department of Radiotherapy, The Second Hospital of Hebei Medical University, Shijiazhuang, China
| | - Xiaoying Xue
- Department of Radiotherapy, The Second Hospital of Hebei Medical University, Shijiazhuang, China
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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11
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Pattarajierapan S, Amornwichet N, Khomvilai S. Rectal irrigation as rescue therapy for refractory and severe hemorrhagic radiation proctitis: A case report. Clin Case Rep 2021; 9:e04985. [PMID: 34721856 PMCID: PMC8529883 DOI: 10.1002/ccr3.4985] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2021] [Revised: 09/30/2021] [Accepted: 10/08/2021] [Indexed: 11/06/2022] Open
Abstract
Rectal irrigation may be considered in refractory and severe hematochezia from chronic radiation proctitis before performing other invasive treatments. It prevents superimposed infection and effectively reduces bleeding.
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Affiliation(s)
- Sukit Pattarajierapan
- Surgical Endoscopy Colorectal Division, Department of SurgeryFaculty of Medicine, Chulalongkorn UniversityBangkokThailand
| | - Napapat Amornwichet
- Division of Radiation Oncology, Department of RadiologyFaculty of Medicine, Chulalongkorn UniversityBangkokThailand
| | - Supakij Khomvilai
- Surgical Endoscopy Colorectal Division, Department of SurgeryFaculty of Medicine, Chulalongkorn UniversityBangkokThailand
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12
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Byrne JD, Young CC, Chu JN, Pursley J, Chen MX, Wentworth AJ, Feng A, Kirtane AR, Remillard KA, Hancox CI, Bhagwat MS, Machado N, Hua T, Tamang SM, Collins JE, Ishida K, Hayward A, Becker SL, Edgington SK, Schoenfeld JD, Jeck WR, Hur C, Traverso G. Personalized Radiation Attenuating Materials for Gastrointestinal Mucosal Protection. Adv Sci (Weinh) 2021; 8:2100510. [PMID: 34194950 PMCID: PMC8224439 DOI: 10.1002/advs.202100510] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/06/2021] [Revised: 03/07/2021] [Indexed: 05/11/2023]
Abstract
Cancer patients undergoing therapeutic radiation routinely develop injury of the adjacent gastrointestinal (GI) tract mucosa due to treatment. To reduce radiation dose to critical GI structures including the rectum and oral mucosa, 3D-printed GI radioprotective devices composed of high-Z materials are generated from patient CT scans. In a radiation proctitis rat model, a significant reduction in crypt injury is demonstrated with the device compared to without (p < 0.0087). Optimal device placement for radiation attenuation is further confirmed in a swine model. Dosimetric modeling in oral cavity cancer patients demonstrates a 30% radiation dose reduction to the normal buccal mucosa and a 15.2% dose reduction in the rectum for prostate cancer patients with the radioprotectant material in place compared to without. Finally, it is found that the rectal radioprotectant device is more cost-effective compared to a hydrogel rectal spacer. Taken together, these data suggest that personalized radioprotectant devices may be used to reduce GI tissue injury in cancer patients undergoing therapeutic radiation.
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Affiliation(s)
- James D. Byrne
- Division of GastroenterologyBrigham and Women's HospitalHarvard Medical School75 Francis St.BostonMA02115USA
- Harvard Radiation Oncology Program55 Fruit StreetBostonMA02114USA
- David H. Koch Institute for Integrative Cancer ResearchMassachusetts Institute of Technology500 Main St Building 76CambridgeMA02142USA
- Department of Mechanical EngineeringMassachusetts Institute of Technology77 Massachusetts AveCambridgeMA02139USA
- Department of Radiation OncologyDana‐Farber Cancer Institute/Brigham and Women's Hospital44 Binney St.BostonMA02115USA
| | - Cameron C. Young
- Division of GastroenterologyBrigham and Women's HospitalHarvard Medical School75 Francis St.BostonMA02115USA
| | - Jacqueline N. Chu
- David H. Koch Institute for Integrative Cancer ResearchMassachusetts Institute of Technology500 Main St Building 76CambridgeMA02142USA
- Department of Mechanical EngineeringMassachusetts Institute of Technology77 Massachusetts AveCambridgeMA02139USA
- Division of GastroenterologyMassachusetts General Hospital55 Fruit St.BostonMA02114USA
| | - Jennifer Pursley
- Division of Medical PhysicsDepartment of Radiation OncologyMassachusetts General Hospital450 Brookline AvenueBostonMA02115USA
| | - Mu Xian Chen
- Division of GastroenterologyBrigham and Women's HospitalHarvard Medical School75 Francis St.BostonMA02115USA
| | - Adam J. Wentworth
- Division of GastroenterologyBrigham and Women's HospitalHarvard Medical School75 Francis St.BostonMA02115USA
- David H. Koch Institute for Integrative Cancer ResearchMassachusetts Institute of Technology500 Main St Building 76CambridgeMA02142USA
- Department of Mechanical EngineeringMassachusetts Institute of Technology77 Massachusetts AveCambridgeMA02139USA
| | - Annie Feng
- David H. Koch Institute for Integrative Cancer ResearchMassachusetts Institute of Technology500 Main St Building 76CambridgeMA02142USA
| | - Ameya R. Kirtane
- David H. Koch Institute for Integrative Cancer ResearchMassachusetts Institute of Technology500 Main St Building 76CambridgeMA02142USA
- Department of Mechanical EngineeringMassachusetts Institute of Technology77 Massachusetts AveCambridgeMA02139USA
| | - Kyla A. Remillard
- Division of Medical PhysicsDepartment of Radiation OncologyMassachusetts General Hospital450 Brookline AvenueBostonMA02115USA
| | - Cindy I. Hancox
- Department of Radiation OncologyDana‐Farber Cancer Institute/Brigham and Women's Hospital44 Binney St.BostonMA02115USA
| | - Mandar S. Bhagwat
- Division of Medical PhysicsDepartment of Radiation OncologyMassachusetts General Hospital450 Brookline AvenueBostonMA02115USA
| | - Nicole Machado
- David H. Koch Institute for Integrative Cancer ResearchMassachusetts Institute of Technology500 Main St Building 76CambridgeMA02142USA
| | - Tiffany Hua
- David H. Koch Institute for Integrative Cancer ResearchMassachusetts Institute of Technology500 Main St Building 76CambridgeMA02142USA
| | - Siddartha M. Tamang
- David H. Koch Institute for Integrative Cancer ResearchMassachusetts Institute of Technology500 Main St Building 76CambridgeMA02142USA
| | - Joy E. Collins
- David H. Koch Institute for Integrative Cancer ResearchMassachusetts Institute of Technology500 Main St Building 76CambridgeMA02142USA
| | - Keiko Ishida
- David H. Koch Institute for Integrative Cancer ResearchMassachusetts Institute of Technology500 Main St Building 76CambridgeMA02142USA
| | - Alison Hayward
- David H. Koch Institute for Integrative Cancer ResearchMassachusetts Institute of Technology500 Main St Building 76CambridgeMA02142USA
- Division of Comparative MedicineMassachusetts Institute of TechnologyBuilding 16‐825, 77 Massachusetts AveCambridgeMA02139USA
| | - Sarah L. Becker
- Division of GastroenterologyBrigham and Women's HospitalHarvard Medical School75 Francis St.BostonMA02115USA
| | - Samantha K. Edgington
- Division of Medical PhysicsDepartment of Radiation OncologyMassachusetts General Hospital450 Brookline AvenueBostonMA02115USA
| | - Jonathan D. Schoenfeld
- Department of Radiation OncologyDana‐Farber Cancer Institute/Brigham and Women's Hospital44 Binney St.BostonMA02115USA
| | | | - Chin Hur
- Department of MedicineColumbia University Medical Center622 West 168th Street, PH 9‐105New YorkNY10032USA
- Department of EpidemiologyMailman School of Public Health and Herbert Irving Comprehensive Cancer CenterColumbia University Medical Center722 West 168th St.New YorkNY10032USA
| | - Giovanni Traverso
- Division of GastroenterologyBrigham and Women's HospitalHarvard Medical School75 Francis St.BostonMA02115USA
- Department of Mechanical EngineeringMassachusetts Institute of Technology77 Massachusetts AveCambridgeMA02139USA
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13
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Nakamura Y, Soma T, Izumi K, Sakai Y, Ushijima H, Kudo S, Saito Y, Kageyama Y. Screening of chronic radiation proctitis and colorectal cancer using periodic total colonoscopy after external beam radiation therapy for prostate cancer. Jpn J Clin Oncol 2021; 51:1298-1302. [PMID: 33889961 DOI: 10.1093/jjco/hyab056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2020] [Accepted: 04/04/2021] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVE To investigate the incidence of colorectal cancer and chronic radiation proctitis after prostate radiotherapy using periodic total colonoscopy screening. METHODS From February 2013 to January 2018, 270 patients who underwent external beam radiation therapy for prostate cancer were advised to receive periodic total colonoscopy screening annually. We evaluated the incidence and characteristics of colorectal cancer and chronic radiation proctitis. RESULTS First, second, third, fourth and fifth total colonoscopy were performed in 256 (95%), 151 (56%), 60 (22%), 23 (8.5%) and 7 (2.6%) patients at a median of 14, 31, 42, 54 and 72 months after radiotherapy, respectively. The prevalence proportion of colorectal cancer in the first colonoscopy since radiotherapy was 3.9%. Twelve (4.4%) patients were diagnosed with colorectal cancer, including four invasive cancers, during a follow-up period. Eight of these 12 patients had not experienced rectal bleeding. The median time to diagnosis of colorectal cancer was 21 months. Chronic radiation proctitis was observed in 136 (50%) patients, including 67 (25%) patients with symptomatic bleeding. CONCLUSIONS The high detection rate of asymptomatic radiation proctitis suggests the utility of total colonoscopy to screen for early-stage colorectal cancer prior to or following radiotherapy for prostate cancer. Considering the longevity after localized prostate cancer treatment, the awareness of chronic radiation-induced proctitis and the risk of colorectal cancer masked by bleeding is needed in treatment decision -making.
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Affiliation(s)
- Yuki Nakamura
- Department of Urology, Saitama Cancer Center, Saitama, Japan
| | - Takahiko Soma
- Department of Urology, Saitama Cancer Center, Saitama, Japan
| | - Keita Izumi
- Department of Urology, Saitama Cancer Center, Saitama, Japan
| | - Yasuyuki Sakai
- Department of Urology, Saitama Cancer Center, Saitama, Japan
| | - Hiroki Ushijima
- Department of Radiation Oncology, Saitama Cancer Center, Saitama, Japan
| | - Shigehiro Kudo
- Department of Radiation Oncology, Saitama Cancer Center, Saitama, Japan
| | - Yoshihiro Saito
- Department of Radiation Oncology, Saitama Cancer Center, Saitama, Japan
| | - Yukio Kageyama
- Department of Urology, Saitama Cancer Center, Saitama, Japan
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14
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Ferini G, Tripoli A, Molino L, Cacciola A, Lillo S, Parisi S, Umina V, Illari SI, Marchese VA, Cravagno IR, Borzì GR, Valenti V. How Much Daily Image-guided Volumetric Modulated Arc Therapy Is Useful for Proctitis Prevention With Respect to Static Intensity Modulated Radiotherapy Supported by Topical Medications Among Localized Prostate Cancer Patients? Anticancer Res 2021; 41:2101-2110. [PMID: 33813420 DOI: 10.21873/anticanres.14981] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2021] [Revised: 02/22/2021] [Accepted: 02/23/2021] [Indexed: 11/10/2022]
Abstract
BACKGROUND/AIM To evaluate if topical support therapy during static-intensity modulated radiotherapy (sIMRT) course is able to equal the characteristic minimum risk for radiation proctitis of Image-guided volumetric modulated arc therapy (IG-VMAT) treatment among localized prostate cancer patients. PATIENTS AND METHODS Rectal toxicity data of the above patients were retrospectively collected throughout three different clinical periods at our Radiotherapy Deparment: from October 2011 to December 2012, prostate cancer patients were treated with sIMRT and in advance supported by means of daily topical corticosteroids; from January 2013 to November 2016, topical corticosteroids were replaced by daily hyaluronic acid enemas; from December 2016 to May 2018 eligible patients were treated with newly introduced IG-VMAT supported by only on-demand topical corticosteroids. RESULTS Among 359 eligible patients, IG-VMAT was proven generally more effective than sIMRT supported by topical medications in terms of proctitis reduction, although without clinical and practical relevance. CONCLUSION Topical medications might have a role in radiation proctitis prevention.
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Affiliation(s)
| | | | - Laura Molino
- Radiation Oncology Unit - Department of Biomedical, Dental Science and Morphological and Functional Images, University of Messina, Messina, Italy
| | - Alberto Cacciola
- Radiation Oncology Unit - Department of Biomedical, Dental Science and Morphological and Functional Images, University of Messina, Messina, Italy
| | - Sara Lillo
- Radiation Oncology Unit - Department of Biomedical, Dental Science and Morphological and Functional Images, University of Messina, Messina, Italy
| | - Silvana Parisi
- Radiation Oncology Unit - Department of Biomedical, Dental Science and Morphological and Functional Images, University of Messina, Messina, Italy
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15
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Salusso P, Testa V, Mochet S, Arezzo A, Allaix ME, Salzano A, Morino M, Mistrangelo M. Management of Hemorrhoidal Disease in Special Conditions: A Word of Caution. Rev Recent Clin Trials 2020; 16:22-31. [PMID: 32250231 DOI: 10.2174/1574887115666200406121308] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2019] [Revised: 01/21/2020] [Accepted: 02/12/2020] [Indexed: 11/22/2022]
Abstract
BACKGROUND Hemorrhoids are a common disease that is often considered an easy problem to solve. Unfortunately, some particular clinical conditions, including Inflammatory Bowel Diseases (IBD), pregnancy, immunosuppression, coagulopathy, cirrhosis with portal hypertension, and proctitis after radiotherapy, challenge hemorrhoids management and the outcomes. METHODS Research and online contents related to hemorrhoids' treatment in special conditions are reviewed in order to help colorectal surgeons in daily practice. RESULTS There are very limited data about the outcomes of hemorrhoids treatment in these subgroups of patients. Patients in pregnancy can be effectively treated with medical therapy, reserving surgical intervention in highly selected and urgent cases. In case of thrombosed haemorrhoids, the excision allows a fast symptoms' resolution, with a low incidence of recurrence and a long remission interval. In case of immunosuppressed patients, there is no consensus for the best treatment, even in most HIV positive patients, a surgical procedure can be safely proposed when indicated. There is no sufficient data in the literature related to transplanted patients. The surgical treatment of hemorrhoids in patients with IBD, especially Crohn's Disease, can be unsafe, although there is a paucity of literature on this topic. In case of previous pelvic radiotherapy, it must always be considered that severe complications, like abscesses and fistulas with subsequent pelvic and retroperitoneal sepsis, can occur after surgical treatment of hemorrhoids, so a conservative treatment is advocated. Moreover, caution is recommended in treating patients with coagulopathy, considering possible complications (mostly bleeding) also after outpatient treatments. In case of portal hypertension and cirrhosis, a 'conservative treatment' is recommended. Bleeding hemorrhoids can be treated with hemorrhoidectomy when they do not respond to other treatments. CONCLUSION International literature is very scant about the treatment of patients affected by hemorrhoids in particular situations. A word of caution and concern even about the indication for minor outpatient procedures must be expressed in these patients, in order to avoid possible life-threatening complications. The first-line treatment is the conservative medical approach associated with the treatment of the primary disease.
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Affiliation(s)
- Paola Salusso
- Department of Surgical Sciences, University of Turin, Citta della Salute e della Scienza Hospital, Turin, Italy
| | - Valentina Testa
- Department of Surgical Sciences, University of Turin, Citta della Salute e della Scienza Hospital, Turin, Italy
| | - Sylvie Mochet
- Department of Surgical Sciences, University of Turin, Citta della Salute e della Scienza Hospital, Turin, Italy
| | - Alberto Arezzo
- Department of Surgical Sciences, University of Turin, Citta della Salute e della Scienza Hospital, Turin, Italy
| | - Marco Ettore Allaix
- Department of Surgical Sciences, University of Turin, Citta della Salute e della Scienza Hospital, Turin, Italy
| | - Antonio Salzano
- Department of Surgical Sciences, University of Turin, Citta della Salute e della Scienza Hospital, Turin, Italy
| | - Mario Morino
- Department of Surgical Sciences, University of Turin, Citta della Salute e della Scienza Hospital, Turin, Italy
| | - Massimiliano Mistrangelo
- Department of Surgical Sciences, University of Turin, Citta della Salute e della Scienza Hospital, Turin, Italy
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16
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Cheng YK, Qin QY, Huang XY, Lan P, Wang L, Gao X, Ma TH. Effect of interval between preoperative radiotherapy and surgery on clinical outcome and radiation proctitis in rectal cancer from FOWARC trial. Cancer Med 2019; 9:912-919. [PMID: 31828956 PMCID: PMC6997091 DOI: 10.1002/cam4.2755] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2019] [Revised: 10/24/2019] [Accepted: 10/28/2019] [Indexed: 12/20/2022] Open
Abstract
Objective The aim of this study was to evaluate the effect of the interval between CRT and surgery on radiation proctitis, the pathologic response, and postoperative morbidity. Methods This was a cohort study from a phase III, randomized controlled trial (FOWARC study, NCT01211210). Data were retrieved from the leading center of the trial. Patients were divided into the short‐interval (≤7 weeks) group and the long‐interval (>7 weeks) group. The rate of radiation proctitis, pathologic complete regression (pCR) and morbidities were calculated for each group. Multivariate analysis was used to verify the impact of interval on radiation proctitis. Results Surgery was performed in 60 patients after an interval of ≤7 weeks and in 97 patients after an interval of >7 weeks. The two groups according to interval were comparable in terms of baseline demographic and clinicotherapeutic characteristics. Radiation proctitis was identified by imaging in 9 (15.0%) patients in short‐interval group and in 31 (32.0%) patients in long‐interval group (P = .018). Multivariate analysis confirmed the correlation between long interval and radiation proctitis (P = .018). The long interval was significantly associated with longer median operation time compared to the short interval (P = .022). The rates of pCR and postoperative complications were not different between two groups. Conclusions A longer interval after CRT may be associated with higher rate of radiation proctitis and longer operation time. Moreover it did not increase the rate of pCR.
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Affiliation(s)
- Yi-Kan Cheng
- Department of Radiation Oncology, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, People's Republic of China
| | - Qi-Yuan Qin
- Department of Colorectal Surgery, The Sixth Affiliated Hospital, Sun Yat-Sen University, Guangzhou, People's Republic of China.,Guangdong Institute of Gastroenterology, Guangzhou, People's Republic of China.,Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, The Sixth Affiliated Hospital, Sun Yat-Sen University, Guangzhou, People's Republic of China
| | - Xiao-Yan Huang
- Department of Colorectal Surgery, The Sixth Affiliated Hospital, Sun Yat-Sen University, Guangzhou, People's Republic of China.,Guangdong Institute of Gastroenterology, Guangzhou, People's Republic of China.,Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, The Sixth Affiliated Hospital, Sun Yat-Sen University, Guangzhou, People's Republic of China
| | - Ping Lan
- Department of Colorectal Surgery, The Sixth Affiliated Hospital, Sun Yat-Sen University, Guangzhou, People's Republic of China.,Guangdong Institute of Gastroenterology, Guangzhou, People's Republic of China.,Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, The Sixth Affiliated Hospital, Sun Yat-Sen University, Guangzhou, People's Republic of China
| | - Lei Wang
- Department of Colorectal Surgery, The Sixth Affiliated Hospital, Sun Yat-Sen University, Guangzhou, People's Republic of China.,Guangdong Institute of Gastroenterology, Guangzhou, People's Republic of China.,Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, The Sixth Affiliated Hospital, Sun Yat-Sen University, Guangzhou, People's Republic of China
| | - Xiang Gao
- Department of Gastroenterology, Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, The Sixth Affiliated Hospital, Sun Yat-Sen University, Guangzhou, People's Republic of China
| | - Teng-Hui Ma
- Department of Colorectal Surgery, The Sixth Affiliated Hospital, Sun Yat-Sen University, Guangzhou, People's Republic of China.,Guangdong Institute of Gastroenterology, Guangzhou, People's Republic of China.,Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, The Sixth Affiliated Hospital, Sun Yat-Sen University, Guangzhou, People's Republic of China
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17
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Qin SB, Gao XS, Li HZ, Liu CX, Hou DL, Nian WD, Li XY, Wang D. Intra-rectal use of epinephrine in radiotherapy of prostate cancer. Cancer Manag Res 2019; 11:4847-4854. [PMID: 31213905 PMCID: PMC6549779 DOI: 10.2147/cmar.s187049] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2018] [Accepted: 04/10/2019] [Indexed: 11/23/2022] Open
Abstract
Purpose: The aim of the study was to evaluate the feasibility and toxicity of intra-rectal epinephrine during prostatic radiotherapy. Materials and methods: A total of 34 patients with prostate cancer were randomized to receive daily intra-rectal epinephrine (4 mg in 40 mL, n=16) or placebo (40 mL normal saline, n=18) 5 min before daily radiotherapy. Physical examination including systolic blood pressure (SBP) and heart rate (HR) was performed before, 5 min after, and 20 min after intra-rectal use. Toxicities were graded using the Radiation Therapy Oncology Group standard. A two-sided Fisher's exact test was used to compare proportions between groups. A mixed-effects model was used to analyze multiple measurements of SBP and HR. Survival curves were calculated using the Kaplan–Meier method and compared between groups using the log-rank test. Results: All patients completed the protocol treatment and reported no cardiovascular symptoms after intra-rectal administration. There were no differences in SBP and HR between these two groups at any time point (before, 5 min after, and 20 min after epinephrine). At 5 weeks after the start of radiotherapy, the incidence of rectal toxicity≥grade 2 was 27.8% (5/18) for the control group versus 12.5% (2/16) for the epinephrine group, but was not statistically significant (p=0.4). There was no rectal toxicity≥grade 2 in these two groups beyond 2-year follow-up. The 5-year biochemical relapse-free survival was 75.0% and 72.2% for the epinephrine and control group, respectively. Conclusion: Results of this pilot randomized trial have demonstrated that intra-rectal administration of epinephrine is feasible and safe in prostatic radiotherapy. Its radio-protective effect warrants further investigation.
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Affiliation(s)
- Shang-Bin Qin
- Department of Radiation Oncology, Peking University First Hospital, Beijing, People's Republic of China
| | - Xian-Shu Gao
- Department of Radiation Oncology, Peking University First Hospital, Beijing, People's Republic of China
| | - Hong-Zhen Li
- Department of Radiation Oncology, Peking University First Hospital, Beijing, People's Republic of China
| | - Chao-Xing Liu
- Department of Radiation Oncology, Shijiazhuang City First Hospital, Shijiazhuang, People's Republic of China
| | - Dong-Liang Hou
- Department of Radiation Oncology, Beijing Shijitan Hospital, Beijing, People's Republic of China
| | - Wei-Dong Nian
- Department of General Surgery, Peking University First Hospital, Beijing, People's Republic of China
| | - Xue-Ying Li
- Department of Medical Statistics, Peking University First Hospital, Beijing, People's Republic of China
| | - Dian Wang
- Department of Radiation Oncology, Rush University Medical Center, Chicago, IL, USA
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18
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Sharma B, Gupta M, Sharma R, Gupta A, Sharma N, Sharma M, Sharma V, Vats S, Gupta M, Seam RK. Four percent formalin application for the management of radiation proctitis in carcinoma cervix patients: An effective, safe, and economical practice. J Cancer Res Ther 2019; 15:92-95. [PMID: 30880761 DOI: 10.4103/jcrt.jcrt_393_17] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Context Radiotherapy is a very effective treatment modality for pelvic malignancies such as carcinoma of the cervix. However, it is quite common for chronic radiation proctitis (CRP) to manifest after radical radiotherapy. CRP is a source of significant morbidity, and there is a lack of effective treatment modalities. There also exists a general lack of guidelines on management of CRP. Aims To assess the benefit from 4% formalin application for the treatment of Grade >2 CRP among patients previously treated with radical radiotherapy for cervical carcinoma. Settings and Design This retrospective descriptive study involved 29 eligible patients who were treated from November 2010 - November 2015 for CRP with 4% formalin application. Materials and Methods Of the 1864 patients of carcinoma cervix treated during the said patients, 29 patients fulfilled the eligibility criteria. Eligible patients were invited telephonically for follow-up and were assessed for response and complications of the procedure. Results The treatment of hemorrhagic radiation proctitis with local formalin instillation is effective, well tolerated and safe procedure. The procedure is inexpensive, technically simple and can be done on an outpatient basis. 62% patients had complete freedom from rectal bleed, while 34.5% patients had partial benefit. Only one patient required diversion colostomy for persistent bleeding.
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Affiliation(s)
- Brij Sharma
- Department of Gastroenterology, IGMC, Shimla, Himachal Pradesh, India
| | - Manish Gupta
- Department of Radiotherapy, Cancer Hospital, IGMC, Shimla, Himachal Pradesh, India
| | - Rajesh Sharma
- Department of Gastroenterology, IGMC, Shimla, Himachal Pradesh, India
| | - Ankur Gupta
- Department of Anatomy, IGMC, Shimla, Himachal Pradesh, India
| | - Neetu Sharma
- Department of Physiology, IGMC, Shimla, Himachal Pradesh, India
| | - Mukesh Sharma
- Department of Radiotherapy, IGMC, Shimla, Himachal Pradesh, India
| | - Vineeta Sharma
- Department of Microbiology, IGMC, Shimla, Himachal Pradesh, India
| | - Siddharth Vats
- Department of Radiotherapy, IGMC, Shimla, Himachal Pradesh, India
| | - Manoj Gupta
- Department of Radiotherapy, IGMC, Shimla, Himachal Pradesh, India
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Abstract
The occurrence of chronic proctitis as a side effect among radiotherapy patients is about 5%. Radiation proctitis and consequent development of chronic proctitis are not associated to each other. However, a lot of samples of proctitis that are limited easily could be treated by typical remedial techniques. Improvements in radiotherapy techniques that make possible the delivery of superior doses of radiation could easily reduce both chronic and acute proctitis. The step-by-step remedial procedure for treatment of this disorder starts with conservative remedial management and includes iron substitution as a second-line therapy. For patients who did not receive initial therapies, sucralfate injection, topical corticosteroids, and antidiarrhea therapy were provided as a means of aggressive care. In cases of continuous rectal bleeding, remedial laser techniques and formaldehyde administration should be attempted before surgical therapy. When surgical therapy is required, a descending or transverse colostomy must be carried out. Advanced methods such as intraperitoneal injections of formalin or novel methods of cold therapy and radiofrequency ablation (RFA) provide a wider remedial field. Exceptionally, unanticipated conclusion of neosquamous wound healing via RFA may have additional preponderances in stopping symptoms and may require better assessment through accurate randomized examination. Since aggressive treatments like coloanal anastomosis and colorectal surgery are correlated with remarkable mortality and morbidity, they must be considered as the final course of remedial treatment.
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Affiliation(s)
- Pejman Porouhan
- Department of Radiation Oncology, Sabzevar University of Medical Sciences, Kermanshah, Iran
| | - Negin Farshchian
- Department of Radiation Oncology, Imam Reza Hospital of Kermanshah, Kermanshah, Iran
| | - Malihe Dayani
- Department of Radiation Oncology, Imam Reza Hospital of Kermanshah, Kermanshah, Iran
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20
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Hama Y, Kaji T. Long-term Follow-up Results of CT-guided Daily Adaptive Radiation Therapy for Localized Prostate Cancer. Anticancer Res 2018; 38:5959-5962. [PMID: 30275225 DOI: 10.21873/anticanres.12942] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2018] [Revised: 09/21/2018] [Accepted: 09/22/2018] [Indexed: 11/10/2022]
Abstract
BACKGROUND/AIM To examine whether CT-guided daily adaptive radiation therapy (ART) can be safely administered against localized prostate cancer. PATIENTS AND METHODS Twenty-six patients with localized prostate adenocarcinoma were irradiated through opposed AP/PA fields up to 46 Gy, then CT-guided daily ART was performed through opposed lateral fields until 76 Gy at 2 Gy/fraction. RESULTS Biochemical relapse-free survival was 89% at 3 years and 85% at 5 years and 76% at 7 years after ART, respectively. The 3-, 5- and 7-year local relapse-free survival rates were 100%, 100% and 95%, respectively. The 5-year incidence rates of grade 1 and 2 late gastrointestinal adverse events were 15.4% (n=4) and 3.8% (n=1), respectively, and those of grade 1 and 2 late genitourinary adverse events were 3.8% (n=1) and 0% (n=0), respectively. CONCLUSION CT-guided daily ART was well tolerated and suggested a good long-term tumor control with minimal adverse events.
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Affiliation(s)
- Yukihiro Hama
- Department of Radiation Oncology, Tokyo-Edogawa Cancer Center, Edogawa Hospital, Tokyo, Japan .,Department of Radiology, National Defense Medical College, Saitama, Japan
| | - Tatsumi Kaji
- Department of Radiology, National Defense Medical College, Saitama, Japan
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21
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Trzcinski R, Dziki A, Brys M, Moszynska-Zielinska M, Chalubinska-Fendler J, Mik M, Kujawski R, Dziki L. Expression of vascular endothelial growth factor and its correlation with clinical symptoms and endoscopic findings in patients with chronic radiation proctitis. Colorectal Dis 2018; 20:321-330. [PMID: 28963746 DOI: 10.1111/codi.13902] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [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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Huang EY, Lin H, Wang CJ, Chanchien CC, Ou YC. Impact of treatment time-related factors on prognoses and radiation proctitis after definitive chemoradiotherapy for cervical cancer. Cancer Med 2016; 5:2205-12. [PMID: 27416796 PMCID: PMC5055176 DOI: 10.1002/cam4.794] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2016] [Revised: 05/15/2016] [Accepted: 05/16/2016] [Indexed: 12/22/2022] Open
Abstract
This study aimed to investigate the impact of treatment time-related factors on outcomes and radiation proctitis in patients undergoing concurrent chemoradiotherapy (CCRT) for cervical cancer. From September 2001 to December 2012, 146 patients with stage IIB cervical squamous cell carcinoma treated with CCRT were reviewed from a prospective cohort. Patients who received the same dose (45 Gy) of external beam radiation therapy (EBRT) were included in the analysis (n = 125). The same equivalent dose of 2 Gy (EQD2) of high-dose-rate intracavitary brachytherapy (HDR-ICBT) was delivered at either 4 fractions of 6 Gy or 6 fractions of 4.5 Gy. The effects of the overall treatment time (OTT) and interval between EBRT and HDR-ICBT on the cancer-specific survival (CSS), local recurrence (LR), and incidence of proctitis were compared. The treatment time-related factors did not adversely affect the CSS and LR rates. The multivariate analyses did not identify the OTT as an independent factor of CSS (P = 0.839) and LR (P = 0.856). However, OTT ≤56 days (P = 0.026) was identified as the only independent factor of overall proctitis. The 5-year Grade 2 or greater proctitis rates were 14.9% and 0% (P = 0.001) in patients with the EBRT to ICBT interval ≤5 days and >5 days, respectively. To reduce rectal damage without compromising prognosis, the gap between EBRT and HDR-ICBT should exceed 5 days in cervical cancer patients undergoing CCRT. Strictly limiting the OTT to 56 days may result in radiation proctitis without improvements in prognosis.
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Affiliation(s)
- Eng-Yen Huang
- Department of Radiation Oncology, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan.,School of Traditional Chinese Medicine, Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Hao Lin
- Department of Obstetrics and Gynecology, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Chong-Jong Wang
- Department of Radiation Oncology, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Chan-Chao Chanchien
- Department of Obstetrics and Gynecology, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Yu-Che Ou
- Department of Obstetrics and Gynecology, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan.
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Abstract
Radiotherapy not only plays a pivotal role in the cancer care pathways of many patients with pelvic malignancies, but can also lead to significant injury of normal tissue in the radiation field (pelvic radiation disease) that is sometimes as challenging to treat as the neoplasms themselves. Acute symptoms are usually self-limited and respond to medical therapy. Chronic symptoms often require operative intervention that is made hazardous by hostile surgical planes and unforgiving tissues. Management of these challenging patients is best guided by the utmost caution and humility.
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Affiliation(s)
- Jean H Ashburn
- Department of Colorectal Surgery, Digestive Diseases Institute, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Matthew F Kalady
- Department of Colorectal Surgery, Digestive Diseases Institute, Cleveland Clinic Foundation, Cleveland, Ohio
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Perotti C, Del Fante C, Alvisi C, Cervio M, Scudeller L. A cure for post- radiation proctitis? Blood Transfus 2014; 12 Suppl 1:s243-s244. [PMID: 23736909 PMCID: PMC3934213 DOI: 10.2450/2013.0272-12] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 11/27/2012] [Accepted: 01/30/2013] [Indexed: 06/02/2023]
Affiliation(s)
- Cesare Perotti
- Immuno-haematology and Transfusion Service and Centre for Transplant Immunology, IRCCS Policlinico San Matteo Foundation, Pavia, Italy
| | - Claudia Del Fante
- Immuno-haematology and Transfusion Service and Centre for Transplant Immunology, IRCCS Policlinico San Matteo Foundation, Pavia, Italy
| | - Costanza Alvisi
- Endoscopic unit, IRCCS Policlinico San Matteo Foundation, Pavia, Italy
| | - Marila Cervio
- Immuno-haematology and Transfusion Service and Centre for Transplant Immunology, IRCCS Policlinico San Matteo Foundation, Pavia, Italy
| | - Luigia Scudeller
- Scientific Direction, IRCCS Policlinico San Matteo Foundation, Pavia, Italy
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Gültekin FA, Bakkal BH, Sümer D, Köktürk F, Bektaş S. Effects of ozonated olive oil on acute radiation proctitis in rats. Balkan Med J 2013; 30:369-74. [PMID: 25207143 DOI: 10.5152/balkanmedj.2013.9158] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2013] [Accepted: 07/22/2013] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Acute radiation proctitis is a common complication of pelvic radiation and management of acute radiation proctitis is under evaluation. The beneficial effects of ozonated olive oil (OzOO) have already been shown in the treatment of chronic wounds. Thus, this study was designed to evaluate the therapeutic effects of topical OzOO on acute radiation proctitis. AIMS To evaluate the therapeutic effects of topical OzOO on acute radiation proctitis. STUDY DESIGN Animal experimentation. METHODS RATS WERE DIVIDED INTO THREE GROUPS: control; irradiation+saline (1 mL); and irradiation +OzOO (1 mL). A single fraction of 17.5 Gy was delivered to each rat. The OzOO was administered rectally each day after irradiation. Each rat was observed daily for signs of proctitis. Irradiated rats were euthanised on days 5 and 10. The mucosal changes were evaluated macroscopically and pathologically. RESULTS According to the clinical findings, five rats in the irradiation+saline group showed Grade 4 symptoms on the 10(th) day. Macroscopic finding scores on the 10(th) day in the irradiation+saline and irradiation+OzOO groups were statistically significantly different. On pathological examination, radiation-induced mucosal damage was the most prominent 10 days after irradiation in saline-treated rats. On the 10(th) day, the irradiation+OzOO group showed mild inflammation and slight crypt change, which corresponded to Grade 1 pathological findings. CONCLUSION OzOO attenuates macroscopic and pathological findings of acute radiation proctitis in rats.
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Affiliation(s)
- Fatma Ayça Gültekin
- Department of General Surgery, Bülent Ecevit University Faculty of Medicine, Zonguldak, Turkey
| | - Bekir Hakan Bakkal
- Department of Radiation Oncology, Bülent Ecevit University Faculty of Medicine, Zonguldak, Turkey
| | - Demet Sümer
- Department of General Surgery, Bülent Ecevit University Faculty of Medicine, Zonguldak, Turkey
| | - Füruzan Köktürk
- Department of Biostatistics, Bülent Ecevit University Faculty of Medicine, Zonguldak, Turkey
| | - Sibel Bektaş
- Department of Pathology, Bülent Ecevit University Faculty of Medicine, Zonguldak, Turkey
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