Anorectal cancer following topical formalin application for haemorrhagic radiation proctitis

OBJECTIVE

Topical formalin has been used as an effective treatment for haemorrhagic radiation proctitis. In the course of reviewing our experience with this modality, we identified two patients who developed anorectal cancer during the follow-up period.

METHOD

From 2001 to 2005, 49 patients who received pelvic radiation for treatment of prostate, rectal or endometrial cancer subsequently developed haemorrhagic radiation proctitis. Four percent formalin was applied in the office setting under direct visualization with a rigid proctoscope and without sedation. Response to treatment was then reviewed.

RESULTS

Seventy-eight per cent of patients reported a complete response to formalin application. Only 14% were refractory to formalin treatment. Two patients subsequently presented with anorectal cancer.

CONCLUSION

Topical formalin application in the outpatient setting appears to be an effective first-line treatment for haemorrhagic radiation proctitis. We report the first cases of anorectal cancer which developed subsequent to formalin application. Pelvic irradiation is known to increase the risk of developing a second malignancy, therefore it is impossible to determine what, if any, role formalin application played in the development of the second malignancies.

Formalin application for the treatment of radiation-induced hemorrhagic proctitis

Radiation-induced hemorrhagic proctitis (RIHP) is a serious complication of pelvic irradiation, and a 4% formalin solution has been used for 20 years in treating this sequelae. The first case involving formalin application for treatment of RIHP in Korea was reported in 1996, but there are no additional studies beyond this date. Our study reviews the use of formalin instillation and selective application. The purpose of this study was to retrospectively evaluate the outcome of such treatments, beginning with the first case at our hospital. From 1996 to 2005, five RIHP patients had received formalin treatment for RIHP symptoms intractable to other medical treatments. All treatments were performed by a single surgeon in the operating room, under spinal anesthesia or intravenous sedation. The mean duration of symptoms before treatment was 15.6 months (which was longer than in other studies), and the transfusion before treatment varied from once per month to twice per week. Using sigmoidoscopy, 100 ml of a 4% formalin solution was instilled directly (or by using a formalin-soaked gauze) and irrigated for five minutes. Formalin-soaked cotton was then applied selectively to focal remnant lesions. Four patients improved after the first treatment, but one patient received the treatment twice because of recurrent symptoms. Complications after treatment included perianal pain (one case), and aggravated incontinence (one case), which improved three months after conservative management. In conclusion, the formalin combination application method in our study is comparable to other formalin treatments for intractable RIHP.

Application of 10 percent formalin for the treatment of radiation-induced hemorrhagic proctitis

PURPOSE

Rectal instillation of 4 percent formalin solution has been described as a successful treatment for hemorrhagic radiation proctitis recalcitrant to medical treatment. We present our experience with a new method of treatment involving the topical application of 10 percent buffered formalin, which is well tolerated and suitable for office use.

METHODS

Patients with marked or refractory rectal bleeding and clinical features consistent with radiation proctitis were reviewed. Treatment involved direct application of a 10 percent buffered formalin solution to the affected mucosa using a 16-inch cotton tip applicator applied through a proctoscope in the office setting.

RESULTS

A total of 100 patients with a mean age of 75 (range, 49-91) years were followed for 18 (range, 1-79) months. The interval from radiation exposure to formalin treatment was 21 months. Overall, 93 percent of patients had cessation of bleeding after an average of 3.5 formalin applications at two-week to four-week intervals. Patients with severe (Grade 3) proctitis and those taking aspirin required an average of 1.5 additional treatments. A total of eight patients rebled at a mean of 24 months from treatment; however, all responded to further applications of formalin. Three patients complained of anal pain and one experienced dizziness postprocedure for a complication rate of 1.1 percent.

CONCLUSIONS

We present a simple, cost-effective, and well-tolerated method of controlling hemorrhagic radiation proctitis. It is performed by using materials readily available in the office of a colon and rectal surgeon, eliminating the need for bowel preparation, anesthesia, or a surgical suite.

Pit patterns in rectal mucosa assessed by magnifying colonoscope are predictive of relapse in patients with quiescent ulcerative colitis

BACKGROUND

Relapse of ulcerative colitis is difficult to predict by routine colonoscopy. A high-resolution video-magnifying colonoscope with chromoscopy enables the observation of colorectal mucosal pit patterns.

AIMS

To investigate the association of pit patterns as assessed by magnifying colonoscopy (MCS) with histological inflammation and mucosal chemokine activity in patients with quiescent ulcerative colitis, and to prospectively analyse the prognostic factors that may predict exacerbations.

METHODS

MCS was performed in 113 patients with ulcerative colitis in remission. Pit patterns in the rectal mucosa were classified into four MCS grades on the basis of size, shape and arrangement. Mucosal interleukin (IL) 8 activity was measured in biopsy specimens of rectal mucosa and the specimens were assessed for histological disease activity. The patients were then followed until relapse or for a maximum of 12 months. Multivariate survival analysis was carried out to determine the independent predictors of clinical relapse.

RESULTS

A positive correlation was identified between MCS grade, histological grade (p = 0.001) and mucosal IL8 activity (p<0.001). Multivariate proportional hazard model analysis showed that MCS grade was a significant predictor of relapse (relative risk 2.06, p = 0.001). Kaplan-Meier estimate of relapse during 12 months of follow-up was found to increase with increasing MCS grade, with values of 0% for grade 1, 21% for grade 2, 43% for grade 3 and 60% for grade 4.

CONCLUSION

MCS grading is associated with the degree of histological inflammation and mucosal IL8 activity in patients with quiescent ulcerative colitis, and may predict the probability of subsequent disease relapse in patients with ulcerative colitis in remission.

Medical management of left-sided ulcerative colitis and ulcerative proctitis: critical evaluation of therapeutic trials

BACKGROUND

The goal of this work was to critically evaluate the published studies on the treatment of ulcerative proctitis (UP) and left-sided ulcerative colitis (L-UC). The results of this review provided the content for the accompanying treatment guidelines, Clinical Guidelines for the Medical Management of Left-sided Ulcerative Colitis and Ulcerative Proctitis: Summary Statement.

METHODS

All English language articles published between 1995 and September 2005 were identified through a comprehensive literature search using OVID and PubMed. The quality of the data supporting or rejecting the use of specific therapies was categorized by a data quality grading scale. An "A+" grade was assigned to treatment supported by multiple high-quality randomized controlled trials with consistent results, whereas a "D" grade was given to therapy supported only by expert opinion. The therapeutic efficacy of a treatment was defined by its success in treating UP and L-UC compared with placebo. A medication was ranked as "excellent" if it was specifically studied for UP and L-UC and had consistently positive results compared with placebo or another agent. Quality and efficacy scores were agreed on by author consensus.

RESULTS

For the acute treatment of UP or L-UC, the rectally administered corticosteroids and mesalazine (5-ASA), either alone or in combination with oral 5-ASAs, are the most effective therapy: evidence quality, A+; efficacy, excellent. Only rectally administered 5-ASA received an A+/excellent rating for maintenance of remission. Infliximab received an A+ grade for induction and maintenance of remission but only a "good" rating because the studies were performed in all UC, not specifically UP or L-UC.

CONCLUSIONS

This critical evaluation of treatment provides a "report card" on medications available for the management of patients with UP and L-UC. The guidelines should provide a useful reference and supplement for physicians treating UC patients.

Clinical guidelines for the medical management of left-sided ulcerative colitis and ulcerative proctitis: summary statement

There are few published guidelines for the treatment of inflammatory bowel disease. Physicians choose therapy based on evidence-based data, peer and expert opinion, and personal experience. This article provides treatment guidelines for the induction and maintenance of ulcerative proctitis and left-sided colitis and the management of disease refractory to 5-aminosalicylic acid (5-ASA) compounds and corticosteroids The guidelines are derived from evidence-based data and, when lacking, expert opinion or the authors' experience. The comprehensive review of the literature is presented in the accompanying article, "The Medical Management of Left-Sided Ulcerative Colitis and Ulcerative Proctitis: Critical Evaluation of Therapeutic Trials". Rectally administered 5-ASA and corticosteroid suppositories are effective treatment for most ulcerative proctitis patients. Corticosteroid and 5-ASA enemas, which reach the splenic flexure of the colon, are recommended for patients with left-sided ulcerative colitis. The combination of rectally administered 5-ASA enemas and oral 5-ASA agents may afford better treatment of left-sided colitis and possibly prevent proximal extension of disease. Patients refractory to 5-ASAs and corticosteroids may require an immunomodulator or biological response modifier therapy. Those who have ongoing signs and symptoms of ulcerative proctitis and left-sided ulcerative colitis despite maximal medical therapy require a proctocolectomy.

Histopathological comparison of topical therapy modalities for acute radiation proctitis in an experimental rat model

AIM: To evaluate the prevalent topical therapeutic modalities available for the treatment of acute radiation proctitis compared to formalin.

METHODS: A total of 120 rats were used. Four groups (n = 30) were analyzed with one group for each of the following applied therapy modalities: control, mesalazine, formalin, betamethasone, and misoprostol. A single fraction of 17.5 Gy was delivered to each rat. The rats in control group rats were given saline, and the rats in the other three groups received appropriate enemas twice a day beginning on the first day after the irradiation until the day of euthanasia. On d 5, 10, and 15, ten rats from each group were euthanized and a pathologist who was unaware of treatment assignment examined the rectums using a scoring system.

RESULTS: The histopathologic scores for surface epithelium, glands (crypts) and lamina propria stroma of the rectums reached their maximum level on d 10. The control and formalin groups had the highest and mesalazine had the lowest, respectively on d 10. On the 15^th d, mesalazine, betamethasone, and misoprostol had the lowest scores of betamethasone.

CONCLUSION: Mesalazine, betamethasone, and misoprostol are the best topical agents for radiation proctitis and formalin has an inflammatory effect and should not be used.

[The usefulness of mesalazine suppositories for the treatment of lymphoid follicular proctitis]

BACKGROUND/AIMS

Lymphoid follicular proctitis (LFP) is an uncommon inflammatory condition confined to the rectum. Patients with LFP constitute a special group with clinical, endoscopic, and histological features unrelated to other types of inflammatory bowel diseases, and have been reported to be refractory to local steroid and/or oral sulfasalazine therapy. The aim of this study was to clarify whether mesalazine suppositories have a therapeutic effect in LFP.

METHODS

The histologic slides of 8 cases indexed in our pathology files as "lymphoid follicular proctitis of the rectal mucosa" from January 2001 to November 2003 were reviewed retrospectively.

RESULTS

The most common symptom in the patients with LFP was rectal bleeding. The endoscopic mucosal changes were discontinuous, sparing whole circumferential involvement, and were strictly confined to the rectum. Average period of medication was 12 months. All the symptomatic patients with LFP responded to mesalazine suppository therapy. In addition, these patients did not progress to other disease including ulcerative proctitis or lymphoma.

CONCLUSIONS

Mesalazine suppository treatment is a useful therapeutic option for symptomatic patients with LFP.

Treatment of haemorrhagic radiation-induced proctopathy using small volume topical formalin instillation

BACKGROUND

Between 2 and 5% of patients undergoing pelvic radiotherapy develop chronic radiation proctopathy, occurring as a result of damage to the rectal mucosa during the treatment. Rectal bleeding of varying severity can occur as a consequence. There have been no formal trials of treatment for haemorrhagic radiation proctopathy and a variety of methods are currently used.

AIM

In a retrospective study of 20 patients treated at a single centre, we assessed the efficacy of small volume topical formalin instillation to control bleeding from radiation proctopathy.

METHOD

Patients were treated by a single operator using 20 mL of a 5% solution of formalin instilled into the rectum via a flexible sigmoidoscope for 3 min. Patients were followed up for an average of 22.7 months (range: 2-69).

RESULTS

A single session of formalin treatment was effective in 13 of 20 (65%) patients and a further four (20%) patients responded to a second treatment. No complications of the treatment was identified.

CONCLUSION

Small volume formalin instillation therapy appears to be safe and effective in the context of haemorrhagic radiation proctopathy. The technique is simple, inexpensive, quick and requires no sedation. We suggest that it should be considered as a first line for patients presenting with this distressing condition.

Endoluminal formalin application for haemorrhagic radiation proctitis

BACKGROUND

Radiation proctitis is a common complication following radiation therapy for pelvic malignancies. This is associated with significant morbidity which adversely affects the quality of life. Local application of formalin has been used effectively in the treatment of radiation proctitis.

METHODOLOGY

Thirty patients with haemorrhagic radiation proctitis who underwent endoluminal application of 4% formalin between January 1998 to October 2002 were followed up prospectively to assess the efficacy of the treatment.

RESULTS

The follow up ranged from 5 to 36 months (mean 18.1 months). Nineteen (63.3%) patients had complete response to formalin application while 7 (23.3%) patients had partial response. There were 4 (13.3%) failures. No procedure related complication was observed.

CONCLUSION

Local application of formalin is a simple, safe, inexpensive and fairly effective outpatient treatment modality for chronic radiation proctitis.

Phase III study of pentosanpolysulfate (PPS) in treatment of gastrointestinal tract sequelae of radiotherapy

OBJECTIVES

To evaluate the effectiveness of pentosanpolysulfate (PPS) in the treatment of gastrointestinal tract sequelae of radiotherapy.

METHODS

Eligible patients were those with grade 1 to 3 radiation related proctitis, diarrhea and/or melena. At least 4 weeks had to elapse since the completion of the radiotherapy course. Patients with bleeding diathesis or ulcers, and patients receiving anticoagulants or chemotherapy were excluded. Stratification criteria included the type of sequelae (proctitis, diarrhea, melena), the severity grade and the onset (<3 months post-RT, >3 months post-RT). Patients were randomized to one of the following arms: 100 mg PPS 3 times per day (300 mg/day), 200 mg PPS 3 times per day (600 mg/day), or placebo 3 times per day. If there was no improvement in symptoms after 2 months, the protocol treatment was discontinued. If the symptoms improved or resolved, the protocol treatment was continued for additional 4 months. Patients under treatment were evaluated monthly, than every 2 to 3 months for the next 18 months. A symptom assessment questionnaire was used to measure quality of life endpoints.

RESULTS

From June 1999 to March 2001 180 patients were accessioned from 34 institutions. A total of 168 were analyzable. Neither the best observed response within 3 months for the entire population, nor the response rate within sequelae category or the quality of life measures differed significantly between the 3 arms of the study.

CONCLUSION

Administration of PPS has not been associated with an improvement in the clinical course of radiation related morbidity of the gastrointestinal tract.

Amifostine in the management of radiation-induced and chemo-induced mucositis

INTRODUCTION

Mucositis is a significant complication of cancer therapy, with important clinical and economic implications. In June 2005, the Mucositis Study Group of the Multinational Association of Supportive Care in Cancer/International Society for Oral Oncology (MASCC/ISOO) conducted an evidence-based update review of the literature on mucositis. The goal of this literature review is to update previously published guidelines for the management of mucositis.

RESULTS

This article reports the findings of the subgroup charged with reviewing the literature related to amifostine.

Budesonide foam versus budesonide enema in active ulcerative proctitis and proctosigmoiditis

BACKGROUND

Rectal budesonide is an effective treatment of active ulcerative proctitis or proctosigmoiditis.

AIM

To compare the therapeutic efficacy, tolerability and safety, and patient's preference of budesonide foam vs. budesonide enema.

METHODS

Patients with active ulcerative proctitis or proctosigmoiditis (clinical activity index > 4 and endoscopic index > or = 4) were eligible for this double-blind, double-dummy, randomized, multicentre study. They received 2 mg/25 mL budesonide foam and placebo enema (n = 265), or 2 mg/100 mL budesonide enema and placebo foam (n = 268) for 4 weeks. Primary endpoint was clinical remission (clinical activity index < or = 4) at the final/withdrawal visit (per protocol).

RESULTS

A total of 541 patients were randomized--533 were evaluable for intention-to-treat analysis and 449 for per protocol analysis. Clinical remission rates (per protocol) were 60% for budesonide foam and 66% for budesonide enema (P = 0.02362 for non-inferiority of foam vs. enema within a predefined non-inferiority margin of 15%). Both formulations were safe and no drug-related serious adverse events were observed. Because of better tolerability and easier application most patients preferred foam (84%).

CONCLUSION

Budesonide foam is as effective as budesonide enema in the treatment of active ulcerative proctitis or proctosigmoiditis. Both budesonide formulations are safe, and most patients prefer foam.

Traitement antibiotique des urétrites et cervicités non compliquées

In sexually transmitted infections and more precisely in uncomplicated urethritis and cervicitis, the two infectious agents most commonly identified in France are Neisseria gonorrhoeae (gonococci) and Chlamydia trachomatis, alone or associated. The resistance of N. gonorrhoeae to ciprofloxacin has reached over 20 % in France. A new national strategy for the therapeutic management of probabilistic treatment applied to uncomplicated urethritis and cervicitis is required. Bacteriological sampling before treatment is mandatory. Anti-gonococcal probabilistic treatment is a monodose using one of the following molecules: third generation cephalosporin: ceftriaxone (intra-muscular or intra-venous), cefixime (oral); aminoside: spectinomycin (intra- muscular); fluoroquinolone (bacteriologically controlled): ciprofloxacin (oral); An oral anti-Chlamydia treatment must be associated: azithromycin (monodose); or doxycycline (standard treatment). Blood tests (screening for syphilis, HIV infection, hepatitis B, hepatitis C) must be performed taking into account the delay for sero-conversion. Hepatitis B vaccination must be offered to any non-immunized patient. Protected intercourse (using condoms) must be recommended.