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Kohoutova D, Wilson A, Gee C, Elhusseiny R, Wanders L, Cunningham D. Intrarectal formalin treatment for haemorrhagic radiation-induced proctopathy: efficacy and safety. Colorectal Dis 2024; 26:932-939. [PMID: 38519847 DOI: 10.1111/codi.16956] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2022] [Revised: 01/15/2024] [Accepted: 03/01/2024] [Indexed: 03/25/2024]
Abstract
AIM Pelvic radiotherapy is limited by dose-dependent toxicity to surrounding organs. The aim of this prospective study was to evaluate the efficacy and safety of intrarectal formalin treatment for radiotherapy-induced haemorrhagic proctopathy (RHP) at the Royal Marsden Hospital. METHOD Adult patients were enrolled. Haemoglobin was evaluated before and after formalin treatment. Antiplatelet and/or anticoagulation treatment and administration of transfusion were recorded. The interval between completion of radiotherapy and the first intrarectal 5% formalin treatment was assessed and the dose of radiotherapy was evaluated. Clinical assessment of the frequency and amount of rectal bleeding (rectal bleeding score 1-6) and endoscopic appearance (grade 0-3) were classified. Complications were recorded. RESULTS Nineteen patients were enrolled, comprising 13 men (68%) and 6 women. The mean age was 75 ± 9 years. The median time between completion of radiotherapy and the first treatment was 20 months [interquartile range (IQR) 15 months] and the median dose of radiotherapy was 68 Gy (IQR 14 Gy). Thirty-two procedures were performed (average 1.7 per patient). In total, 9/19 (47%) patients were receiving anticoagulation and/or antiplatelet medication and 5/19 (26%) received transfusion prior to treatment. The mean value of serum haemoglobin before the first treatment was 110 ± 18 g/L and afterwards it was 123 ± 16 g/L (p = 0.022). The median rectal bleeding score before the first treatment was 6 (IQR 0) and afterwards 2 (IQR 1-4; p < 0.001), while the median endoscopy score on the day of first treatment was 3 (IQR 0) compared with 1 (IQR 1-2) on the day of the last treatment 1 (p < 0.001). One female patient with a persistent rectal ulcer that eventually healed (18 months of healing) subsequently developed rectovaginal fistula (complication rate 1/19, 5%). CONCLUSIONS Treatment with intrarectal formalin in RHP is effective and safe.
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Affiliation(s)
| | - Ana Wilson
- The Royal Marsden Hospital NHS Foundation Trust, London, UK
- St Mark's Hospital, London, UK
| | - Caroline Gee
- The Royal Marsden Hospital NHS Foundation Trust, London, UK
| | | | - Linda Wanders
- The Royal Marsden Hospital NHS Foundation Trust, London, UK
- Amsterdam UMC, Location VUMC, Amsterdam, The Netherlands
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Feakins R, Torres J, Borralho-Nunes P, Burisch J, Cúrdia Gonçalves T, De Ridder L, Driessen A, Lobatón T, Menchén L, Mookhoek A, Noor N, Svrcek M, Villanacci V, Zidar N, Tripathi M. ECCO Topical Review on Clinicopathological Spectrum and Differential Diagnosis of Inflammatory Bowel Disease. J Crohns Colitis 2022; 16:343-368. [PMID: 34346490 DOI: 10.1093/ecco-jcc/jjab141] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
INTRODUCTION Many diseases can imitate inflammatory bowel disease [IBD] clinically and pathologically. This review outlines the differential diagnosis of IBD and discusses morphological pointers and ancillary techniques that assist with the distinction between IBD and its mimics. METHODS European Crohn's and Colitis Organisation [ECCO] Topical Reviews are the result of an expert consensus. For this review, ECCO announced an open call to its members and formed three working groups [WGs] to study clinical aspects, pathological considerations, and the value of ancillary techniques. All WGs performed a systematic literature search. RESULTS Each WG produced a draft text and drew up provisional Current Practice Position [CPP] statements that highlighted the most important conclusions. Discussions and a preliminary voting round took place, with subsequent revision of CPP statements and text and a further meeting to agree on final statements. CONCLUSIONS Clinicians and pathologists encounter a wide variety of mimics of IBD, including infection, drug-induced disease, vascular disorders, diverticular disease, diversion proctocolitis, radiation damage, and immune disorders. Reliable distinction requires a multidisciplinary approach.
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Affiliation(s)
- Roger Feakins
- Department of Cellular Pathology, Royal Free Hospital, London, and University College London, UK
| | - Joana Torres
- Department of Gastroenterology, Hospital Beatriz Ângelo, Loures, Portugal
| | - Paula Borralho-Nunes
- Department of Pathology, Hospital Cuf Descobertas, Lisboa and Faculdade de Medicina da Universidade de Lisboa, Lisbon, Portugal
| | - Johan Burisch
- Gastrounit, Medical Division, Hvidovre Hospital, University of Copenhagen, Denmark
| | - Tiago Cúrdia Gonçalves
- Department of Gastroenterology, Hospital da Senhora da Oliveira, Guimarães, Portugal.,School of Medicine, University of Minho, Braga/Guimarães, Portugal.,ICVS/3B's-PT Government Associate Laboratory, Braga/Guimarães, Portugal
| | - Lissy De Ridder
- Department of Paediatric Gastroenterology, Erasmus MC Sophia Children's Hospital, University Medical Center Rotterdam, The Netherlands
| | - Ann Driessen
- Department of Pathology, University Hospital Antwerp, University Antwerp, Edegem, Belgium
| | - Triana Lobatón
- Department of Gastroenterology, Ghent University Hospital, Ghent, Belgium
| | - Luis Menchén
- Department of Digestive System Medicine, Hospital General Universitario-Insitituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain.,Department of Medicine, Universidad Complutense, Madrid, Spain.,Centro de Investigación Biomédica En Red de Enfermedades Hepáticas y Digestivas [CIBEREHD], Madrid, Spain
| | - Aart Mookhoek
- Department of Pathology, Amsterdam UMC, Amsterdam, The Netherlands
| | - Nurulamin Noor
- Department of Gastroenterology, Addenbrooke's Hospital, Cambridge University Hospitals NHS Trust, Cambridge, UK
| | - Magali Svrcek
- Department of Pathology, Sorbonne Université, AP-HP, Saint-Antoine Hospital, Paris, France
| | - Vincenzo Villanacci
- Department of Histopathology, Spedali Civili and University of Brescia, Brescia, Italy
| | - Nina Zidar
- Institute of Pathology, Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Monika Tripathi
- Department of Histopathology, Cambridge Biomedical Campus, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
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Nunes VRT, Vidigal PVT, Pereira MT, Ladeira LCD, Caliari MV, Oliveira FMS, Cesar ALA, Faraco AAG, Barbuto RC, Duval-Araujo I. Evaluation of mesalazine polymeric conjugate in the treatment of actinic proctitis in rats. Acta Cir Bras 2021; 36:e360805. [PMID: 34644773 PMCID: PMC8516428 DOI: 10.1590/acb360805] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2021] [Accepted: 07/24/2021] [Indexed: 11/21/2022] Open
Abstract
Purpose: The present study aimed at testing a new formulation of mesalazine linked to
chondroitin sulfate and its components alone in the treatment of actinic
proctitis in rats. Methods: Forty-seven female Wistar rats were submitted to pelvic radiation and divided
into eight groups: control A, mesalazine A, chondroitin A, and conjugate A,
gavage of the according substance two weeks after irradiation and sacrifice
three weeks after oral treatment; control C, mesalazine C, chondroitin C,
and conjugate C, sacrifice six weeks after oral treatment. The rectum was
submitted to histological characterization for each of the findings:
inflammatory infiltrate, epithelial degeneration, mucosal necrosis, and
fibrosis. Results: The inflammatory infiltrate was more intense in chondroitin A, mesalazine A,
and conjugate C. The collagen deposition was less intense in chondroitin A,
and mesalazine A, and more intense in control C. Conclusions: Mesalazine and chondroitin alone were efficacious in inducing a delayed
inflammatory response, hence reducing the late fibrosis. The conjugate was
able to induce an ever more delayed inflammatory response.
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Li Y, Zhang Y, Wei K, He J, Ding N, Hua J, Zhou T, Niu F, Zhou G, Shi T, Zhang L, Liu Y. Review: Effect of Gut Microbiota and Its Metabolite SCFAs on Radiation-Induced Intestinal Injury. Front Cell Infect Microbiol 2021; 11:577236. [PMID: 34307184 PMCID: PMC8300561 DOI: 10.3389/fcimb.2021.577236] [Citation(s) in RCA: 33] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Accepted: 06/23/2021] [Indexed: 12/12/2022] Open
Abstract
Gut microbiota is regarded as the second human genome and forgotten organ, which is symbiotic with the human host and cannot live and exist alone. The gut microbiota performs multiple physiological functions and plays a pivotal role in host health and intestinal homeostasis. However, the gut microbiota can always be affected by various factors and among them, it is radiotherapy that results in gut microbiota 12dysbiosis and it is often embodied in a decrease in the abundance and diversity of gut microbiota, an increase in harmful bacteria and a decrease in beneficial bacteria, thereby affecting many disease states, especially intestine diseases. Furthermore, gut microbiota can produce a variety of metabolites, among which short-chain fatty acids (SCFAs) are one of the most abundant and important metabolites. More importantly, SCFAs can be identified as second messengers to promote signal transduction and affect the occurrence and development of diseases. Radiotherapy can lead to the alterations of SCFAs-producing bacteria and cause changes in SCFAs, which is associated with a variety of diseases such as radiation-induced intestinal injury. However, the specific mechanism of its occurrence is not yet clear. Therefore, this review intends to emphasize the alterations of gut microbiota after radiotherapy and highlight the alterations of SCFAs-producing bacteria and SCFAs to explore the mechanisms of radiation-induced intestinal injury from the perspective of gut microbiota and its metabolite SCFAs.
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Affiliation(s)
- Yangyang Li
- Provincial-Level Key Laboratory for Molecular Medicine of Major Diseases and The Prevention and Treatment With Traditional Chinese Medicine Research in Gansu Colleges and Universities, Gansu University of Chinese Medicine, Lanzhou, China
| | - Yiming Zhang
- Provincial-Level Key Laboratory for Molecular Medicine of Major Diseases and The Prevention and Treatment With Traditional Chinese Medicine Research in Gansu Colleges and Universities, Gansu University of Chinese Medicine, Lanzhou, China
| | - Kongxi Wei
- Provincial-Level Key Laboratory for Molecular Medicine of Major Diseases and The Prevention and Treatment With Traditional Chinese Medicine Research in Gansu Colleges and Universities, Gansu University of Chinese Medicine, Lanzhou, China
| | - Jinpeng He
- Key Laboratory of Space Radiobiology of Gansu Province & Key Laboratory of Heavy Ion Radiation Biology and Medicine of Chinese Academy of Sciences Institute of Modern Physics, Chinese Academy of Sciences, Lanzhou, China
| | - Nan Ding
- Key Laboratory of Space Radiobiology of Gansu Province & Key Laboratory of Heavy Ion Radiation Biology and Medicine of Chinese Academy of Sciences Institute of Modern Physics, Chinese Academy of Sciences, Lanzhou, China
| | - Junrui Hua
- Key Laboratory of Space Radiobiology of Gansu Province & Key Laboratory of Heavy Ion Radiation Biology and Medicine of Chinese Academy of Sciences Institute of Modern Physics, Chinese Academy of Sciences, Lanzhou, China
| | - Ting Zhou
- Provincial-Level Key Laboratory for Molecular Medicine of Major Diseases and The Prevention and Treatment With Traditional Chinese Medicine Research in Gansu Colleges and Universities, Gansu University of Chinese Medicine, Lanzhou, China
| | - Fan Niu
- Provincial-Level Key Laboratory for Molecular Medicine of Major Diseases and The Prevention and Treatment With Traditional Chinese Medicine Research in Gansu Colleges and Universities, Gansu University of Chinese Medicine, Lanzhou, China
| | - Gucheng Zhou
- Provincial-Level Key Laboratory for Molecular Medicine of Major Diseases and The Prevention and Treatment With Traditional Chinese Medicine Research in Gansu Colleges and Universities, Gansu University of Chinese Medicine, Lanzhou, China
| | - Tongfan Shi
- Provincial-Level Key Laboratory for Molecular Medicine of Major Diseases and The Prevention and Treatment With Traditional Chinese Medicine Research in Gansu Colleges and Universities, Gansu University of Chinese Medicine, Lanzhou, China
| | - Liying Zhang
- Provincial-Level Key Laboratory for Molecular Medicine of Major Diseases and The Prevention and Treatment With Traditional Chinese Medicine Research in Gansu Colleges and Universities, Gansu University of Chinese Medicine, Lanzhou, China.,Gansu Institute of Cardiovascular Diseases, Lanzhou, China
| | - Yongqi Liu
- Provincial-Level Key Laboratory for Molecular Medicine of Major Diseases and The Prevention and Treatment With Traditional Chinese Medicine Research in Gansu Colleges and Universities, Gansu University of Chinese Medicine, Lanzhou, China.,Key Laboratory of Dunhuang Medicine and Transformation at Provincial and Ministerial Level, Lanzhou, China
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5
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Steinhauff D, Jensen M, Talbot M, Jia W, Isaacson K, Jedrzkiewicz J, Cappello J, Oottamasathien S, Ghandehari H. Silk-elastinlike copolymers enhance bioaccumulation of semisynthetic glycosaminoglycan ethers for prevention of radiation induced proctitis. J Control Release 2021; 332:503-515. [PMID: 33691185 DOI: 10.1016/j.jconrel.2021.03.001] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2020] [Revised: 02/17/2021] [Accepted: 03/01/2021] [Indexed: 12/22/2022]
Abstract
Radiation-induced proctitis (RIP) is a debilitating adverse event that occurs commonly during lower abdominal radiotherapy. The lack of prophylactic treatment strategies leads to diminished patient quality of life, disruption of radiotherapy schedules, and limitation of radiotherapy efficacy due to dose-limiting toxicities. Semisynthetic glycosaminoglycan ethers (SAGE) demonstrate protective effects from RIP. However, low residence time in the rectal tissue limits their utility. We investigated controlled delivery of GM-0111, a SAGE analogue with demonstrated efficacy against RIP, using a series of temperature-responsive polymers to compare how distinct phase change behaviors, mechanical properties and release kinetics influence rectal bioaccumulation. Poly(lactic acid)-co-(glycolic acid)-block-poly(ethylene glycol)-block-poly(lactic acid)-co-(glycolic acid) copolymers underwent macroscopic phase separation, expelling >50% of drug during gelation. Poloxamer compositions released GM-0111 cargo within 1 h, while silk-elastinlike copolymers (SELPs) enabled controlled release over a period of 12 h. Bioaccumulation was evaluated using fluorescence imaging and confocal microscopy. SELP-415K, a SELP analogue with 4 silk units, 15 elastin units, and one elastin unit with lysine residues in the monomer repeats, resulted in the highest rectal bioaccumulation. SELP-415K GM-0111 compositions were then used to provide localized protection from radiation induced tissue damage in a murine model of RIP. Rectal delivery of SAGE using SELP-415K significantly reduced behavioral pain responses, and reduced animal mass loss compared to irradiated controls or treatment with traditional delivery approaches. Histological scoring showed RIP injury was ameliorated for animals treated with GM-0111 delivered by SELP-415K. The enhanced bioaccumulation provided by thermoresponsive SELPs via a liquid to semisolid transition improved rectal delivery of GM-0111 to mice and radioprotection in a RIP model.
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Affiliation(s)
- D Steinhauff
- Department of Biomedical Engineering, University of Utah, Salt Lake City, UT 84112, USA; Utah Center for Nanomedicine, University of Utah, Salt Lake City, UT 84112, USA
| | - M Jensen
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02115, USA
| | - M Talbot
- Department of Biomedical Engineering, University of Utah, Salt Lake City, UT 84112, USA; Utah Center for Nanomedicine, University of Utah, Salt Lake City, UT 84112, USA
| | - W Jia
- Utah Center for Nanomedicine, University of Utah, Salt Lake City, UT 84112, USA
| | - K Isaacson
- Department of Biomedical Engineering, University of Utah, Salt Lake City, UT 84112, USA; Utah Center for Nanomedicine, University of Utah, Salt Lake City, UT 84112, USA
| | - J Jedrzkiewicz
- Department of Pathology, University of Utah, Salt Lake City, UT 84112, USA
| | - J Cappello
- Department of Pharmaceutics and Pharmaceutical Chemistry, University of Utah, Salt Lake City, UT 84112, USA
| | - S Oottamasathien
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02115, USA; Department of Urology, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02115, USA.
| | - H Ghandehari
- Department of Biomedical Engineering, University of Utah, Salt Lake City, UT 84112, USA; Utah Center for Nanomedicine, University of Utah, Salt Lake City, UT 84112, USA; Department of Pharmaceutics and Pharmaceutical Chemistry, University of Utah, Salt Lake City, UT 84112, USA.
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6
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Sukhina OM, Nemaltsova KV, Panov OV. LATE RADIATION TOXICITY AFTER RADICAL RADIOTHERAPY FOR GENITAL CANCER. PROBLEMY RADIATSIINOI MEDYTSYNY TA RADIOBIOLOHII 2020; 25:130-147. [PMID: 33361832 DOI: 10.33145/2304-8336-2020-25-130-147] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/07/2020] [Indexed: 06/12/2023]
Abstract
Radiation therapy for malignant tumors of the female genital area, even with the use of modern radiotherapy equipment and dosimetric planning, causes the development of local radiation changes. An approach involving methodsof general and local exposure is used in their treatment. One of the most promising directions is the creation of optimal combinations of medicines (in the form of ointments, gels, aerosols, suppositories, etc.), which have a therapeutic effect on the inflammatory process. The article reflects the clinical course and stage of occurrence of late radiation reactions of the skin, vaginal/cervix mucosa, bladder, and intestines, as well as the features of their treatment.Literary data and own practical experience in the treatment of radiation complications are presented. Whenreviewing the topic under study, it could be concluded that the leading cause of the development of local radiationdamage is the errors in the planning and implementation of radiation therapy, when high absorbed doses thatexceed the tolerance of healthy tissues are used. Another reason for this is the poor accounting for dose distribution of ionizing radiation in tissues, the presence of concomitant diseases in patients, and the underestimation ofthe long-term effects of radiation.
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Affiliation(s)
- O M Sukhina
- State Institution «Grigoriev Institute for Medical Radiology and Oncology NAMS of Ukraine», 82 Pushkinska St., Kharkiv, 61024, Ukraine
| | - K V Nemaltsova
- State Institution «Grigoriev Institute for Medical Radiology and Oncology NAMS of Ukraine», 82 Pushkinska St., Kharkiv, 61024, Ukraine
| | - O V Panov
- State Institution «Grigoriev Institute for Medical Radiology and Oncology NAMS of Ukraine», 82 Pushkinska St., Kharkiv, 61024, Ukraine
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7
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MiR-122-5p increases radiosensitivity and aggravates radiation-induced rectal injury through CCAR1. Toxicol Appl Pharmacol 2020; 399:115054. [DOI: 10.1016/j.taap.2020.115054] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2020] [Revised: 04/26/2020] [Accepted: 05/12/2020] [Indexed: 12/13/2022]
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8
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Rizza S, Mistrangelo M, Ribaldone DG, Morino M, Astegiano M, Saracco GM, Pellicano R. Proctitis: a glance beyond inflammatory bowel diseases. MINERVA GASTROENTERO 2020; 66:252-266. [PMID: 32218425 DOI: 10.23736/s1121-421x.20.02670-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Proctitis is an inflammation involving the anus and the distal part of the rectum, frequently diagnosed in the context of inflammatory bowel diseases (IBD). Nevertheless, when the standard therapy for IBD is ineffective, it becomes necessary for the clinician to review alternative etiologies, beginning from the broad chapter of infectious causes up to rare causes such as radiation, ischemia, diversion and traumatisms. While it is possible to find infectious proctitides caused by pathogens generally inducing extensive colitis, the growing incidence of both sexually transmitted infections and isolated proctitis reported in the recent years require a lot of attention. The risk appears to be higher in individuals participating in anal intercourse, especially men having sex with men (MSM) or subjects who use sex toys and participate to sex parties, dark rooms and so on. The commonest implicated pathogens are Neysseria gonorrhoeae, Chlamydia trachomatis, Herpes Simplex virus and Treponema pallidum. Herpes and Chlamydia infections mainly occur in HIV-positive MSM patients. Since symptoms and signs are common independently from etiology, performing a differential diagnosis based on clinical manifestations is complicated. Therefore, the diagnosis is supported by the combination of clinical history and physical examination and, secondly, by endoscopic, serologic and microbiologic findings. Particular emphasis should be given to simultaneous infections by multiple organisms. The involvement of experts in infectious diseases and in sexual health is crucial for the diagnostic and therapeutic management. The available therapies, empirically initiated or specific, in many cases are able to guarantee a good prognosis and to prevent relapses.
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Affiliation(s)
- Stefano Rizza
- Unit of Gastroenterology, Department of Medical Sciences, University of Turin, Turin, Italy
| | | | - Davide G Ribaldone
- Unit of Gastroenterology, Department of Medical Sciences, University of Turin, Turin, Italy
| | - Mario Morino
- Department of Surgical Sciences, University of Turin, Turin, Italy
| | - Marco Astegiano
- Unit of Gastroenterology, Molinette Hospital, Città della Salute e della Scienza, Turin, Italy
| | - Giorgio M Saracco
- Unit of Gastroenterology, Department of Medical Sciences, University of Turin, Turin, Italy.,Unit of Gastroenterology, Molinette Hospital, Città della Salute e della Scienza, Turin, Italy
| | - Rinaldo Pellicano
- Unit of Gastroenterology, Molinette Hospital, Città della Salute e della Scienza, Turin, Italy -
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9
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McCarty TR, Garg R, Rustagi T. Efficacy and safety of radiofrequency ablation for treatment of chronic radiation proctitis: A systematic review and meta-analysis. J Gastroenterol Hepatol 2019; 34:1479-1485. [PMID: 31111527 DOI: 10.1111/jgh.14729] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2018] [Revised: 04/22/2019] [Accepted: 05/11/2019] [Indexed: 12/16/2022]
Abstract
BACKGROUND AND AIM Although argon plasma coagulation is the current standard endoscopic treatment for chronic radiation proctitis (CRP), radiofrequency ablation (RFA) has emerged as an attractive alternative. The aim of this study is to evaluate the efficacy and safety of RFA for the treatment of CRP. METHODS Searches of PubMed, EMBASE, Web of Science, and Cochrane Library databases were performed from 2004 through March 2018. Review and data abstraction were performed independently by two authors. Measured outcomes included hemoglobin, transfusion dependence, number of treatment sessions, RFA settings, and serious adverse events. RESULTS Six studies (n = 71; mean age 73.41 ± 1.88 years; 90.14% male) were included. Thirty-eight percent of patients failed prior treatment with argon plasma coagulation. Patients underwent a mean of 1.71 ± 0.34 RFA sessions with 24.54 ± 16.47 RFA applications per session. Pooled clinical and endoscopic success of RFA was 99% (95% confidence interval [CI]: 90-100; P < 0.001) and 100% (95% CI: 94-100; P < 0.001), respectively. Serious adverse events were reported in one patient-pooled rate of 0% (95% CI: 0-3; P < 0.001). Mean pre-procedure hemoglobin was 10.38 ± 1.82 g/dL with significant improvement observed post-RFA [weighted mean difference 2.49 g/dL (95% CI: 2.16-2.82; P < 0.001)]. Among transfusion-dependent patients, 85% (95% CI: 68-97; P < 0.001) became transfusion-free post-RFA. Pooled mean follow-up was 19.73 ± 9.72 months. CONCLUSION Despite limited long-term data on RFA for CRP, available evidence suggests RFA is an effective and safe treatment.
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Affiliation(s)
- Thomas R McCarty
- Department of Gastroenterology, Hepatology, and Endoscopy, Brigham and Women's Hospital, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
| | - Rajat Garg
- Department of Internal Medicine, Saint John Hospital and Medical Center, Detroit, Michigan, USA
| | - Tarun Rustagi
- Division of Gastroenterology and Hepatology, University of New Mexico, Albuquerque, New Mexico, USA
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10
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Ferrero VT, Oset MM, Masferrer JP, Pardo EH, Sorolla EJ, Largo SC. Prevalence and characterization of breakthrough pain in cancer patients with proctalgia treated with 3D pelvic radiotherapy. Clin Transl Oncol 2019; 21:1707-1711. [PMID: 30949931 DOI: 10.1007/s12094-019-02102-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2019] [Accepted: 03/22/2019] [Indexed: 12/11/2022]
Abstract
PURPOSE Radiotherapy-induced dysfunction of the gastrointestinal tract is common in cancer patients and has a significant impact on their quality of life. In this study, we investigated the prevalence of breakthrough cancer pain (BTcP) in patients undergoing 3D pelvic radiotherapy and who had proctalgia. METHODS This observational, multicenter, cross-sectional epidemiological study was performed in 13 Spanish hospitals. Data were obtained on the presence and characteristics of BTcP, demographics, common comorbidities, and treatments prescribed to the patients. RESULTS The prevalence of BTcP in patients undergoing pelvic 3D external radiotherapy with proctalgia (N = 105) was 48.6% (95% CI 39.0-58.1%). BTcP was further characterized in 59 patients. The mean (± SD) intensity of the BTcP episodes was 7.45 ± 1.47 in a visual analog scale. We found several statistically significant associations between the descriptive variables of BTcP with demographic and clinical variables associated with the tumor or the patient, such as an increased number of BTcP episodes per day depending on the presence or absence of diabetes (p = 0.001, Chi-square) or time to the onset of pain relief depending on the location of the tumor (p = 0.019, Chi-square). Fentanyl was the drug of choice in BTcP episodes for 95% of the patients. CONCLUSIONS This study demonstrated a high prevalence of BTcP prevalence in cancer patients undergoing pelvic 3D radiotherapy and with proctalgia. Although the variables determining the onset of BTcP are still unclear, our results could help in the design of future clinical studies addressing the treatment of BTcP in these patients.
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Affiliation(s)
- V T Ferrero
- Department of Radiation Oncology, Hospital Universitary de Sant Joan D'Alacant, Carretera Nacional 332 Alicante-Valencia s/n, Sant Joan D'Alacant, 03550, Alicante, Spain.
| | - M M Oset
- Department of Radiation Oncology, Hospital Universitary de Sant Joan D'Alacant, Carretera Nacional 332 Alicante-Valencia s/n, Sant Joan D'Alacant, 03550, Alicante, Spain
| | - J P Masferrer
- Department of Radiation Oncology, Hospital Universitari Son Espases, Palma de Mallorca, Spain
| | - E H Pardo
- Department of Radiation Oncology, Hospital Universitario de Araba, Vitoria, Spain
| | - E J Sorolla
- Department of Radiotherapy, Hospital Clínico Universitario de Valencia, Valencia, Spain
| | - S C Largo
- Department of Radiation Oncology, Hospital Clínico San Carlos, Madrid, Spain
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11
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Li JJ, Tu WZ, Chen XM, Ying HY, Chen Y, Ge YL, Wang J, Xu Y, Chen TF, Zhang XW, Ye JJ, Liu Y. FAK alleviates radiation-induced rectal injury by decreasing apoptosis. Toxicol Appl Pharmacol 2018; 360:131-140. [PMID: 30292832 DOI: 10.1016/j.taap.2018.10.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2018] [Revised: 10/01/2018] [Accepted: 10/04/2018] [Indexed: 12/13/2022]
Abstract
Radiation-induced rectal injury is closely related with radiotherapy efficiency. Here, we investigated the effect of focal adhesion kinase (FAK) in radiation-induced rectal injury. Peripheral blood samples of patients with rectal cancer were collected prior to radiotherapy. Differentially expressed genes and copy number variations (CNVs) were analyzed by microarray analysis. The CTCAE v3.0 toxicity grades were used to assess acute rectal injury. The radiosensitivity of human intestinal epithelial crypt (HIEC) cells were assayed by colony formation, mitochondrial membrane potential, flow cytometry and western blotting. The rectums of C57BL/6 mice were X-irradiated locally with a single dose of 15 Gy. The effect of FAK on radiation-induced injury was investigated by hematoxylin-eosin (H&E) staining, terminal deoxynucleotidyl transferase-mediated dUTP nick end labeling (TUNEL), immunohistochemistry (IHC) and quantitative real-time PCR (qRT-PCR). FAK mRNA level was inversely correlated with rectal injury severity in patient samples. A CNV amplification located on chromosome 8 was closely related with FAK. Further functional assays revealed increased levels of γH2AX expression and apoptosis-related proteins in FAK-silenced HIEC cells. The ratio of TUNEL, cl-caspase-3, cyto-c and bax/bcl-2 expression in the rectum mucosa treated with a FAK inhibitor increased significantly. These results demonstrated that FAK reduced radiation-induced rectal injury by decreasing apoptosis.
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Affiliation(s)
- Jun-Jun Li
- Department of Radiation Oncology, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 201620, China
| | - Wen-Zhi Tu
- Department of Radiation Oncology, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 201620, China
| | - Xu-Ming Chen
- Department of Radiation Oncology, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 201620, China
| | - Hou-Yu Ying
- Department of Radiation Oncology, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 201620, China
| | - Ying Chen
- Department of Radiation Oncology, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 201620, China
| | - Yu-Long Ge
- Department of Radiation Oncology, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 201620, China
| | - Jing Wang
- Department of Pathology, Cancer Hospital of Handan, Handan 056001, China
| | - Yi Xu
- Department of Radiation Oncology, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 201620, China
| | - Ting-Feng Chen
- Department of Radiation Oncology, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 201620, China
| | - Xiao-Wei Zhang
- Department of Oncology, Fudan University Shanghai Cancer Center, Shanghai 200032, China
| | - Jin-Jun Ye
- Department of Radiation Oncology, Jiangsu Cancer Hospital, Nanjing Medical University, Nanjing 210009, China.
| | - Yong Liu
- Department of Radiation Oncology, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 201620, China.
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Abstract
Radiation proctitis is radiation-induced rectal mucositis, occurring as a result of radiation therapy for various pelvic malignancies. The management of radiation proctitis is challenging as guidelines are not currently available, and studies of the various treatment modalities are limited. There are various medical, endoscopic, and surgical measures for treating chronic radiation proctitis. Medical options such as anti-inflammatory agents, antioxidants, formalin application, and hyperbaric oxygen may improve bleeding related to chronic radiation proctitis. Endoscopic measures such as argon plasma coagulation are effective and safe. Surgery is considered for refractory or severe cases. A review and discussion of the different treatment modalities is presented.
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Affiliation(s)
- Lameese Tabaja
- Department of Colon and Rectal Surgery, Digestive Disease Institute, Cleveland Clinic Abu Dhabi, Abu Dhabi, United Arab Emirates. .,Lerner School of Medicine, Case Western Reserve University, Cleveland, OH, USA.
| | - Shafik M Sidani
- Department of Colon and Rectal Surgery, Digestive Disease Institute, Cleveland Clinic Abu Dhabi, Abu Dhabi, United Arab Emirates.,Lerner School of Medicine, Case Western Reserve University, Cleveland, OH, USA
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Safety and Indications of Laparoscopic Surgery for Postoperative Small-bowel Obstruction: A Single-center Study of 121 Patients. Surg Laparosc Endosc Percutan Tech 2018; 27:301-305. [PMID: 28614173 DOI: 10.1097/sle.0000000000000430] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND/AIMS The purpose of this study was to evaluate the safety and effectiveness of laparoscopic surgery for the treatment of small-bowel obstruction. MATERIALS AND METHODS The study group comprised 121 patients who underwent laparoscopic surgery for small-bowel obstruction. RESULTS Previous operations were open surgery in 107 patients and laparoscopic surgery in 14. On univariate analysis, 4 risk factors were related to conversion to open surgery: radiotherapy (P=0.0002), previous episode of intestinal obstruction (P=0.0064), bleeding volume of ≥50 mL (P=0.0059), and the presence or absence of previous bowel resection (P=0.0269). On multivariate analysis, only radiotherapy was an independent risk factor for conversion to open surgery (odds ratio, 5.5141; P=0.0091). CONCLUSIONS Laparoscopic surgery can be safely performed in patients with postoperative small-bowel obstruction and is considered an effective treatment with a low rate of recurrent bowel obstruction.
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Gandhi J, Seyam O, Smith NL, Joshi G, Vatsia S, Khan SA. Clinical utility of hyperbaric oxygen therapy in genitourinary medicine. Med Gas Res 2018; 8:29-33. [PMID: 29770194 PMCID: PMC5937301 DOI: 10.4103/2045-9912.229601] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
Hyperbaric oxygen therapy (HBOT) is a medical technique which delivers oxygen at ambient pressures to increase the amount of dissolved oxygen in the blood and oxygen distribution to tissues. There are several beneficial properties of HBOT concomitant with elevated oxygen distribution in tissue including anti-inflammation, angiogenesis through vascular endothelial growth factor proliferation, augmented fibroblast activity through fibroblast growth factor proliferation, tissue and wound repair, enhancement of lymphocyte and macrophage activity, increased male testosterone secretion, and bactericidal activity. Given its renown in treating conditions such as decompression sickness and carbon monoxide poisoning, HBOT is making gradual strides for use in genitourinary medicine due to its low risk and likeliness to achieve favorable results. Early success has been observed in the treatment of Fournier's gangrene, radiation cystitis, and interstitial cystitis via the elimination of clinical symptoms such as pain. Further indications that have exhibited positive outcomes despite HBOT's ambiguous mechanism of action include cyclophosphamide hemorrhagic cystitis, emphysematous cystitis, pelvic radiation disease, radiation-induced proctopathy, dystrophic calcification of the prostate, erectile dysfunction secondary to urethroplasty, priapism, abnormal renal morphology, blood testosterone, calcific uremic arteriolopathy, and hidradenitis suppurativa. For other indications, multicenter studies must be conducted to determine HBOT's true efficacy, mechanism of action, risks, and advantages over conventional treatments.
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Affiliation(s)
- Jason Gandhi
- Department of Physiology and Biophysics, Stony Brook University School of Medicine, Stony Brook, NY, USA.,Medical Student Research Institute, St. George's University School of Medicine, Grenada, West Indies
| | - Omar Seyam
- Department of Physiology and Biophysics, Stony Brook University School of Medicine, Stony Brook, NY, USA
| | | | - Gunjan Joshi
- Department of Internal Medicine, Stony Brook Southampton Hospital, Southampton, NY, USA
| | - Sohrab Vatsia
- Department of Cardiothoracic Surgery, Lenox Hill Hospital, New York, NY, USA
| | - Sardar Ali Khan
- Department of Physiology and Biophysics, Stony Brook University School of Medicine, Stony Brook, NY, USA.,Department of Urology, Stony Brook University School of Medicine, Stony Brook, NY, USA
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Gee C, Andreyev J, Muls A. Developing advanced clinical practice skills in gastrointestinal consequences of cancer treatment. BRITISH JOURNAL OF NURSING (MARK ALLEN PUBLISHING) 2018. [PMID: 29517330 DOI: 10.12968/bjon.2018.27.5.237] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
This article explores the transition from a clinical nurse specialist (CNS) towards developing advanced clinical practice skills within a gastrointestinal consequences of cancer clinic. It presents data on the first 50 patients assessed by the CNS from a prospective service evaluation, demonstrating how this informed the nurse's future learning. There is high demand for advanced clinical practice skills to address unmet health needs and improve the quality, efficiency, and sustainability of healthcare services. However, a literature review found no literature on developing advanced clinical practice skills in this setting. Emerging themes from the service evaluation focused on barriers and enablers, ongoing support, organisational commitment and working in a multidisciplinary team. Blended learning provided both structured and opportunistic learning, embedding both formal and tacit knowledge, as roles require increasing flexibility. Clinical supervision and reflective practice were key in maintaining professional and peer support.
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Affiliation(s)
- Caroline Gee
- Senior Clinical Nurse Specialist GI Consequences of Cancer Treatment, Royal Marsden Hospital, London
| | - Jervoise Andreyev
- Consultant Gastroenterologist, United Lincolnshire Hospitals NHS Trust, Lincoln
| | - Ann Muls
- Macmillan Nurse Consultant GI Consequences of Cancer Treatment, Royal Marsden Hospital, London
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Bansal N, Soni A, Kaur P, Chauhan AK, Kaushal V. Exploring the Management of Radiation Proctitis in Current Clinical Practice. J Clin Diagn Res 2016; 10:XE01-XE06. [PMID: 27504391 DOI: 10.7860/jcdr/2016/17524.7906] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2015] [Accepted: 02/24/2016] [Indexed: 02/07/2023]
Abstract
INTRODUCTION Radiation proctitis is radiation induced rectal mucositis, occurring as a consequence to radiation therapy of the pelvic organs for various pelvic region malignancies. The management of radiation proctitis is extremely challenging as no recommended guidelines are available and limited number of studies are there in the literature involving the various treatment options. AIM The aim of the study is the in-depth review of published literature to see the role of various treatment modalities in the management of radiation proctitis. MATERIALS AND METHODS An integrative review was undertaken within PubMed, MEDLINE, PMC, GOOGLE SEARCH databases and articles published upto February 2015 were reviewed and analysed. A total of 54 studies were included. RESULTS Literature suggests that non surgical therapies are the first line of treatment and surgery is reserved for advanced or refractory cases. Endoscopic therapies form the mainstay of treatment in managing the patients of radiation proctitis. Argon plasma coagulation and laser therapies are preferred. Radiofrequency ablation, cryoablation and mesenchymal stem cell therapy are the upcoming modalities. Medical therapy can be tried alone or in conjunction to endoscopic therapies. In the resistant or refractory cases, surgery can be looked for in the form of diversion or resection with or without anastamosis. CONCLUSION Though, a number of options are available, still a lot can be explored in this field to improve the morbidity in the patients and to confirm the superiority of one treatment over other.
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Affiliation(s)
- Nupur Bansal
- Senior Resident, Department of Radiotherapy, Pt. B.D. Sharma PGIMS , Rohtak, India
| | - Abhishek Soni
- Senior Resident, Department of Radiotherapy, Pt. B.D. Sharma PGIMS , Rohtak, India
| | - Paramjeet Kaur
- Associate Professor, Department of Radiotherapy, Pt. B.D. Sharma PGIMS , Rohtak, India
| | - Ashok Kumar Chauhan
- Senior Professor, Department of Radiotherapy, Pt. B.D. Sharma PGIMS , Rohtak, India
| | - Vivek Kaushal
- Senior Professor, Department of Radiotherapy, Pt. B.D. Sharma PGIMS , Rohtak, India
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Tang Y, Huang Y, Mo X, Yi G, Wen H, Guo Z, Feng K, Liu Y, Bu Q, JiAng W. Efficacy and safety of Yunxiangjing derived from Chinese herbal medicine administered as an enema in the management of acute radiation-induced proctitis in patients with pelvic malignancy. J TRADIT CHIN MED 2016; 36:45-50. [PMID: 26946618 DOI: 10.1016/s0254-6272(16)30007-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
OBJECTIVE To assess the efficacy and safety of Yunxiangjing (YXJ), derived from Chinese herbal medicine, in the management of acute radiation-induced proctitis (ARIP) in patients with pelvic malignancy. METHODS Forty-eight patients with grade 2 ARIP were administered YXJ as an enema (1 : 30 dilution) for 2 weeks and followed up for 2 years. All were assessed for response and ARIP grade. Quality of life (QOL) was assessed with the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire-Core 30. RESULTS Of the 48 patients, six (12.5%) achieved complete remission of ARIP and 28 (58.3%) showed a decrease from grade 2 to grade 1 ARIP. No patient experienced a grade ≥3 toxicity. At the end of radiotherapy, patients showed significant improvements in QOL (P < 0.05). Two years after treatment, 46 patients showed no late toxicity, with only two experiencing grade 1 late toxicity. CONCLUSION YXJ can be used as an enema to manage acute radiation-induced proctitis in cancer patients undergoing radiotherapy. These findings suggest that YXJ enema may be an alternative treatment of ARIP.
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18
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Lenz L, Rohr R, Nakao F, Libera E, Ferrari A. Chronic radiation proctopathy: A practical review of endoscopic treatment. World J Gastrointest Surg 2016; 8:151-60. [PMID: 26981189 PMCID: PMC4770169 DOI: 10.4240/wjgs.v8.i2.151] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2015] [Revised: 11/20/2015] [Accepted: 12/13/2015] [Indexed: 02/06/2023] Open
Abstract
Chronic radiation proctopathy (CRP) is a troublesome complication of pelvic radiotherapy. The most common presentation is rectal bleeding. CRP symptoms interfere with daily activities and decrease quality of life. Rectal bleeding management in patients with CRP represents a conundrum for practitioners. Medical therapy is ineffective in general and surgical approach has a high morbid-mortality. Endoscopy has a role in the diagnosis, staging and treatment of this disease. Currently available endoscopic modalities are formalin, potassium titanyl phosphate laser, neodymium:yttrium-aluminum-garnet laser, argon laser, bipolar electrocoagulation (BiCAP), heater probe, band ligation, cryotherapy, radiofrequency ablation and argon plasma coagulation (APC). Among these options, APC is the most promising.
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19
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Abstract
Radiation therapy is a widely utilized treatment modality for pelvic malignancies, including prostate cancer, rectal cancer, and cervical cancer. Given its fixed position in the pelvis, the rectum is at a high risk for injury secondary to ionizing radiation. Despite advances made in radiation science, up to 75% of the patients will suffer from acute radiation proctitis and up to 20% may experience chronic symptoms. Symptoms can be variable and include diarrhea, bleeding, incontinence, and fistulization. A multitude of treatment options exist. This article summarizes the latest knowledge relating to radiation proctopathy focusing on the vast array of treatment options.
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Affiliation(s)
- Marc B. Grodsky
- Section of Colon and Rectal Surgery, MedStar Washington Hospital Center, Washington, District of Columbia
| | - Shafik M. Sidani
- Department of Colorectal Surgery, Virginia Hospital Center Physician Group, Arlington, Virginia
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20
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Pathogenesis, diagnosis, and management of ulcerative proctitis, chronic radiation proctopathy, and diversion proctitis. Inflamm Bowel Dis 2015; 21:703-15. [PMID: 25687266 DOI: 10.1097/mib.0000000000000227] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Chronic proctitis refers to persistent or relapsing inflammation of the rectum, which results from a wide range of etiologies with various pathogenic mechanisms. The patients may share similar clinical presentations. Ulcerative proctitis, chronic radiation proctitis or proctopathy, and diversion proctitis are the 3 most common forms of chronic proctitis. Although the diagnosis of these disease entities may be straightforward in the most instances based on the clinical history, endoscopic, and histologic features, differential diagnosis may sometimes become problematic, especially when their etiologies and the disease processes overlap. The treatment for the 3 forms of chronic proctitis is different, which may shed some lights on their pathogenetic pathway. This article provides an overview of the latest data on the clinical features, etiologies, diagnosis, and management of ulcerative proctitis, chronic radiation proctopathy, and diversion proctitis.
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21
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Abstract
Radiation damage to the rectum following radiotherapy for pelvic malignancies can range from acute dose-limiting side effects to major morbidity affecting health-related quality of life. No standard guidelines exist for diagnosis and management of radiation proctitis. This article reviews the definitions, staging, and clinical features of radiation proctitis, and summarizes the modalities available for the treatment of acute and chronic radiation proctitis. Because of the paucity of well-controlled, blinded, randomized studies, it is not possible to fully assess the comparative efficacy of the different approaches to management. However, the evidence and rationale for use of the different strategies are presented.
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Affiliation(s)
- Ankit Sarin
- Division of Colon and Rectal Surgery, University of California-San Francisco, San Francisco, CA, USA
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22
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Hogan NM, Kerin MJ, Joyce MR. Gastrointestinal complications of pelvic radiotherapy: medical and surgical management strategies. Curr Probl Surg 2013; 50:395-407. [PMID: 23930906 DOI: 10.1067/j.cpsurg.2013.04.004] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Affiliation(s)
- Niamh M Hogan
- Department of Colorectal Surgery, University College Hospital Galway, Ireland
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23
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Chronic radiation-induced proctitis: the 4 % formalin application as non-surgical treatment. Int J Colorectal Dis 2013; 28:261-6. [PMID: 22932907 DOI: 10.1007/s00384-012-1571-y] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/14/2012] [Indexed: 02/06/2023]
Abstract
PURPOSE Radiation proctitis is a known complication following radiation therapy for pelvic malignancy. The majority of cases are treated nonsurgically. Rectal instillation of formalin solution has been described as a successful treatment for chronic radiation-induced hemorrhagic proctitis resistant to medical treatment. We present our results in patients undergoing treatment with application of 4 % formalin for radiation-induced injury to the rectum. METHODS All patients were treated under anesthesia by direct application of 4 % formalin solution to the affected rectal areas. Patient gender, initial malignancy, grade of proctitis, need for blood transfusion, previous therapy, number of applications and response to treatment with formalin, complications, and length of follow-up were reviewed. RESULTS A total of 15 patients with a mean age of 68.9 (range, 48-77) years were followed for 31.3 (range, 18-51) months. The mean interval from the conclusion of radiotherapy and the onset of symptoms was 6.9 months. The mean duration of hemorrhagic proctitis before formalin application was 7.9 months. Ten patients had only one formalin application and five patients required a second application because of the persistent bleeding. Thirteen patients (87 %) had complete cessation of bleeding. No complications related to the formalin treatment were observed. CONCLUSIONS According to a revision of the literature and our experience, despite the small number of patients in our trial, we can state that the application of 4 % formalin solution is an effective, safe, and well-tolerated treatment for chronic radiation-induced hemorrhagic proctitis with minimal discomfort and no severe complications.
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Beyazit Y, Kekilli M, Haznedaroglu IC, Kayacetin E, Basaranoglu M. Ankaferd hemostat in the management of gastrointestinal hemorrhages. World J Gastroenterol 2011; 17:3962-70. [PMID: 22046083 PMCID: PMC3199553 DOI: 10.3748/wjg.v17.i35.3962] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2011] [Revised: 03/01/2011] [Accepted: 03/08/2011] [Indexed: 02/06/2023] Open
Abstract
Gastrointestinal (GI) bleeding refers to any hemorrhage ascribed to the pathologies of the gastrointestinal tract, extending from the mouth to the anal canal. Despite the recent improvements in the endoscopic, hemostatic and adjuvant pharmacologic techniques, the reported mortality is still around 5%-10% for peptic ulcer bleeding and about 15%-20% for variceal hemorrhages. Although endoscopic management reduces the rates of re-bleeding, surgery, and mortality in active bleeding; early recurrence ratios still occur in around 20% of the cases even with effective initial hemostatic measures. In this quest for an alternative pro-hemostatic agent for the management of GI bleedings, Ankaferd blood stopper (ABS) offers a successful candidate, specifically for “difficult-to-manage” situations as evidenced by data presented in several studies. ABS is a standardized mixture of the plants Thymus vulgaris, Glycyrrhiza glabra, Vitis vinifera, Alpinia officinarum, and Urtica dioica. It is effective in both bleeding individuals with normal hemostatic parameters and in patients with deficient primary and/or secondary hemostasis. ABS also modulates the cellular apoptotic responses to hemorrhagic stress, as well as hemostatic hemodynamic activity. Through its effects on the endothelium, blood cells, angiogenesis, cellular proliferation, vascular dynamics, and wound healing, ABS is now becoming an effective alternative hemostatic medicine for gastrointestinal bleedings that are resistant to conventional anti-hemorrhagic measurements. The aim of this review is to outline current literature experience suggesting the place of ABS in the management of GI bleeding, and potential future controlled trials in this complicated field.
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Al-Amin A, Cowley R, Scott N. Formalin dab for treatment of haemorrhagic radiation proctitis. BMJ Case Rep 2011; 2011:bcr.05.2011.4255. [PMID: 22689607 DOI: 10.1136/bcr.05.2011.4255] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
The authors present a case of a 75-year-old man who underwent 2 months of radiotherapy for prostate cancer. He developed rectal bleeding 6 months later. A colonoscopy showed radiation proctitis with no other abnormalities up to the caecum. He was treated with a variety of medical therapies and argon beam laser with minimal effect. He was treated with epinephrine injection after a subsequent flexible sigmoidoscopy. He required multiple blood transfusions because of the resulting anaemia. He was finally treated with topical formalin dab therapy over three sessions, after which his rectal bleeding subsided and haemoglobin levels eventually reached normal levels.
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Affiliation(s)
- Azzam Al-Amin
- Department of Vascular Surgery, Royal Blackburn Hospital, Blackburn, UK.
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Bazan JG, Hara W, Hsu A, Kunz PA, Ford J, Fisher GA, Welton ML, Shelton A, Kapp DS, Koong AC, Goodman KA, Chang DT. Intensity-modulated radiation therapy versus conventional radiation therapy for squamous cell carcinoma of the anal canal. Cancer 2011; 117:3342-51. [PMID: 21287530 DOI: 10.1002/cncr.25901] [Citation(s) in RCA: 119] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2010] [Revised: 10/15/2010] [Accepted: 11/12/2010] [Indexed: 12/13/2022]
Abstract
BACKGROUND The purpose of this study was to compare outcomes in patients with anal canal squamous cell carcinoma (SCCA) who were treated with definitive chemoradiotherapy by either intensity-modulated radiation therapy (IMRT) or conventional radiotherapy (CRT). METHODS Forty-six patients who received definitive chemoradiotherapy from January 1993 to August 2009 were included. Forty-five patients received 5-fluorouracil with mitomycin C (n = 39) or cisplatin (n = 6). Seventeen (37%) were treated with CRT and 29 (63%) with IMRT. The median dose was 54 Gy in both groups. Median follow-up was 26 months (CRT) and 32 months (IMRT). T3-T4 stage (P = .18) and lymph node-positive disease (P = .6) were similar between groups. RESULTS The CRT group required longer treatment duration (57 days vs 40 days, P < .0001), more treatment breaks (88% vs 34.5%, P = .001), and longer breaks (12 days vs 1.5 days, P < .0001) than patients treated with IMRT. Eleven (65%) patients in the CRT group experienced grade >2 nonhematologic toxicity compared with 6 (21%) patients in the IMRT group (P = .003). The 3-year overall survival (OS), locoregional control (LRC), and progression-free survival were 87.8%, 91.9%, and 84.2%, respectively, for the IMRT groups and 51.8%, 56.7%, and 56.7%, respectively, for the CRT group (all P < .01). On multivariate analysis, T stage, use of IMRT, and treatment duration were associated with OS, and T stage and use of IMRT were associated with LRC. CONCLUSIONS The use of IMRT was associated with less toxicity, reduced need for treatment breaks, and excellent LRC and OS compared with CRT in patients with SCCA of the anal canal.
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Affiliation(s)
- Jose G Bazan
- Department of Radiation Oncology, Stanford University, Stanford, CA, USA
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Shorbagi A, Sivri B. Successful management of a difficult case of radiation proctopathy with Ankaferd BloodStopper: a novel indication (with video). Gastrointest Endosc 2010; 72:666-7. [PMID: 20417509 DOI: 10.1016/j.gie.2009.12.018] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2009] [Accepted: 12/07/2009] [Indexed: 12/10/2022]
Affiliation(s)
- Ali Shorbagi
- Faculty of Medicine, Department of Gastroenterology, Hacettepe University, Ankara, Turkey
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Phan J, Swanson DA, Levy LB, Kudchadker RJ, Bruno TL, Frank SJ. Late rectal complications after prostate brachytherapy for localized prostate cancer: incidence and management. Cancer 2009; 115:1827-39. [PMID: 19248043 DOI: 10.1002/cncr.24223] [Citation(s) in RCA: 71] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
This review of the literature on late rectal complications after prostate brachytherapy indicated that it is a highly effective treatment modality for patients with clinically localized prostate cancer but can cause chronic radiation proctitis. The most common manifestation of chronic radiation proctitis was anterior rectal wall bleeding, which often occurred within the first 2 years after brachytherapy. It is interesting to note that the rates of late rectal morbidity appear to have declined over time, which may reflect improvements in implantation techniques and imaging. Rectal biopsy as part of the workup to evaluate rectal bleeding can lead to rectal fistula and the need for colostomy, a rare but major complication. The authors recommend 1) screening colonoscopy before brachytherapy for patients who have not had a screening colonoscopy within the preceding 3 years to rule out colorectal malignancies and, thus, facilitate conservative management should rectal bleeding occur; 2) lifestyle modifications during treatment to limit exposure of the rectum to radiation; and 3) conservative management for rectal bleeding that occurs within 2 years after brachytherapy. Cancer 2009. (c) 2009 American Cancer Society.
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Affiliation(s)
- Jack Phan
- Department of Radiation Oncology, The University of Texas M. D. Anderson Cancer Center, Houston, Texas, USA
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Clarke RE, Tenorio LMC, Hussey JR, Toklu AS, Cone DL, Hinojosa JG, Desai SP, Dominguez Parra L, Rodrigues SD, Long RJ, Walker MB. Hyperbaric Oxygen Treatment of Chronic Refractory Radiation Proctitis: A Randomized and Controlled Double-Blind Crossover Trial With Long-Term Follow-Up. Int J Radiat Oncol Biol Phys 2008; 72:134-143. [PMID: 18342453 DOI: 10.1016/j.ijrobp.2007.12.048] [Citation(s) in RCA: 142] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2007] [Revised: 12/07/2007] [Accepted: 12/12/2007] [Indexed: 12/13/2022]
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Ng SSM, Ng NC, Lee JFY, Yiu RYC, Li JCM, Leung KL. Formalin dab for refractory radiation proctitis: Preliminary Hong Kong experience. SURGICAL PRACTICE 2006. [DOI: 10.1111/j.1744-1633.2006.00316.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Korkut C, Asoglu O, Aksoy M, Kapran Y, Bilge H, Kiremit-Korkut N, Parlak M. Histopathological comparison of topical therapy modalities for acute radiation proctitis in an experimental rat model. World J Gastroenterol 2006; 12:4879-83. [PMID: 16937473 PMCID: PMC4087625 DOI: 10.3748/wjg.v12.i30.4879] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
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 15th 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.
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Dall'Era MA, Hampson NB, Hsi RA, Madsen B, Corman JM. Hyperbaric oxygen therapy for radiation induced proctopathy in men treated for prostate cancer. J Urol 2006; 176:87-90. [PMID: 16753375 DOI: 10.1016/s0022-5347(06)00491-5] [Citation(s) in RCA: 59] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2005] [Indexed: 02/06/2023]
Abstract
PURPOSE Radiation proctitis is a common complication following external beam radiation therapy and brachytherapy for prostate cancer. While 95% percent of radiation induced proctitis is temporary and self-limiting, up to 5% of patients experience toxicities that are refractory to conservative management. Hyperbaric oxygen has a well-defined role in treating chronic wounds, osteomyelitis, hemorrhagic cystitis and necrotizing fasciitis. We reviewed our experience with hyperbaric oxygen therapy for radiation induced proctitis in patients undergoing radiation treatment for prostate cancer. MATERIALS AND METHODS From October 1998 to December 2003, 27 patients with radiation induced proctitis secondary to brachytherapy (4), external beam radiation therapy (16) or combined modality (7) for prostate cancer were treated with hyperbaric oxygen therapy at Virginia Mason Medical Center in Seattle, Washington. In all patients primary medical or endoscopic management had failed. Patients received 100% oxygen in a multiplace hyperbaric chamber at a pressure of 2.4 atmospheres absolute for 90 minutes 5 to 7 days weekly for an average of 36 sessions (range 29 to 60). Data were collected from a retrospective review of medical records following approval by the Institutional Review Board at Virginia Mason Medical Center. RESULTS All 27 men completed the planned course of therapy. Of patients with bleeding 48% showed complete resolution after therapy, while 28% reported significantly fewer bleeding episodes. Of patients 50% noted complete resolution of fecal urgency. Six of the 8 patients (75%) with pain noticed some improvement after therapy, although no patients reported complete resolution of rectal pain. Of patients with rectal ulceration 21% showed complete resolution of the ulcer on posttreatment endoscopy, while 29% showed evidence of improvement. Six patients (43%) had no change or worsening of rectal ulcers. Overall 67% of patients had a partial to good response, while 33% showed no response or disease progression. CONCLUSIONS This series of patients showed a good overall response rate to hyperbaric oxygen for radiation induced proctopathy after other attempts at management had failed. Hyperbaric oxygen is generally well tolerated and it remains an important treatment option for managing this common and difficult disease.
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Affiliation(s)
- Marc A Dall'Era
- Section of Urology and Renal Transplantation, Virginia Mason Medical Center and Department of Urology, University of Washington, 1100 Ninth Avenue, Seattle, WA 98111, USA
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Matsuu-Matsuyama M, Shichijo K, Okaichi K, Ishii K, Wen CY, Fukuda E, Nakayama T, Nakashima M, Okumura Y, Sekine I. Sucralfate protects intestinal epithelial cells from radiation-induced apoptosis in rats. JOURNAL OF RADIATION RESEARCH 2006; 47:1-8. [PMID: 16571913 DOI: 10.1269/jrr.47.1] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/08/2023]
Abstract
Radiotherapy for malignant pelvic disease is often followed by acute radiation colitis (ARC). It has been reported that sucralfate treatment has a protective effect against ARC, though the mechanisms of action are unknown. The effects of sucralfate on X-ray radiation-induced apoptosis was studied at 4 Gy in the colonic crypt cells of rats. Sucralfate enemas given prior to radiation resulted in the following: (1) reduction in number of apoptotic colonic crypt cells; (2) reduction in number of caspase-3 positive cells; (3) decreases in p53 accumulation and p21 expression; (4) decreases of Bax/Bcl-2 ratio. The protective effects of sucralfate against ARC may be partially due to the suppression of radiation-induced apoptosis by way of p53 in the colon and the protection of the colonic epithelial stem cell region.
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Affiliation(s)
- Mutsumi Matsuu-Matsuyama
- Department of Molecular Pathology, Nagasaki University Graduate School of Biomedical Sciences, Japan.
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de Parades V, Etienney I, Bauer P, Bourguignon J, Meary N, Mory B, Sultan S, Taouk M, Thomas C, Atienza P. Formalin application in the treatment of chronic radiation-induced hemorrhagic proctitis--an effective but not risk-free procedure: a prospective study of 33 patients. Dis Colon Rectum 2005; 48:1535-41. [PMID: 15933799 DOI: 10.1007/s10350-005-0030-z] [Citation(s) in RCA: 64] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
PURPOSE This prospective study evaluated the efficacy and safety of local formalin application in chronic refractory radiation-induced hemorrhagic proctitis. METHODS All patients were treated under anesthesia by direct application of 4 percent formalin to the affected rectal areas. RESULTS The study included 33 patients (17 women) and was conducted between January 1994 and December 2001. There were 11 anal cancers (33 percent), 11 prostate cancers, 9 cervical or endometrial cancers, 1 bladder cancer, and 1 rectal cancer. The mean number of daily rectal bleeds was 2.7 (range, 0.5-15). Nineteen patients (58 percent) were blood transfusion dependent. Twenty-three patients had only one formalin application and 10 patients required a second application because of the persistent bleeding. The treatment was effective in 23 cases (70 percent): 13 patients had complete cessation of bleeding and 10 patients had only minor bleeding. Six anal or rectal strictures occurred: 4 patients had been treated for anal cancer (36 percent) and 2 patients had been treated for other cancers (9 percent). None of the strictures was malignant. Anal incontinence worsened in 5 patients of the 11 who had been treated for anal cancer (45 percent) and occurred in 4 of the 22 other patients (18 percent). CONCLUSION Formalin application is an effective treatment for chronic radiation-induced hemorrhagic proctitis. However, local morbidity is not negligible. This result may be related to the high proportion of anal cancers in the series. In our opinion, therefore, formalin application should be reserved for severe hemorrhagic proctitis refractory to medical treatment and should be thoroughly discussed in cases of anorectal radiation-induced stricture, prior anal incontinence, or treated anal cancer.
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Affiliation(s)
- Vincent de Parades
- Proctologie Médico-Interventionnelle, Groupe Hospitalier Diaconesses-Croix Saint Simon, Paris, France
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Konishi T, Watanabe T, Kitayama J, Shibahara J, Nagawa H. Endoscopic and histopathologic findings after formalin application for hemorrhage caused by chronic radiation-induced proctitis. Gastrointest Endosc 2005; 61:161-4. [PMID: 15672081 DOI: 10.1016/s0016-5107(04)02458-7] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Affiliation(s)
- Tsuyoshi Konishi
- Department of Surgical Oncology, Graduate School of Medicine, the University of Tokyo, Japan
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Ehrenpreis ED, Jani A, Levitsky J, Ahn J, Hong J. A prospective, randomized, double-blind, placebo-controlled trial of retinol palmitate (vitamin A) for symptomatic chronic radiation proctopathy. Dis Colon Rectum 2005; 48:1-8. [PMID: 15690650 DOI: 10.1007/s10350-004-0821-7] [Citation(s) in RCA: 63] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
PURPOSE This study was designed to determine whether oral retinol palmitate (vitamin A) can reduce the symptoms of radiation proctopathy. METHODS A randomized, double-blind trial comparing retinol palmitate (10,000 IU by mouth for 90 days) to placebo was conducted. Eligible patients were more than six months postpelvic radiotherapy and had significant symptoms as measured with the Radiation Proctopathy System Assessments Scale. Nineteen patients were randomized in total: ten to retinol palmitate and nine to placebo. The Radiation Proctopathy System Assessments Scale scores before and every 30 days for 90 days were measured. Five placebo nonresponders were crossed over to the retinol palmitate for another 90 days. Response was defined as a reduction in two or more symptoms by at least two Radiation Proctopathy System Assessments Scale points. RESULTS Seven of ten retinol palmitate patients responded, whereas two of nine responded to placebo (P = 0.057). Mean pre-post-treatment change in Radiation Proctopathy System Assessments Scale (delta Radiation Proctopathy System Assessments Scale) in the retinol palmitate group was 11 +/- 5, whereas delta Radiation Proctopathy System Assessments Scale in the placebo group was 2.5 +/- 3.6 (P = 0.013, Mann-Whitney U test). Additionally, all five placebo nonresponders who were crossed over to treatment with retinal palmitate responded to treatment. CONCLUSIONS In our trial, retinol palmitate significantly reduced rectal symptoms of radiation proctopathy, perhaps because of wound-healing effects. The current results can serve as the foundation for future trials examining retinol palmitate in the multi-institutional setting.
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Affiliation(s)
- Eli D Ehrenpreis
- Gastroenterology and Radiation Oncology Divisions, University of Chicago Medical Center, Chicago, Illinois, USA.
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Abstract
Prostate cancer is one of the most common malignant diseases for which health-care intervention is sought worldwide, and in many developed countries it is the most common. Some patients with early-stage prostate cancer, especially those who are elderly and have comorbidities, can be observed without treatment. Surgery (radical prostatectomy) and radiotherapy (external-beam radiotherapy, brachytherapy, or both) are the most widely accepted curative options for patients with early-stage disease who need intervention. All these local treatments have been refined, resulting in comparable cure rates; however, they all have different side-effect profiles. Adjuvant systemic treatments (hormones or chemotherapy), which are effective for advanced-stage disease, might have a greater role in early-stage disease. Selecting the best option for individuals from the available options is challenging--the decision on whether and how to treat is based on many disease and patient factors. Here, we review the major treatment options, discuss their relative advantages and disadvantages, and provide a general approach to management of patients with early-stage prostate cancer.
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Affiliation(s)
- Ashesh B Jani
- Department of Radiation and Cellular Oncology, University of Chicago, Chicago, IL 60637, USA
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