Uterine transposition in a patient with vulvar cancer

Objective

To report the first uterine transposition for fertility preservation in a patient with vulvar cancer.Case: A 26-year-old nulliparous patient with stage IIIB vulvar cancer, which was resected with adequate margins and bilateral inguinofemoral lymphadenectomy.Laparoscopic transposition of the uterus to the upper abdomen, outside of the scope of radiation was performed to preserve fertility and ovarian function. After the end of radiotherapy, the uterus was repositioned into the pelvis.Main Outcome Measure: Uterine and ovarian function preservation.

Result

The patient recovered her menstrual cycles spontaneously 1 month after the reimplantation and exhibited normal variation in ovarian hormones.Twelve months after the surgery, the uterus was normal and there was no sign of recurrent disease.

Conclusion

Uterine transposition might represent a valid option for fertility preservation in women who require pelvic radiotherapy. However, studies that assess its viability, effectiveness, and safety are required.

From pelvic radiation to social isolation: a qualitative study of survivors' experiences of chronic bowel symptoms after pelvic radiotherapy

PURPOSE

We explored survivors' experiences of chronic bowel symptoms following pelvic radiotherapy, strategies employed in living with these symptoms, effects on daily activities, and roles at home and in the workplace.

METHODS

Semi-structured interviews were conducted with 28 individuals (10 gynaecological, 14 prostate, four anal/rectal cancer survivors) who had completed pelvic radiotherapy at least six months prior to data collection and who had experience of bowel symptoms during this post-treatment period. Reflexive thematic analysis was undertaken.

RESULTS

We propose four themes describing a process leading from experience of symptoms to withdrawal from activities and roles. These are (1) losing control (the experience of unintended anal leakage or discharge); (2) experiencing embarrassment and fear (the experience of embarrassment or fear of embarrassment as a result of discharge becoming public); (3) managing and reacting (acting to reduce the likelihood of discharge or to prevent this becoming public); and (4) restriction and withdrawal (avoiding specific activities or situations so as to reduce or remove the risk of embarrassment). Returning to the workplace presented additional challenges across these themes.

CONCLUSIONS

Impacts of chronic bowel symptoms can be severe. Survivors employ a variety of methods and strategies in living with their symptoms. Some of these support continued role fulfilment but some constitute a withdrawal from pre-treatment roles. Current healthcare provision and statutory protections fail to fully meet needs following pelvic radiotherapy.

IMPLICATIONS FOR CANCER SURVIVORS

There is a need to develop and implement evidence-based services and supported self-management programmes for survivors experiencing chronic bowel problems post-radiotherapy.

Pelvic irradiation induces behavioural and neuronal damage through gut dysbiosis in a rat model

Radiation exposure can cause gut dysbiosis and there is a positive correlation between gut microbial imbalance and radiation-induced side effects in cancer patients. However, the influence of radiation on the gut-brain axis (GBA) and its neurological consequences are not well understood. Therefore, this study aimed to investigate the impact of pelvic irradiation on gut microbiota and the brain. Sprague Dawley rats were irradiated with a single dose of 6 Gy, and faecal samples were collected at different time points (7 and 12-days post-irradiation) for microbial analysis. Behavioural, histological, and gene expression analysis were performed to assess the effect of microbial dysbiosis on the brain. The findings indicated alterations in microbial diversity, disrupted intestinal morphology and integrity, neuronal death-related brain changes, neuroinflammation and reduced locomotor activity. Hippocampal gene expression analysis also showed a reduced expression of neural plasticity-related genes. Overall, this study demonstrated that pelvic irradiation affects gut microbiota, intestinal morphology, integrity, brain neuronal maturation, neural plasticity gene expression, and behaviour.

Impact of reduced margin pelvic radiotherapy on gastrointestinal toxicity and outcome in gynecological cancer

Purpose

To investigate the effect of reduced margin pelvic radiotherapy on gastrointestinal toxicity and outcomes in gynecological cancer.

Materials and methods

This retrospective study analyzed data of 590 patients who underwent hysterectomy and adjuvant pelvic radiotherapy between 2010 and 2020 at two tertiary centers. The pelvic nodal region was delineated based on a reduced margin definition or the Radiation Therapy Oncology Group (RTOG) guidelines. All patients were treated with intensity-modulated radiotherapy with imaging guidance. Gastrointestinal toxicity was assessed using the Common Terminology Criteria for Adverse Events (CTCAE) and the Patient-Reported Outcome version (PRO-CTCAE).

Results

Overall, 352 (59.7%) and 238 (40.3%) patients underwent RTOG and reduced margin pelvic radiotherapy, respectively. Median follow-up was 6.4 years (IQR: 3.7-9.6). Reduced margin pelvic radiotherapy significantly lowered the radiation dose to the small bowel. For CTCAE grade ≥ 2 or 3, acute gastrointestinal toxicity was lower in the reduced margin group than in the RTOG group (16.4% vs. 33.5%, p < 0.001; 2.9% vs. 8.5%, p < 0.001). The reduced margin group reported less severe acute gastrointestinal toxicity (PRO-CTCAE score ≥ 3) than the RTOG group (12.5% vs. 28.7%, p < 0.001). Late grade 3 gastrointestinal toxicity was lower in the reduced margin group than in the RTOG group (0.8% vs. 4.8%, p = 0.006). The 5-year pelvic recurrence-free survival and disease-free survival in the RTOG and reduced margin pelvic radiotherapy groups were 97.4% and 97.9% (p = 0.55) and 80.7% and 83.5% (p = 0.18), respectively.

Conclusion

Reduced margin pelvic radiotherapy decreased acute and late gastrointestinal toxicity and achieved favorable outcomes.

Low-grade intestinal inflammation two decades after pelvic radiotherapy

BACKGROUND

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

METHODS

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

FINDINGS

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

INTERPRETATION

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

FUNDING

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

Barriers to and strategies for dealing with vaginal dilator therapy - Female pelvic cancer survivors' experiences: A qualitative study

PURPOSE

Vaginal changes, a frequently reported late effect among women treated with pelvic radiotherapy, can result in sexual dysfunction and distress. Women are recommended vaginal dilator therapy after completed radiotherapy; however, low adoption has been recognized. This study aims to provide insight into women's difficulties with carrying out vaginal dilator therapy and their experiences of information.

METHODS

Face-to-face, semi-structured interviews were undertaken with 12 pelvic cancer survivors in a selected sample of women with difficulties adopting the therapy. Interviews were audio-recorded, transcribed and analyzed using qualitative content analysis.

RESULTS

One overarching theme, Being unprepared, emerged from three identified categories relating to Experience of received information, Experience of performing the therapy, and Motivation to perform the therapy. The women experienced the information as unrealistic and insufficient, and requested clearer and earlier information. Bleeding, pain, fear of cancer recurrence, and recalling memories from treatments were experienced. Women described intestinal symptoms, fatigue, and feeling that the therapy was self-harm as barriers to performing the therapy. They described creating routines, breathing exercises, relaxation, pre-warming the dilator and performing therapy together with their partner as helpful strategies.

CONCLUSIONS

Careful discussion, early and clear communication, psychoeducation and supportive follow-up of vaginal changes should be integrated into cancer treatment and follow up. Healthcare professionals should be aware of potential difficulties with vaginal dilator therapy and identify women in need of extended support. Research is required to investigate interventions that suit the needs of female pelvic cancer survivors.

Can pelvic radiotherapy induce a leiomyosarcoma of the prostate? (A case report)

Leiomyosarcoma of the prostate is an extremely rare neoplasm. It represents less than 0.1% of all prostate malignancies. It is considered to have a poor prognosis, an aggressive nature, and high metastatic potential. Additionally, the relationship between radiation exposure for the treatment of primary prostatic cancer and the occurrence of leiomyosarcoma as second cancer at the irradiated site is rare, with unknown etiology. We reported a 72-year-old male known case of prostate adenocarcinoma with radio-hormonotherapy for six years who presented with acute urinary retention. Magnetic resonance imaging revealed a large malignant obstructive prostate with direct invasion of surrounding organs and multiple metastases. Trans-urethral resection of the prostate was performed, and the histopathology result showed high-grade leiomyosarcoma. The patient passed away after four months due to multiorgan failure. In conclusion, there may be a causal relationship between radiation therapy to the prostate and the development of prostate leiomyosarcoma.

Symptom burden and health-related quality of life six months after hyperbaric oxygen therapy in cancer survivors with pelvic radiation injuries

PURPOSE

Late radiation tissue injuries (LRTIs) after treatment for pelvic cancer may impair health related quality of life (HRQoL). Hyperbaric oxygen therapy is an adjuvant therapy for LRTIs, but limited studied. The aim of this study was to explore the development and association between symptoms of LRTI and HRQoL following hyperbaric oxygen treatment.

METHODS

A pretest-posttest design was used to evaluate the changes in pelvic LRTIs and HRQoL from baseline (T1), immediately after treatment (T2) and at six-month follow-up (T3). EPIC and EORTC-QLQ-C30 were used to assess LRTIs and HRQoL. Changes were analysed with t-tests, and associations with Pearson's correlation and multiple regression analyses.

RESULTS

Ninety-five participants (mean age 65 years, 52.6% men) were included. Scores for urinary and bowel symptoms, overall HRQoL, all function scales and the symptoms scales sleep, diarrhoea, pain and fatigue were significantly improved six months after treatment (P-range = 0.00-0.04). Changes were present already at T2 and maintained or further improved to T3. Only a weak significant correlation between changes in symptoms and overall HRQoL was found (Pearson r-range 0.20-0.27).

CONCLUSION

The results indicate improvement of pelvic LRTIs and HRQoL following hyperbaric oxygen therapy, corresponding to minimal or moderate important changes. Cancer survivors with pelvic LRTIs and impaired HRQoL may benefit from undergoing hyperbaric oxygen therapy. Especially the reduced symptom-severity and improved social- and role function can influence daily living positively.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT03570229. Released 2. May 2018.

Prostate radiotherapy and the risk of secondary rectal cancer-a meta-analysis

PURPOSE

Radiotherapy is being used increasingly in the treatment of prostate cancer. However, ionising radiation may confer a small risk of a radiation-induced secondary malignancy. We aim to assess the risk of rectal cancer following pelvic radiotherapy for prostate cancer.

METHODS

A search was conducted of the PubMed/MEDLINE, EMBASE and Web of Science databases identifying studies reporting on the risk of rectal cancer following prostatic radiotherapy. Studies must have included an appropriate control group of non-irradiated prostate cancer patients. A meta-analysis was performed to assess the risk of prostatic radiotherapy on subsequent rectal cancer diagnosis.

RESULTS

In total, 4757 articles were screened with eight studies meeting the predetermined criteria. A total of 796,386 patients were included in this meta-analysis which showed an increased odds ratio (OR) for subsequent rectal cancer in prostate cancer patients treated with radiotherapy compared to those treated by non-radiotherapy means (OR 1.45, 1.07-1.97, p = 0.02).

CONCLUSION

These findings confirm that prostate radiotherapy significantly increases the risk of subsequent rectal cancer. This risk has implications for treatment selection, surveillance and patient counselling. However, it is crucial that this information is presented in a rational and comprehensible manner that does not disproportionately frighten or deter patients from what might be their most suitable treatment modality.

Symptom burden, psychological distress, and health-related quality of life in cancer survivors with pelvic late radiation tissue injuries

Purpose

Curative radiotherapy for cancer may lead to severe late radiation tissue injuries (LRTIs). However, limited knowledge exists about pelvic cancer survivors’ LRTI symptoms, distress, and health-related quality of life (HRQOL). We sought to assess the symptom burden, distress, and HRQOL in survivors with established pelvic LRTIs compared to norm populations and to investigate the relation between these factors.

Methods

Cancer survivors referred for treatment of established pelvic LRTIs were recruited nationwide. LTRIs were assessed with the Expanded Prostate Cancer Index Composite (EPIC), psychological distress was assessed with the General Health Questionnaire (GHQ-12), and HRQOL was assessed with the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire (EORCT-QLQ-C30).

Results

A total of 107 participants (mean age 64, 53% men) were included. Compared to norms, participants reported more urinary (mean 68.7 vs. 89.5; p = 0.00; d = 1.4) and bowel symptoms (mean 62.5 vs. 92.4; p = 0.00; d = 2.7), increased psychological distress (mean 13.4 vs. 10.3; p = 0.00; d = 0.6), and overall poorer HRQOL (mean 54.9 vs. 71.2; p = 0.00; d = 0.7). Higher symptom burden and higher levels of psychological distress were associated with lower HRQOL (r² = 46%), but psychological distress did not moderate the influence of symptoms on HRQOL.

Conclusion

Cancer survivors with established pelvic LRTIs are highly burdened compared to norms. The association of the LRTI-related symptom burden with HRQOL is independent of the level of psychological distress. Both coping and treatment interventions are crucial to promoting long-term health and HRQOL.

Trial registration

NCT03570229.

Living in limbo: Meanings of living with fecal incontinence as narrated by women after treatment for pelvic cancer

PURPOSE

After pelvic radiotherapy, individuals suffer from loose stools and defecation urgency, often resulting in fecal incontinence (FI). Women who have been treated for pelvic cancer report FI as one of the most troubling symptoms, yet they avoid seeking healthcare due to shame and stigmatization. There is a lack of knowledge concerning women's lived experiences of FI in daily life after pelvic radiotherapy. The objective was to illuminate meanings of living with FI among women previously treated with radiotherapy for gynecological or rectal cancer.

METHOD

Interviews were performed with ten women, treated with pelvic radiotherapy. Data were analyzed with phenomenological-hermeneutic method.

RESULTS

Living with FI, was illuminated by one overarching main theme: Living in Limbo, consisting of two themes (including three sub-themes each): Living in uncertainty and Wanting to take part in life.

CONCLUSION

Living with FI means that life is no longer the same as before the disease and treatment. The new life is lived in limbo, which means a daily struggle with insecurity because of the lack of control over one's body. It is also a struggle to take part in life, keep one's human dignity intact, experience meaning in life and can be and do what one wants.

OLIGOPELVIS GETUG P07, a Multicenter Phase II Trial of Combined High-dose Salvage Radiotherapy and Hormone Therapy in Oligorecurrent Pelvic Node Relapses in Prostate Cancer

BACKGROUND

Oligorecurrent pelvic nodal relapse in prostatic cancer is a challenge for regional salvage treatments. Androgen depriving therapies (ADTs) are a mainstay in metastatic prostate cancer, and salvage pelvic radiotherapy may offer long ADT-free intervals for patients harboring regional nodal relapses.

OBJECTIVE

To assess the efficacy of the combination of ADT and salvage radiotherapy in men with oligorecurrent pelvic node relapses of prostate cancer.

DESIGN, SETTING, AND PARTICIPANTS

We performed an open-label, phase II trial of combined high-dose intensity-modulated radiotherapy and ADT (6 mo) in oligorecurrent (five or fewer) pelvic node relapses in prostate cancer, detected by fluorocholine positron-emission tomography computed tomography imaging.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

The primary endpoint was 2-yr progression-free survival defined as two consecutive prostate-specific antigen levels above the level at inclusion and/or clinical evidence of progression as per RECIST 1.1 and/or death from any cause.

RESULTS AND LIMITATIONS

Between August 2014 and July 2016, 67 patients were recruited in 15 centers. Half of the patients had received prior prostatic irradiation. The median age was 67.7 yr. After a median follow-up of 49.4 mo, 2- and 3-yr progression-free survival rates were 81% and 58%, respectively. Median progression-free survival was 45.3 mo. The median biochemical relapse-free survival (BRFS) was 25.9 mo. At 2 and 3 yr, the BRFS rates were 58% and 46%, respectively. Grade 2 + 2-yr genitourinary and gastrointestinal toxicities were 10% and 2%, respectively.

CONCLUSIONS

Combined high-dose salvage pelvic radiotherapy and ADT appeared to prolong tumor control in oligorecurrent pelvic node relapses in prostate cancer with limited toxicity. After 3 yr, nearly half of patients were in complete remission. Our study showed initial evidence of benefit, but a randomized trial is required to confirm this result.

PATIENT SUMMARY

In this report, we looked at the outcomes of combined high-dose salvage pelvic radiotherapy and 6-mo-long hormone therapy in oligorecurrent pelvic nodal relapse in prostatic cancer. We found that 46% of patients presenting with oligorecurrent pelvic node relapses in prostate cancer were in complete remission after 3 yr following combined treatment at the cost of limited toxicity.

The role of dietary supplements, including biotics, glutamine, polyunsaturated fatty acids and polyphenols, in reducing gastrointestinal side effects in patients undergoing pelvic radiotherapy: A systematic review and meta-analysis

BACKGROUND AND PURPOSE

Pelvic radiotherapy (RT) often results in gastrointestinal toxicity and clinical trials have demonstrated a potential benefit of dietary supplements in alleviating acute effects. However, no prophylactic agents have been approved to date for relief of gastrointestinal side-effects caused by pelvic radiation. In this systematic review, we evaluated the efficacy of dietary supplements in preventing or alleviating symptoms of gastrointestinal toxicity in patients undergoing pelvic RT.

MATERIALS AND METHODS

CENTRAL, MEDLINE, EMBASE, and ClinicalTrials.gov were searched up to June 2020 for randomised controlled trials. Interventions included four supplement categories: biotics, glutamine, poly-unsaturated fatty acids and polyphenols. Efficacy was determined with reference to outcomes based on symptoms of acute gastrointestinal toxicity, including diarrhoea, nausea, vomiting, flatulence/bloating, bowel movement frequency, tenesmus and rectal bleeding.

RESULTS

Twenty-three randomised controlled trials (1919 patients) were identified in this review. Compared with placebo, probiotics (RR = 0.71; 95% CI: 0.52 to 0.99), synbiotics (RR = 0.45; 95% CI: 0.28 to 0.73) and polyphenols (RR = 0.30; 95% CI: 0.13 to 0.70) were significantly associated with a lower risk of diarrhoea. Biotic supplements also reduced the risk of moderate to severe diarrhoea (RR = 0.49; 95% CI: 0.36 to 0.67) and the need for anti-diarrhoeal medication (RR = 0.64; 95%CI: 0.44 to 0.92). In contrast, glutamine had no effect on acute symptoms (RR = 1.05; 95% CI: 0.86 to 1.29). There was a non-significant trend for reduction in nausea and mean bowel movements per day using dietary supplements.

CONCLUSIONS

Biotic supplements, especially probiotics and synbiotics, reduce acute symptoms of gastrointestinal toxicity in patients undergoing pelvic radiotherapy.

Sexual health and wellbeing after pelvic radiotherapy among women with and without a reported history of sexual abuse: important issues in cancer survivorship care

Aims

Sexual abuse is a women’s health concern globally. Although experience of sexual abuse and cancer may constitute risk factors for sexual dysfunction and low wellbeing, the effects of sexual abuse have received little attention in oncology care. This study aims to explore sexual health and wellbeing in women after pelvic radiotherapy and to determine the relationship between sexual abuse and sexual dysfunction, and decreased wellbeing.

Methods

Using a study-specific questionnaire, data were collected during 2011–2017 from women with gynaecological, anal, or rectal cancer treated with curative pelvic radiotherapy in a population-based cohort and a referred patient group. Subgroup analyses of data from women with a reported history of sexual abuse were conducted, comparing socio-demographics, diagnosis, aspects of sexual health and wellbeing.

Results

In the total sample of 570 women, 11% reported a history of sexual abuse and among these women the most common diagnosis was cervical cancer. More women with than without a history of sexual abuse reported feeling depressed (19.4% vs. 9%, p = 0.007) or anxious (22.6% vs. 11.8%, p = 0.007) and suffering genital pain during sexual activity (52% vs. 25.1%, p = 0.011, RR 2.07, CI 1.24–3.16). In the total study cohort, genital pain during sexual activity was associated with vaginal shortness (68.5% vs. 31.4% p ≤ 0.001) and inelasticity (66.6% vs. 33.3%, p ≤ 0.001).

Conclusions

Our findings suggest that a history of both sexual abuse and pelvic radiotherapy in women are associated with increased psychological distress and sexual impairment, challenging healthcare professionals to take action to prevent retraumatisation and provide appropriate interventions and support.

Ovarian transposition and cervical cancer

Cervical cancer is the fourth most common female malignancy worldwide. As the focus of treatment is shifting towards balancing oncological outcomes with reproductive benefit, women are becoming increasingly aware of their fertility options. Cervical cancer is one of the primary malignancies where transposition of the ovaries may be indicated. Ovarian transposition should be performed in pre-menopausal women, undergoing pelvic irradiation to preserve ovarian function and prevent early menopause. The review discusses the available literature and synthesises a concise summary for gynaecologic oncology surgeons to counsel affected women. The paradoxical controversy, leading to its under use is acknowledged, due to the scarcity of published data with regard to functional outcomes, and the lack of clinical trials. In cervical cancer, ovarian transposition remains a safe fertility preservation (FP) option, which is associated with high ovarian function preservation, an acceptable rate of ovarian cysts and a negligible risk for metastases in the transposed ovaries.

Pelvic floor muscle assessment by digital palpation and translabial ultrasound of women with cervical or endometrial cancer after pelvic radiotherapy: a cross-sectional study

INTRODUCTION AND HYPOTHESIS

We hypothesized that anatomical changes in the pelvic floor muscles (PFM) could be detected using four-dimensional translabial ultrasound (4D TLUS) in patients with cervical (CC) or endometrial cancer (EC) who underwent pelvic radiotherapy (RT) as digital palpation may present sensitivity limitations.

METHODS

This was a cross-sectional study that included 64 women (26 with CC and 38 with EC). PFM function was assessed by digital palpation, grading muscle strength according to the Modified Oxford Scale and by 4D TLUS. Ultrasonographic variables were: levator plate angle, hiatal area, puborectalis muscle thickness, puborectalis strain and levator ani muscle integrity. These variables were also correlated with clinical and sociodemographic data from all these patients. A 5% significance level was adopted.

RESULTS

When assessed by digital palpation, no significant difference was found in PFM strength between women with CC and those with EC (p = 0.747). However, when assessed by 4D TLUS, women with CC presented greater thickening of the left (p = 0.039) and right (p = 0.014) lower portion of the puborectalis muscle during PFM contraction compared to those with EC. After pooling the groups, higher cancer staging (p = 0.028) was associated with smaller narrowing in the symphysis-levator distance, and shorter RT finishing duration (< 60 months) was associated with higher thickening in the left (p = 0.029) and right (p = 0.013) upper portion of the puborectalis muscle during PFM contraction as well as a shorter menopause duration (p = 0.007 and p = 0.002, respectively).

CONCLUSIONS

Anatomical changes in the puborectalis muscle during PFM contraction were detected by 4D TLUS within gynecological cancer patients after pelvic RT.

Stereotactic Pelvic Reirradiation for Locoregional Cancer Relapse

AIMS

Up to 40% of patients who have received radiation for a pelvic malignancy will develop locoregional recurrence in the previously irradiated volume. Stereotactic body radiotherapy (SBRT) has been used in the oligometastatic setting, and provides an ablative approach ideal for reirradiation. The purpose of this study was to evaluate the outcomes after SBRT reirradiation of extraosseous recurrences in the pelvis.

MATERIALS AND METHODS

This single institution retrospective study evaluated patients treated with SBRT reirradiation in the pelvis from January 2011 to February 2018. Patients with more than five oligometastatic lesions, >7 cm in size, and recurrence within the prostate were excluded.

RESULTS

In total, 30 patients were treated with SBRT with a median follow-up of 29.4 months. The primary tumour sites were most commonly rectum (30.8%) and prostate (30.8%). The median time interval between irradiation for the primary and SBRT reirradiation was 48 months (3-245). The typical reirradiation treatment was 35 Gy in five fractions, the median gross tumour volume size was 10.2 (0.3-110.5) ml and the most common target was the iliac nodes (40%). There were three (10%) acute grade 3 toxicities and no late grade 3 or more toxicities. At 12/24 months, local relapse-free survival, metastasis-free survival, progression-free survival and overall survival were 67.7%/50.7%, 67%/41.7%, 34.8%/14.9% and 83.2%/62.5%, respectively. On univariate analysis, improved local control was associated with low gross tumour volume (<10 ml) (P = 0.003) and prostate primary (P = 0.02), but was no longer significant on multivariate analysis. The proximity of organ at risk to the target did not significantly correlate with worse toxicity (P = 0.14) or tumour coverage (gross tumour volume: P = 0.8, planning target volume: P = 0.4).

CONCLUSION

SBRT pelvic reirradiation in oligometastatic patients is a safe and effective treatment modality. Careful consideration should be taken with larger tumour size, as it may be associated with worse oncological and toxicity outcome.

Three-piece inflatable penile prosthesis: Ectopic reservoir placement

INTRODUCTION

The complications associated to the placement of the reservoir are infrequent but potentially serious. Therefore, technical alternatives have been developed for the performance of the procedure in different locations (ectopic). The aim of this review is to revise the evidence available on the different options for the ectopic placement of the reservoir.

MATERIAL AND METHOD

Narrative review based on a bibliographical search limited to PubMed- indexed relevant manuscripts, in Spanish or English, for the period 2000-2019, using «penile prosthesis», «ectopic reservoir», radical prostatectomy», «radical cystectomy», «pelvic radiotherapy», and «renal transplantation» as key words. Non original articles and reviews were not considered eligible. A total of 11 manuscripts were included.

RESULTS

Pelvic alterations after surgery and/or radiotherapy increase the difficulty in the placement of the prosthesis reservoir. In order to minimize the risk of complications, different modifications have been performed on the devices, and technical innovations have been developed for the submuscular placement of the reservoir. The available evidence regarding the functionality and complications of these techniques is limited to single institution, low volume, and retrospective series with short follow-up periods. The functionality seems to be adequate using the adapted devices. The complications are infrequent and mild in severity.

CONCLUSIONS

Although the available evidence is still limited, the ectopic placement of the reservoir may be considered a safe, effective, and reproducible technique. In addition, it may result particularly useful in cases of altered pelvic anatomy.

Pelvic radiation therapy with volumetric modulated arc therapy and intensity-modulated radiotherapy after renal transplant: A report of 3 cases

Aim

Describe characteristics and outcomes of three patients treated with pelvic radiation therapy after kidney transplant.

Background

The incidence of pelvic cancers in kidney transplant (KT) recipients is rising. Currently it is the leading cause of death. Moreover, treatment is challenging because anatomical variants, comorbidities, and associated treatments, which raises the concern of using radiotherapy (RT). RT has been discouraged due to the increased risk of urethral/ureteral stricture and KT dysfunction.

Materials and methods

We reviewed the electronic health records and digital planning system of patients treated with pelvic RT between December 2013 and December 2018 to identify patients with previous KT.

Cases description

We describe three successful cases of KT patients in which modern techniques allowed full standard RT for pelvic malignances (2 prostate and 1 vaginal cancer) with or without elective pelvic nodal RT, without allograft toxicity at short and long follow-up (up to 60 months).

Conclusion

When needed, RT modern techniques remain a valid option with excellent oncologic results and acceptable toxicity. Physicians should give special considerations to accomplish all OAR dose constraints in the patient's specific setting. Recent publications recommend KT mean dose <4 Gy, but graft proximity to CTV makes this unfeasible. We present 2 cases where dose constraint was not achieved, and to a short follow-up of 20 months renal toxicity has not been documented. We recommend the lowest possible mean dose to the KT, but never compromising the CTV coverage, since morbimortality from recurrent or progressive cancer disease outweighs the risk of graft injury.

Late toxicity and quality of life with prostate only or whole pelvic radiation therapy in high risk prostate cancer (POP-RT): A randomised trial

AIM

To report toxicity and quality of life (QOL) outcomes from a randomised trial of prostate only versus whole pelvic radiotherapy in high risk, node negative prostate cancer.

MATERIALS/METHODS

Patients with localised prostate adenocarcinoma and nodal involvement risk > 20%, were randomised to prostate only (PORT, 68 Gy/25# to prostate) and whole pelvis (WPRT, 68 Gy/25# to prostate and 50 Gy/25# to pelvis) arms with stratification for TURP, Gleason score, baseline PSA, and type of androgen deprivation therapy (ADT). Image guided intensity modulated radiotherapy (IG-IMRT) and two years of ADT were mandatory. Acute and late genitourinary (GU) and gastrointestinal (GI) toxicities were graded using RTOG grading. QOL was assessed using EORTC QLQ-C30 and PR-25 questionnaire pre-treatment and every 3-6 months post RT.

RESULTS

Total 224 patients were randomised (PORT 114, WPRT 110) from November 2011 to August 2017. Median follow up was 44.5 months. No RTOG grade IV toxicity was observed. Acute GI and GU toxicities were similar between both the arms. Cumulative ≥ grade II late GI toxicity was similar for WPRT and PORT (6.5% vs. 3.8%, p = 0.39) but GU toxicity was higher (17.7% vs. 7.5%, p = 0.03). Dosimetric analysis showed higher bladder volume receiving 30-40 Gy in the WPRT arm (V30, 60% vs. 36%, p < 0.001; V40, 41% vs. 25%, p < 0.001). There was no difference in QOL scores of any domain between both arms.

CONCLUSION

Pelvic irradiation using hypofractionated IG-IMRT resulted in increased grade II or higher late genitourinary toxicity as compared to prostate only RT, but the difference was not reflected in patient reported QOL. CLINICALTRIALS.GOV NCT02302105: Prostate Only or Whole Pelvic Radiation Therapy in High Risk Prostate Cancer (POP-RT).

The Horse is at the Stable Door: Management of N1M0 Prostate Cancer

Pelvic lymph node involvement in prostate cancer is a significant poor prognostic factor with very little evidence on the optimal management options for these patients. It is estimated that lymph node-positive patients make up 12% of newly diagnosed prostate cancer and this figure is expected to rise with the advancement and increasing use of novel imaging. The controversy around this subgroup of patients is whether this is an intermediary stage before disseminated disease and hence amenable to curative treatment options. Systemic therapies have been the mainstay of treatment for these patients for decades, but in recent years, studies have emerged supporting the addition of local therapy. This review will focus on the current multimodal management approach for clinical and pathological lymph node-positive prostate cancer with a focus on radiotherapy options and aims to provide the rationale for a curative approach with a combination of local and systemic therapy.

Association between the location of transposed ovary and ovarian dose in patients with cervical cancer treated with postoperative pelvic radiotherapy

Background and purpose

How to protect the ovarian function during radiotherapy is uncertain. The purpose of this study was to explore the association between the location of the transposed ovary and the ovarian dose in patients with cervical cancer received radical hysterectomy, ovarian transposition, and postoperative pelvic radiotherapy.

Methods

A retrospective analysis was conducted of 150 young patients with cervical cancer who received radical hysterectomy, intraoperative ovarian transposition, and postoperative adjuvant radiotherapy in Zhejiang Cancer Hospital. Association between location of the transposed ovaries and ovarian dose was evaluated. The transposed position of ovaries with a satisfactory dose was explored using a receiver operator characteristic curve (ROC) analysis. Patients’ ovarian function was followed up 3 months and 1 year after radiotherapy.

Results

A total of 32/214 (15%) transposed ovaries were higher than the upper boundary of the planning target volume (PTV). The optimum cutoff value of > 1.12 cm above the iliac crest plane was significantly associated with ovaries above the upper PTV boundary. When the ovaries were below the upper boundary of PTV, the optimum cutoff value of transverse distance > 3.265 cm between the ovary and PTV was significantly associated with ovarian max dose (Dmax) ≤ 4Gy, and the optimum cutoff value of transverse distance > 2.391 cm was significantly associated with ovarian Dmax≤5Gy. A total of 77 patients had received complete follow-up, and 56 patients (72.7%) showed preserved ovarian function 1 year after radiotherapy, which was significantly increased compared with 3 months (44.2%) after radiotherapy.

Conclusions

The location of transposed ovaries in patients with cervical cancer is significantly correlated with ovarian dose in adjuvant radiotherapy. We recommend transposition of ovaries > 1.12 cm higher than the iliac crest plane to obtain ovarian location above PTV. When the transposed ovary is below the upper boundary of PTV, ovarian Dmax ≤4Gy may be obtained when the transverse distance between the ovary and PTV was > 3.265 cm, and the ovarian Dmax≤5Gy may be obtained when the transverse distance was > 2.391 cm.

Fertility preservation in chemo-radiotherapy for rectal cancer: A combined approach

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Young females affected by rectal cancer need counselling on fertility preservation.

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Ovarian transposition and cryopreservation are feasible.

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Advances in radiation therapy techniques can help reducing fertility impairment.

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A multidisciplinar approach is recommended.

Introduction

Colorectal cancer is a very common form of cancer worldwide, affecting an increasing number of young women. Standard treatment for locally advanced rectal cancer (LARC) can pose a threat to fertility in these patients.

Case presentation

We present the case of a young woman affected by LARC who expressed a desire for child-bearing. The treatment she was proposed, according to guidelines, was neoadjuvant chemo-radiotherapy (CRT) followed by delayed surgery, carrying with it a high risk for amenorrhea. Counselling was performed before the initiation of treatment, with the aim of preserving fertility by the proposal of GnRH agonist administration, ovarian transposition and ovarian tissue cryopreservation, which the patient accepted. Treatment was then successfully completed. The patient presented regular menstrual period from before the surgery.

Discussion

Ovarian tissue is very sensitive to radiations. Transposition of the organ can prevent ovarian insufficiency by placing it outside the radiation field, while ovarian tissue cryopreservation and orthotopic transplantation offers the possibility to restore fertility in the case of organ failure. We performed both of the techniques. GnRH analogs administration allowed to diminish the risk of ovarian cytotoxicity. Radiation treatment plan was optimized in order to minimize the dose to organs at risk (ovary and vagina in particular); position of the uterus, which is quite radiosensitive too, was monitored with daily cone-beam CT (CBCT).

Conclusion

The strategy proposed seemed safe and effective, resulting in radical treatment and persistence of regular menstrual period. Further studies are needed.

Treatment outcomes of prostate cancer patients with Gleason score 8-10 treated with definitive radiotherapy : TROD 09-001 multi-institutional study

PURPOSE

To validate the clinical outcomes and prognostic factors in prostate cancer (PCa) patients with Gleason score (GS) 8-10 disease treated with external beam radiotherapy (EBRT) + androgen deprivation therapy (ADT) in the modern era.

METHODS

Institutional databases of biopsy proven 641 patients with GS 8-10 PCa treated between 2000 and 2015 were collected from 11 institutions. In this multi-institutional Turkish Radiation Oncology Group study, a standard database sheet was sent to each institution for patient enrollment. The inclusion criteria were, T1-T3N0M0 disease according to AJCC (American Joint Committee on Cancer) 2010 Staging System, no prior diagnosis of malignancy, at least 70 Gy total irradiation dose to prostate ± seminal vesicles delivered with either three-dimensional conformal RT or intensity-modulated RT and patients receiving ADT.

RESULTS

The median follow-up time was 5.9 years (range 0.4-18.2 years); 5‑year overall survival (OS), biochemical relapse-free survival (BRFS) and distant metastases-free survival (DMFS) rates were 88%, 78%, and 79%, respectively. Higher RT doses (≥78 Gy) and longer ADT duration (≥2 years) were significant predictors for improved DMFS, whereas advanced stage was a negative prognosticator for DMFS in patients with GS 9-10.

CONCLUSIONS

Our results validated the fact that oncologic outcomes after radical EBRT significantly differ in men with GS 8 versus those with GS 9-10 prostate cancer. We found that EBRT dose was important predictive factor regardless of ADT period. Patients receiving 'non-optimal treatment' (RT doses <78 Gy and ADT period <2 years) had the worst treatment outcomes.

Pelvic radiotherapy for cervical cancer affects importantly the reproducibility of cytological alterations evaluation

Background

to evaluate the intraobserver and interobserver reproducibility of cervical cytopathology according to previous knowledge of whether patients received radiotherapy (RT) treatment or not.

Methods

The study analyzed a sample of 95 cervix cytological slides; 24 with cytological abnormalities (CA) and presence of RT; 21 without CA and presence of RT; 25 without CA and without previous RT; 25 with CA and without previous RT. Two cytopathology (CP) evaluations of the slides were carried out. For the first CP re-evaluation, the cytotechnologist was blinded for the information of previous RT. For the second CP re-evaluation, the cytotechnologist was informed about previous RT. The results were analyzed through inter and intraobserver agreement using the unweighted and weighted kappa.

Results

Post radiotherapy effects were identified in 44.4% of cases that undergone previous pelvic RT. The agreement for RT status was 66.32% (unweighted K = 0.31, 95%CI: 0.13; 0.49, moderate agreement). The intraobserver agreement, regarding the cytological diagnoses, regardless of radiotherapy status, was 80.32% (weighted K = 0.52, 95%CI: 0.34; 0.68). In no RT group, the intraobserver agreement was 70% (weighted K = 0.47, 95%CI: 0.27;0.65) and in patients that received RT, the intraobserver agreement was 84.09% (unweighted K = 0.37, 95%CI: 0.01;0.74). The interobserver agreement between cytopathology result (abnormal or normal) in the group with RT, considering normal and abnormal CP diagnosis was 14.0% and 12.5%, respectively. There was no association between the cytological alterations and the median time between the end of RT and the cytological diagnosis.

Conclusion

This study showed that RT has an important impact in CP diagnosis because the agreement, also in interobserver and intraobserver analysis, had high discrepancy in patients that received RT. Also, demonstrated that it is difficult to recognize the presence of RT in cytological slides when this information is not provided.

Immobilization versus no immobilization for pelvic external beam radiotherapy

Aim

To identify the most reproducible technique of patient positioning and immobilization during pelvic radiotherapy.

Background

Radiotherapy plays an important role in the treatment of pelvic malignancies. Errors in positioning of patient are an integral component of treatment. The present study compares two methods of immobilization with no immobilization with an aim of identifying the most reproducible method.

Materials and methods

65 consecutive patients receiving pelvic external beam radiotherapy were retrospectively analyzed. 30, 21 and 14 patients were treated with no-immobilization with a leg separator, whole body vacuum bag cushion (VBC) and six point aquaplast immobilization system, respectively. The systematic error, random error and the planning target volume (PTV) margins were calculated for all the three techniques and statistically analyzed.

Results

The systematic errors were the highest in the VBC and random errors were the highest in the aquaplast group. Both systematic and random errors were the lowest in patients treated with no-immobilization. 3D Systematic error (mm, mean ± 1SD) was 4.31 ± 3.84, 3.39 ± 1.71 and 2.42 ± 0.97 for VBC, aquaplast and no-immobilization, respectively. 3D random error (mm, 1SD) was 2.96, 3.59 and 1.39 for VBC, aquaplast and no-immobilization, respectively. The differences were statistically significant between all the three groups. The calculated PTV margins were the smallest for the no-immobilization technique with 4.56, 4.69 and 4.59 mm, respectively, in x, y and z axes, respectively.

Conclusions

Among the three techniques, no-immobilization technique with leg separator was the most reproducible technique with the smallest PTV margins. For obvious reasons, this technique is the least time consuming and most economically viable in developing countries.

Acute toxicity with intensity modulated radiotherapy versus 3-dimensional conformal radiotherapy during preoperative chemoradiation for locally advanced rectal cancer

BACKGROUND AND PURPOSE

We examined acute toxicity profiles and outcomes among rectal cancer patients treated with pre-operative chemoradiation using intensity modulated radiotherapy (IMRT) or 3-dimensional conformal radiotherapy (3DCRT) to identify predictive clinical factors associated with increased acute toxicity.

MATERIAL AND METHODS

We retrospectively reviewed records of 301 consecutive rectal cancer patients treated with pre-operative chemotherapy and radiotherapy (median dose 5000cGy) at our institution between 2007 and 2014.

RESULTS

Of the 301 patients, 203 (67.4%) were treated with IMRT and 98 (32.6%) with 3DCRT. Significantly more patients experienced ⩾grade 2 diarrhea in the 3DCRT group compared to the IMRT group (22% vs 10%, p=0.004), and those who received 3DCRT had 2.7 times greater odds of a higher diarrhea score than those on IMRT, even after adjusting for patient characteristics and chemotherapy (OR 2.71, p=0.01) Fewer patients experienced grade 2 genitourinary toxicity in the IMRT group (6% vs 13% 3DCRT, p=0.04) and there was a trend toward decreased grade 2 proctitis in the IMRT group (22% vs 32% 3DCRT, p=0.07). Patients over the age of 55 had 45% lower odds of proctitis than patients younger than 55.

CONCLUSION

The use of IMRT significantly reduced grade ⩾2 diarrhea and GU toxicity during chemoradiation. Younger patients were more likely to report grade 2 or higher proctitis.

Chronic radiation proctopathy: A practical review of endoscopic treatment

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.

Urinary adverse effects of pelvic radiotherapy

Objective

Radiation is an integral part of the treatment of many pelvic tumors. The cellular death induced by radiotherapy (RT) benefits cancer control but can also result in adverse effects (AEs) on the organ being treated or those adjacent to it. RT for cancers of the pelvis (bladder, prostate, rectum, uterus or cervix) can result in AEs in the urinary tract. While the acute urinary AEs of pelvic RT are well described, late AEs are less well characterized. The burden of treatment for late AEs may be large given the prevalence of tumors in the pelvis and the high utilization of RT to treat them.

Review

For prostate cancer, grade 1 and 2 urinary AEs following external beam radiation therapy (EBRT) are reported to occur in 20-43% and 7-19%, respectively, with a follow up of 10 years. Three-year cumulative risk for grade ≥2 urinary AEs is 28-30%. Following brachytherapy (BT), rates of urinary AEs at 5 years are reported to be 36%, 24%, 6.2% and 0.1% for Radiation Therapy Oncology Group (RTOG) grade 1, 2, 3, and 4, respectively. For bladder cancer, with a median follow-up of 5 years, 7-12% of patients who receive RT experience urinary AEs of grade 3 or more. For cervical cancer, there remains a 0.25% per year risk of severe AEs for at least 25 years following RT, and ureteral stricture is a well-described AE. For endometrial cancer, severe urinary AEs are rare, but at 13 years of follow up, patients report a significantly worse quality of life with respect to urinary function. In rectal cancer, preoperative RT has a lower risk of AEs than postoperative RT, and few urinary AEs are reported in the literature.

Conclusions

Urinary AEs can manifest long after RT, and there is a paucity of studies describing rates of these long-term AEs. It is important that the possible complications of RT are recognized by providers and properly communicated to patients so that they are able to make informed decisions about their cancer treatment.

Pelvic radiation therapy: Between delight and disaster

In the last few decades radiotherapy was established as one of the best and most widely used treatment modalities for certain tumours. Unfortunately that came with a price. As more people with cancer survive longer an ever increasing number of patients are living with the complications of radiotherapy and have become, in certain cases, difficult to manage. Pelvic radiation disease (PRD) can result from ionising radiation-induced damage to surrounding non-cancerous tissues resulting in disruption of normal physiological functions and symptoms such as diarrhoea, tenesmus, incontinence and rectal bleeding. The burden of PRD-related symptoms, which impact on a patient’s quality of life, has been under appreciated and sub-optimally managed. This article serves to promote awareness of PRD and the vast potential there is to improve current service provision and research activities.

Application of 1H NMR spectroscopy-based metabonomics to feces of cervical cancer patients with radiation-induced acute intestinal symptoms

OBJECTIVE

Radiation-induced acute intestinal symptoms (RIAISs) are a common complication of radiotherapy for cervical cancer. The aim of this study was to use (1)H nuclear magnetic resonance ((1)H NMR) combined with chemometric analysis to develop a metabolic profile of patients with RIAISs.

METHODS

Fecal samples were collected from 66 patients with cervical cancer before and after pelvic radiotherapy. After radiotherapy, RIAISs occurred in eleven patients. We selected another 11 patients from participants without RIAISs whose age, stage, histological type and treatment methods are matched with RIAIS patients as the control group. (1)H NMR spectroscopy combined with multivariate pattern recognition analysis was used to generate metabolic profile data, as well as to establish a RIAIS-specific metabolic phenotype.

RESULTS

Orthogonal partial least-squares discriminant analysis was used to distinguish samples between the pre- and post-radiotherapy RIAIS patients and between RIAIS patients and controls. Fecal samples from RIAIS patients after pelvic radiotherapy were characterized by increased concentrations of α-ketobutyrate, valine, uracil, tyrosine, trimethylamine N-oxide, phenylalanine, lysine, isoleucine, glutamine, creatinine, creatine, bile acids, aminohippurate, and alanine, accompanied by reduced concentrations of α-glucose, n-butyrate, methylamine, and ethanol relative to samples from RIAIS patients before pelvic radiotherapy, while in RIAIS patients relative to controls, trimethylamine, n-butyrate, fumarate and acetate were down-regulated and valine, TMAO, taurine, phenylalanine, lactate, isoleucine and creatinine were up-regulated.

CONCLUSIONS

We obtained the metabolic profile of RIAIS patients from fecal samples using NMR-based metabonomics. This profile has the potential to be developed into a novel clinical tool for RIAIS diagnosis or therapeutic monitoring, and could contribute to an improved understanding of the disease mechanism. However, because of the limitations of methods, technique, bacterial contamination of feces and small sample size, further research and verification are needed.

Prospective study of vaginal dilator use adherence and efficacy following radiotherapy

BACKGROUND AND PURPOSE

Vaginal stenosis (VS) after pelvic radiotherapy (RT) can impair long-term quality of life. We prospectively assessed adherence and efficacy of vaginal dilator (VD) use in women after pelvic RT.

MATERIAL AND METHODS

Women with gastrointestinal (n=63) and gynecologic (n=46) cancers self-reported use and VD size in monthly diaries for 12months after radiotherapy. Adherence was measured as actual VD use out of recommended times over 12months (3×/week×52weeks=156).

RESULTS

Among 109 participants, aged 28-81years (median, 58years), mean percent adherence over 12months was 42% (95% confidence interval [CI], 36-48%). Adherence was highest in the first quarter (56%), but fell to 25% by the fourth. Disease type, treatment sequence, and chemotherapy were predictors of adherence (all P<.05). Eighty-two percent maintained pre-RT VD size at 12months; of 49% with a decrease in VD size at 1month post-RT, 71% returned to pre-RT VD size at 12months. Disease type, younger age, and increased adherence at 6months were associated with maintaining or returning to pre-RT size at 12months (all P⩽.05).

CONCLUSION

VD use is effective in minimizing VS, but adherence at 12months was poor. Studies evaluating methods of improving adherence and determining the optimal frequency and duration of use are needed.

A randomized double-blind controlled trial: impact of probiotics on diarrhea in patients treated with pelvic radiation

BACKGROUND & AIMS

Radical radiation therapy is commonly used for treatment of pelvic cancer. Up to 80% of patients receiving radiotherapy will develop acute radiation induced diarrhea. The primary aim of this randomized double blind controlled trial is to evaluate the effect of the probiotic Bifilact(®) on moderate and severe treatment-induced diarrhea during pelvic radiation.

METHODS

Patients with pelvic cancers were treated between 2006 and 2010 at L'Hôtel-Dieu de Québec, University Health Center. Some patients had surgery before pelvic radiotherapy and some received chemotherapy. A total of 246 Patients were randomized between a placebo and either of two regiments of double strain Bifilact(®) probiotics (Lactobacillus acidophilus LAC-361 and Bifidobacterium longum BB-536): a standard dose twice a day (1.3 billion CFU) or a high dose three times a day (10 billion CFU). Patients were trained to record their digestive symptoms daily with a standardized scale and they met a registered dietician and radiation oncologist every week during treatment. The main analysis compared time to first appearance of grade ≥2-3-4 diarrhea using Kaplan-Meier curves as measured by proportion of patients without moderate and severe diarrhea.

RESULTS

229 patients were analyzed. The difference between the groups for overall grade 2-3-4 diarrhea was not statistically significant (p = 0.13). However at 60 days, the proportion of patients without moderate and severe diarrhea in the standard dose group (35%) was more than twice as high as that of the placebo group (17%) with a hazard ratio of 0.69 (p = 0.04). In patients who had surgery, the standard probiotics dose group had a better proportion of patients without very severe diarrhea than the placebo group, respectively 97% and 74% (p = 0.03). In all groups, the average number of bowel movements per day during treatment was less than 3 soft stools (p = 0.80) and the median abdominal pain less than 1 based on the National Cancer Institute scale (p = 0.23).

CONCLUSION

Standard dose of Bifilact(®) may reduce radiation induced grade 2-3-4 diarrhea at the end of the treatment of patients with pelvic cancer. In patients operated on before RT, a standard dose of probiotics may reduce radiation induced grade 4 diarrhea. Nutritional interventions by a registered dietician seemed to reduce global digestive symptoms.

TRIAL REGISTRATION

clinicaltrials.gov. Identifier NCT01839721.

Hypofractionated intensity-modulated arc therapy for lymph node metastasized prostate cancer: early late toxicity and 3-year clinical outcome

BACKGROUND AND PURPOSE

For patients with N1 prostate cancer (PCa) aggressive local therapies can be advocated. We evaluated clinical outcome, gastro-intestinal (GI) and genito-urinary (GU) toxicity after intensity modulated arc radiotherapy (IMAT)+androgen deprivation (AD) for N1 PCa.

MATERIAL AND METHODS

Eighty patients with T1-4N1M0 PCa were treated with IMAT and 2-3years of AD. A median dose of 69.3Gy (normalized isoeffective dose at 2Gy per fraction: 80Gy [α/β=3]) was prescribed in 25 fractions to the prostate. The pelvic lymph nodes received a minimal dose of 45Gy. A simultaneous integrated boost to 72Gy and 65Gy was delivered to the intraprostatic lesion and/or pathologically enlarged lymph nodes, respectively. GI and GU toxicity was scored using the RTOG/RILIT and RTOG-SOMA/LENT-CTC toxicity scoring system respectively. Three-year actuarial risk of grade 2 and 3/4 GI-GU toxicity and biochemical and clinical relapse free survival (bRFS and cRFS) were calculated with Kaplan-Meier statistics.

RESULTS

Median follow-up was 36months. Three-year actuarial risk for late grade 3 and 2 GI toxicity is 8% and 20%, respectively. Three-year actuarial risk for late grade 3-4 and 2 GU toxicity was 6% and 34%, respectively. Actuarial 3-year bRFS and cRFS was 81% and 89%, respectively. Actuarial 3-year bRFS and cRFS was, respectively 26% and 32% lower for patients with cN1 disease when compared to patients with cN0 disease.

CONCLUSION

IMAT for N1 PCa offers good clinical outcome with moderate toxicity. Patients with cN1 disease have poorer outcome.

Endoscopic findings of rectal mucosal damage after pelvic radiotherapy for cervical carcinoma: correlation of rectal mucosal damage with radiation dose and clinical symptoms

PURPOSE

To describe chronic rectal mucosal damage after pelvic radiotherapy (RT) for cervical cancer and correlate these findings with clinical symptoms and radiation dose.

MATERIALS AND METHODS

Thirty-two patients who underwent pelvic RT were diagnosed with radiation-induced proctitis based on endoscopy findings. The median follow-up period was 35 months after external beam radiotherapy (EBRT) and intracavitary radiotherapy (ICR). The Vienna Rectoscopy Score (VRS) was used to describe the endoscopic findings and compared to the European Organization for Research and Treatment of Cancer (EORTC)/Radiation Therapy Oncology Group (RTOG) morbidity score and the dosimetric parameters of RT (the ratio of rectal dose calculated at the rectal point [RP] to the prescribed dose, biologically effective dose [BED] at the RP in the ICR and EBRT plans, α/β = 3).

RESULTS

Rectal symptoms were noted in 28 patients (rectal bleeding in 21 patients, bowel habit changes in 6, mucosal stools in 1), and 4 patients had no symptoms. Endoscopic findings included telangiectasia in 18 patients, congested mucosa in 20, ulceration in 5, and stricture in 1. The RP ratio, BEDICR, BEDICR+EBRT was significantly associated with the VRS (RP ratio, median 76.5%; BEDICR, median 37.1 Gy3; BEDICR+EBRT, median 102.5 Gy3; p < 0.001). The VRS was significantly associated with the EORTC/RTOG score (p = 0.038).

CONCLUSION

The most prevalent endoscopic findings of RT-induced proctitis were telangiectasia and congested mucosa. The VRS was significantly associated with the EORTC/RTOG score and RP radiation dose.