Abstract
BackgroundRadiation proctitis after intensity-modulated radiation therapy (IMRT) differs from that seen after pelvic irradiation in that this adverse event is a result of high-dose radiation to a very small area in the rectum. We evaluated the results of treatment for hemorrhagic proctitis after IMRT for prostate cancer.MethodsBetween November 2004 and February 2010, 403 patients with prostate cancer were treated with IMRT at 2 institutions. Among these patients, 64 patients who developed late rectal bleeding were evaluated. Forty patients had received IMRT using a linear accelerator and 24 by tomotherapy. Their median age was 72 years. Each patient was assessed clinically and/or endoscopically. Depending on the severity, steroid suppositories or enemas were administered up to twice daily and Argon plasma coagulation (APC) was performed up to 3 times. Response to treatment was evaluated using the Rectal Bleeding Score (RBS), which is the sum of Frequency Score (graded from 1 to 3 by frequency of bleeding) and Amount Score (graded from 1 to 3 by amount of bleeding). Stoppage of bleeding over 3 months was scored as RBS 1.ResultsThe median follow-up period for treatment of rectal bleeding was 35 months (range, 12–69 months). Grade of bleeding was 1 in 31 patients, 2 in 26, and 3 in 7. Nineteen of 45 patients (42%) observed without treatment showed improvement and bleeding stopped in 17 (38%), although mean RBS did not change significantly. Eighteen of 29 patients (62%) treated with steroid suppositories or enemas showed improvement (mean RBS, from 4.1 ± 1.0 to 3.0 ± 1.8, p = 0.003) and bleeding stopped in 9 (31%). One patient treated with steroid enema 0.5-2 times a day for 12 months developed septic shock and died of multiple organ failure. All 12 patients treated with APC showed improvement (mean RBS, 4.7 ± 1.2 to 2.3 ± 1.4, p < 0.001) and bleeding stopped in 5 (42%).ConclusionsAfter adequate periods of observation, steroid suppositories/enemas are expected to be effective. However, short duration of administration with appropriate dosage should be appropriate. Even when patients have no response to pharmacotherapy, APC is effective.
Highlights
Radiation proctitis after intensity-modulated radiation therapy (IMRT) differs from that seen after pelvic irradiation in that this adverse event is a result of high-dose radiation to a very small area in the rectum
Patients Between November 2004 and February 2010, 403 patients with localized prostate cancer were treated with IMRT with or without hormone therapy at 2 institutions, Nagoya City University Hospital (NCUH) and Nagoya Daini Red Cross Hospital (NDRCH)
Forty-five patients were observed without treatment for at least 3 months, including patients who were administered steroid or argon plasma coagulation (APC) after the observation period
Summary
Radiation proctitis after intensity-modulated radiation therapy (IMRT) differs from that seen after pelvic irradiation in that this adverse event is a result of high-dose radiation to a very small area in the rectum. We evaluated the results of treatment for hemorrhagic proctitis after IMRT for prostate cancer. Chronic rectal bleeding is one of the most common complications of radiation therapy for prostate cancer. The etiology of radiation proctitis is considered to be chronic mucosal ischemia caused by tissue fibrosis and obliterative endarteritis. This injured rectal wall can bleed occasionally leading to a chronic ischemic state and causing episodes of severe rectal bleeding [1]. Argon plasma coagulation (APC) is established as an effective treatment for moderate or severe radiation proctitis, reducing rectal bleeding and iron or blood transfusion requirements by cauterizing mucosal telangiectasias [3]. Few complications have been reported with the use of APC, with a reported rate of 2.5% compared with 5% to 15% for laser treatment [4]
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