Radiotherapy For Pelvic Malignancies Research Articles

Dual-modal ablation treatment for refractory radiation proctitis

Dear Editor: A 77-year-old male with recent history of radiation therapy for prostate cancer was referred with symptoms of fresh bleeding per rectum. Radiation proctitis (RP) was previously diagnosed on endoscopy at an outside facility. He had undergone three endoscopic ablation treatments with argon plasma coagulation (APC) but lower GI bleeding persisted, requiring multiple blood transfusions. On flexible sigmoidoscopy, multiple bleeding telangiectatic lesions with erythema and friability extending to 10 cm from the anal verge were noted, consistent with moderate grade radiation proctitis. Radiofrequency ablation (RFA) was offered as a rescue treatment. RFA was performed using the HALO 90 system (Covidien, Sunnyvale, CA), and the scope was rotated circumferentially to target all areas. Energy was delivered at settings of 12–15 J/cm and power density of 40 W/cm. At least two ablation sets were applied to each area. Post ablation, the coagulum was not scraped to promote hemostasis. The patient underwent a total of three RFA sessions at 4to 6-week intervals. His symptoms markedly improved with treatment sessions. On repeat endoscopy, the patient was found to have few spotty telangiectasias that were ablated with APC, 30 W, pulsed at 2 s (Erbe, Tubingen, Germany). On close follow-up, he was asymptomatic and hemoglobin levels were stable from prior. Rectal bleeding can occur from chronic radiation proctitis in up to 20 % of patients as a late complication following radiation therapy for pelvic malignancy. Ablation of the abnormal microvessels with subsequent re-epithelization is beneficial, and APC is currently offered as treatment of choice. However, in refractory cases, endoscopic RFA has recently been proposed as an alternative treatment for RP. RFA confers additional advantages over other modalities such as APC, as illustrated as follows. Firstly, RFA allows simultaneous treatment of broader areas of targeted tissue compared to APC. Also, RFA delivers a consistent amount of energy to the surface causing uniform coagulation of vessels achieving adequate hemostasis. Finally, by the tightly spaced bipolar array, RFA has limited energy penetration, which avoids energy dissipation and further injury to deeper tissue. The technical challenge was to maintain an optimal apposition to the targeted tissue applying torque and rotation of the scope with the electrode attached over the tip in a clockwise fashion, such that circumferential ablation to all areas was feasible. Targeting lesions close to the dentate line may be better using APC. This unique case exhibits a Bdual^ approach to achieve complete resolution of symptoms and bleeding related to chronic RP. In this proposed dual approach, RFA serves to deliver an initial ablative Bhit^ by significantly decreasing the burden of lesions, and APC is used to subsequently target the remaining point lesions. We believe that this combined approach also will prevent ulceration and long-term structuring compared to a single-mode RFA treatment. In conclusion, dual-modal ablation offers an ideal approach to management of RP, especially in refractory cases. * Kevin P. Cowley kcowley@uabmc.edu

PTU-325 Developing a pelvic radiation disease service – which patients do we see in a regional secondary care centre?: Abstract PTU-325 Table 1

Introduction Pelvic radiation disease (PRD) is a common yet under recognised condition causing significant gastrointestinal symtptoms in patients who have recieved radiotherapy for pelvic malignancy. Most studies to date have involved large, sub specialist centres, but the situation in other regions of the UK is unclear. Recent studies have advocated an algorithm based approach to managing these patients.1We have set up a PRD service as part of our general gastroenterology clinic and direct access endoscopy services. We performed a service evaluation to identify the trends of patients presenting to our service, and the investigations that we were performing. Method Using a database search and retrospective notes analysis, we identified patients seen by the gastroenterology service between 2005 and 2014 with PRD. We noted their initial cancer diagnosis, symptoms and investigation results. Results 108 patients were identified (57 female, 51 male). Overall median age was 70 years, however women were younger (median age 67 years) than men (76 years). The majority of male patients had urological malignancy (84%), in contrast to gynaecological (64%) in the female group. All males with urological malignancies were treated for prostate cancer. Rectal bleeding (43%) and diarrhoea (42%) were the most common symptoms recorded. Other symptom frequencies are outlined in [Table 1][1]. 88% of patients (n = 84) had more than one symptom at presentation. View this table: Abstract PTU-325 Table 1 For patients experiencing rectal bleeding, endoscopy revealed angioectasia and radiation proctopathy in 49%, whereas Bile acid diarrhoea was the most common diagnosis made in the diarrhoea group, with 40% of SeHCAT scans being abnormal. Other diagnositic yields of performed tests included positive results in 20% of glucose hydrogen breath tests, 33% of lactose breath tests and 36% of positive fructose breath tests respectively. Conclusion Patients with PRD present with a variety of multiple symptoms following radiotherapy for pelvic malignancy. Service development to cater for this group must include adequate access to investigations and endoscopy. Although patients often require large numbers of investigations, the diagnostic yields are high. Disclosure of interest None Declared. Reference 1. Andreyev HJN, Benton BE, Lalji A, et al . Algorithm-based management of patients with gastrointestinal symptoms in patients after pelvic radiation treatment (ORBIT): a randomised controlled trial. Lancet 2013;382(9910):2084–2092 [1]: #T1

Longitudinal Study of Fat Composition Changes in Bone Marrow During Chemotherapy and Radiation Therapy for Pelvic Malignancies

Longitudinal Study of Fat Composition Changes in Bone Marrow During Chemotherapy and Radiation Therapy for Pelvic Malignancies

Radyasyon proktitinde argon plazma koagulasyon tedavisinin etkinliği

Proctitis may be a long term complication of radiation therapy for pelvic malignancies. The exact treatment of radiation proctitis is controversial. Argon plasma coagulation (APC) is the most acceptable therapy of radiation proctitis. In our clinic, two patients were included into the APC therapy protocol in the last two years of follow-up. The underlying diseases of the patients diagnosed with radiation proctitis were prostate cancer and the radiation proctitis were seen 12 and 8 months after cessation of radiation therapy. The APC therapy was perfomed at 15 days intervals. Both of the patients were free of symptoms at the end of the fifth and sixth months of follow up period. In conclusion, APC treatment seems to be effective and safe in radiation proctitis.

Therapie der chronischen Strahlenproktitis - Effektive Lokaltherapie durch RFA

Chronic radiation proctitis can develop after radiation therapy of pelvic malignancies. Symptoms include haematochezia, diarrhoea, tenesmus, urgency, faecal incontinence, and rectal pain. Various therapies have been attempted with argon plasma coagulation (APC) currently being the treatment of choice, but complications such as ulceration and stricture are commonly encountered. There are limited data suggesting that radiofrequency ablation (RFA) may be an effective alternative to APC, in particular in transfusion-dependent patients. Here we report two cases of chronic radiation proctitis, one of whom was transfusion-dependent, who were safely and successfully treated with focal RFA. Haematochezia decreased significantly the day subsequent to treatment, and transfusion independence was achieved after a single session. Three to four sessions were required to eradicate the neovascular lesions. Post-therapeutic rectal re-epithelialisation occurred, and no bleeding was encountered during up to nine months of follow-up.

Nonendoscopic therapies for the management of radiation-induced rectal bleeding

Rectal bleeding is one of several gastrointestinal side effects that occur after radiotherapy for pelvic malignancy. It can develop during treatment as a result of inflammation, or may be delayed for up to several years, where it is characteristically due to vascular neogenesis within ischaemic tissue. More patients with radiation-induced rectal bleeding are presenting to medical professionals as the number of cancer survivors continues to increase. This review outlines the nonendoscopic treatments that presently exist. Guidance was published on the management of gastrointestinal side effects of radiotherapy in 2012. Recent publications have assessed many agents for the treatment of rectal bleeding including antibiotics, colonic irrigation, formalin and ozone therapy. The 'HOT-II' randomized controlled trial of hyperbaric oxygen (HBO) therapy is keenly awaited. There is no consensus on the optimal management of radiation-induced rectal bleeding. Therapies with evidence of benefit from randomized trials (of variable quality) are sucralfate enemas, antibiotics, vitamin A and HBO therapy. Other nonendoscopic therapies exist; however, there is a paucity of evidence to recommend these at present. Well constructed, randomized controlled trials are required to compare and evaluate therapeutic options.

EP-1217: Comparison of volumetric modulated arc therapy and intensity modulated radiotherapy for pelvic malignancies

EP-1217: Comparison of volumetric modulated arc therapy and intensity modulated radiotherapy for pelvic malignancies

Endoscopic treatments for chronic radiation proctitis.

Chronic radiation proctitis is a complication that occurs in patients who receive radiation therapy for pelvic malignancies. The common presentation is with rectal bleeding, but also rectal pain, diarrhea, tenesmus and even passage of mucus can occur. The optimal treatment of bleeding due to radiation proctitis remains unclear. Among various therapeutic options, medical management is generally ineffective and surgical intervention has a high incidence of morbidity. Promising advances have been made in endoscopic therapy, including argon plasma coagulation (APC), formalin application as well as new techniques such as radiofrequency ablation and cryoablation. APC is a safe, highly effective and long-lasting therapy in patients with rectal bleeding associated with radiation proctitis. It has been shown that several sessions of APC reduce the rate of bleeding and therefore the blood transfusion requirements. Moreover, the effect of treatment is long lasting. However, best results are achieved in patients with mild to moderate radiation proctitis, leaving space for alternative treatments for patients with more severe disease. In patients with severe or refractory radiation proctitis intra rectal formalin application is an appropriate treatment option. Radiofrequency ablation and cryoablation have shown efficacy as alternative methods in a limited number of patients with refractory chronic radiation proctitis.

Sucralfate or placebo following argon plasma coagulation for chronic radiation proctitis: a randomized double blind trial

Chronic radiation proctitis is a long-term complication of radiation therapy for pelvic malignancy. The aim of this study was to compare the efficacy and safety of two treatment regimens, sucralfate or placebo, following argon plasma coagulation (APC) for chronic haemorrhagic radiation proctitis. A single-centre, randomized, placebo-controlled, double-blind study was performed on patients with haemorrhagic chronic radiation proctitis after irradiation for prostate, uterine, cervical, rectal or vaginal cancer. All patients received APC, and were then randomized to oral sucralfate (6 g twice a day) or placebo treatment for 4 weeks. APC was repeated every 8 weeks if necessary after the first session. Patients were graded clinically and endoscopically according to the Chutkan and Gilinski scales before and at 8 and 16 weeks after initial APC treatment (1.5-2 l/min, 25-40 W) and after 52 weeks (clinical only). Of 122 patients, 117 completed the entire protocol, with 57/60 in the sucralfate group and 60/62 in the placebo group. At baseline there were no significant differences between the sucralfate and placebo groups. At 1 year, a significant improvement in the clinical scale in both groups occurred compared with baseline. After 16 weeks, the median overall clinical severity scores fell from 4 to 2 points and the median bleeding score from 2 to 0 in both groups. APC is safe and effective for the management of chronic radiation proctitis. Additional sucralfate treatment did not influence the clinical or endoscopic outcome.

Chronic radiation-induced proctitis: the 4 % formalin application as non-surgical treatment

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. 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. 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. 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.

Formalin dab, the effective way of treating haemorrhagic radiation proctitis: a randomized trial from a tertiary care hospital in South India

Chronic radiation proctitis with bleeding is a common problem encountered following radiotherapy for pelvic malignancy. Sucralfate-steroid enema and formalin dab are two common nonsurgical treatments. A randomized trial was conducted to compare the efficacy of these two methods. This was a prospective randomized controlled trial conducted in the Jawaharlal Institute of Postgraduate Medical Education & Research (JIPMER) from August 2005 to May 2007. One-hundred and two patients with chronic radiation proctitis, presenting as rectal bleeding after radiotherapy for carcinoma of the cervix, were recruited and randomly allocated into two treatment groups: Group 1, formalin dab; and Group 2, sucralfate-steroid retention enema. The mean age of the patients was 51.3 ± 5.1 years. The mean interval between the end of radiotherapy and the onset of bleeding was 12.3 ± 3.5 months. Symptom score and sigmoidoscopic grade were assessed before, and at 1 month after, treatment. Ninety per cent of patients in Group 1 and 74.5% of patients in Group 2 responded to treatment (P = 0.038). In spite of having a higher median symptom score before treatment, patients in Group 1 demonstrated a marked decrease in symptom score after treatment compared with patients in Group 2 and the difference once again was statistically significant (P = 0.000). Similarly, the median sigmoidoscopic grade was significantly lower for patients in Group 1 compared with patients in Group 2 after treatment (P = 0.000). There were no specific treatment-related complications in either group. Formalin (4%) dab is superior to sucralfate-steroid retention enema for treatment of chronic haemorrhagic radiation proctitis.

Use of hyperbaric oxygen therapy in management of radiation cystitis

Radiation induced tissue injury is a result of progressive endarteritis which leads to hypovascular, hypocellular and hypoxic tissues. This damage begins as soon as patient is exposed to radiation beam. Most patients experience some acute side effects and it is rare and serious event when late side effects develop. Radiation cystitis is a late complication of radiotherapy for pelvic malignancies like prostate and cervix. Although 85% of the cases resolve with conservative management, the remainder become refractory and progress to involve a more extensive area of bony and soft tissue. Hyperbaric oxygen therapy (HBOT) is used to treat various forms of chronic radiation tissue injury and is a potential primary option for management of radiation cystitis by enhancing healing in such cases by increasing vascular density and oxygen levels in irradiated tissues. We report a case of 60-year-old male with radiation cystitis who showed promising improvement and resolution of his symptoms after forty HBOT sessions.

A novel treatment for haemorrhagic radiation proctitis using colonic irrigation and oral antibiotic administration

Radiation-induced haemorrhagic proctitis is not uncommon after radiotherapy for pelvic malignancy. Various treatments have been described. Recurrent bleeding and subsequent complications associated with treatment have been reported. Colonic irrigation has been used to treat defaecation disorders; however, it has not been used to treat radiation-induced proctitis. A pilot study was undertaken of 12 patients with haemorrhagic radiation proctitis after radiotherapy. Four patients had had cervical cancer, five had uterine cancer, one had prostatic cancer, one had vesical cancer and one had vaginal cancer. Daily self-administered colonic irrigation with tap water and a 1-week period of oral antibiotics (ciprofloxacin and metronidazole) were prescribed. The median dose of radiation given was 54 (50-70) Gy. The median interval from radiation to the development of haemorrhagic proctitis was 26 (8-44) months. The median duration of symptomatic rectal haemorrhage prior to treatment was 8 (1-48) months. There was a significant improvement in rectal bleeding after treatment with colonic irrigation and oral antibiotic administration, accompanied by an improvement in bowel frequency and urgency, and diarrhoea. There were no complications. The majority of the patients (11/12) were satisfied with the treatment. The five patients who had previously undergone formalin therapy preferred the treatment regimen used in this study. The preliminary results of colonic irrigation and oral antibiotics indicate that this treatment is safe and effective for radiation-induced proctitis. Further study is warranted.

Radiation Proctitis: Current Strategies in Management

Radiation proctitis is a known complication following radiation therapy for pelvic malignancy. The majority of cases are treated nonsurgically, and an understanding of the available modalities is crucial in the management of these patients. In this paper, we focus on the current treatments of radiation proctitis.

SU-GG-J-26: Comparison of Intrafractional Motion between Supine and Prone Patient Positions during Radiation Therapy of Pelvic Malignancies Using a 3D Surface Imaging System

Purpose: To compare intrafractional motion between supine and prone positions during radiation therapy of pelvic malignancies using a 3D surface imaging system. Method and Materials: Five patients with pelvic malignanciestreated with radiation therapy were enrolled, three treated in supine and two in prone position. For each patient, both supine and prone position simulation CTs were performed. Body surfaces were generated from simulation CT and then exported to AlignRT as reference images.AlignRT motion tracking was performed for both supine and prone position for each patient once per week for five weeks. The length of the tracking record was between 1.5 to 2 minutes. The maximum and the standard deviation of patient displacement were calculated and compared along the vertical, longitudinal and lateral directions for both positions. Results: A fairly strong correlation was observed between the intrafractional displacement and the BMI. Generally, the displacements were smaller in prone position for patients with a normal BMI in both vertical and longitudinal directions. This is reasonable as the magnitude of the respiratory induced motion is compressed to be smaller in prone position. This phenomenon was reversed for the obese patient with a large BMI value of 30, where the intrafractional displacement was smaller in supine position. For obese patients, it is more difficult to hold still on their large belly with regular respiratory motion. In lateral direction, however, the intrafractional motion did not have statistically difference between supine and prone positions for all the patients. Conclusion: The intrafractional motion between supine and prone position during radiation therapy of pelvic malignancies depends on patient's BMI. Normal BMI patients have a smaller intrafractional motion in prone position in vertical and longitudinal directions, while obese patients have a smaller motion in supine position.

Hemorrhagic cystitis: A challenge to the urologist

Severe hemorrhagic cystitis often arises from anticancer chemotherapy or radiotherapy for pelvic malignancies. Infectious etiologies are less common causes except in immunocompromised hosts. These cases can be challenging problems for the urologist and a source of substantial morbidity and sometimes mortality for the patients. A variety of modalities of treatment have been described for the management of hemorrhagic cystitis but there is none that is uniformly effective. Some progress has been made in the understanding and management of viral hemorrhagic cystitis. This article reviews the common causes of severe hemorrhagic cystitis and the currently available management options.

Functional MRI-guided Bone Marrow-sparing Intensity Modulated Radiotherapy for Pelvic Malignancies

Functional MRI-guided Bone Marrow-sparing Intensity Modulated Radiotherapy for Pelvic Malignancies

Probiotic Therapy in Radiation‐Induced Intestinal Injury and Repair

Intestinal injury from ionizing radiation is a clinically important entity, as enteritis symptoms occur commonly after radiotherapy for pelvic malignancies. Preventative or therapeutic options for radiation enteritis are mostly unsatisfactory; however, available data suggests that probiotic bacteria--those which confer health benefit--may have therapeutic value. Previous reports from both human trials and animal models have evaluated various end points for probiotic usage in limiting radiation-associated intestinal damage. Newer data suggests that particular probiotics and/or their secreted or derived bacterial products may have unique radioprotective properties. We will review the area with a focus on new developments surrounding probiotic therapy in radiation-induced intestinal injury and repair.

Cytoprotective Efficacy of Amifostine Against Radiation- Induced Rectal Toxicity: Objective and Subjective Grading Scales for Radiomucositis

Curative radiation therapy of pelvic malignancies, frequently results in dose-limiting toxicities such as serous, mucoid, or more rarely, bloody diarrhea. Several studies have evaluated the cytoprotective effects of amifostine in preventing rectal mucositis associated with radiation treatment. We searched Medline for published comparative studies that evaluated the use of amifostine to reduce radiation-induced toxicity associated with pelvic irradiation. In ten studies there was an evidence-based cytoprotection (P<0.05) by amifostine. Although results are variable, current evidence suggests that amifostine may have a radioprotective effect in the rectal mucosa, particularly when administered intrarectally. Significant improvements were seen in both symptomatic and objective (rectosigmoidoscopy) end points. There is a need to conduct well-designed clinical trials with sufficient numbers of participants to confirm these findings together with a cost-benefit study. Objective measurements using rectosigmoidoscopy are superior to subjective measures such as WHO or RTOG/EORTC toxicity grading scales.

Rebampide enema therapy as a treatment for patients with chronic radiation proctitis: initial treatment or when other methods of conservative management have failed

Radiation proctitis is a common complication following radiation therapy for pelvic malignancies. There have been no formal trials of treatment for radiation proctitis and a variety of methods are currently used. We assessed the efficacy of rebamipide enema to control symptoms and proctoscopic findings from radiation proctitis. Fifteen patients with radiation proctitis were enrolled. Enemas containing 150 mg rebamipide per dosing were administered after morning bowel movement, and always prior to bedtime, twice daily for 4 weeks. The efficacy of treatment was assessed from clinical symptoms (Subjective Objective Management Analysis Scale for Rectal Toxicity) and endoscopic findings. The mean bleeding score improved from 2.67 to 0.53 (P < 0.01). The mean symptom scores improved in those patients who had pain (0.40 to 0.13), tenesmus (0.40 to 0.20), and stool frequency (0.27 to 0.13). The mean improvement in telangiectasia scores (2.13 to 0.80, P < 0.01), bleeding point scores (1.80 to 0.27, P < 0.01), and friable mucosa scores (1.33 to 0.20, P < 0.01) were all statistically significant. No side effects were noted in any patients. Rebamipide enema therapy for radiation proctitis is a safe and effective treatment of radiation proctitis. We suggest the value of rebamipide enema in the treatment of radiation proctitis when other conservative management or first treatment has failed.