Rectal Tenesmus Research Articles

A Dose-finding and Biomarker Evaluation Phase Ib Study of Everolimus in Association With 5-Fluorouracil and Pelvic Radiotherapy as Neoadjuvant Treatment of Locally Advanced Rectal Cancer (E-LARC Study)

BackgroundDuring the past 20 years, considerable improvement has occurred in the treatment of patients with locally advanced rectal cancer (LARC). With the introduction of multimodal treatment, refinements in preclinical staging and improvements in surgical skills, local relapse is no longer the major problem for patients with LARC. However, many patients die of metastatic disease. The present phase Ib study aimed to establish the maximum tolerated dose of everolimus combined with 5-fluorouracil and radiotherapy in patients with LARC. Patients and MethodsPatients were sequentially assigned to 4 cohorts with an increasing dose of everolimus, starting from 14 days before 5-fluorouracil and radiotherapy and continuing throughout concomitant treatment. The secondary endpoints were the Dworak tumor regression grade, pathologic complete response rate, neoadjuvant rectal score, biomarker assessment (phosphorylated mTOR [mammalian target of rapamycin] protein and phosphorylated-p70S6K protein). ResultsAt the time of this report, 12 patients had been treated, and no dose-limiting toxicity was recorded. The most frequently reported acute toxicities were rectal tenesmus, skin rash, diarrhea, and dysuria. All 12 patients underwent curative R0 resection. Two patients had Dworak tumor regression grade 4 (pathologic complete response). No everolimus-related postoperative complications were observed. No relationship was found between biomarker expression and the clinicopathologic outcomes. ConclusionAlthough the addition of everolimus did not appear to worsen the toxicity of chemoradiation in patients with LARC, evaluation of its activity deserves further investigation in larger clinical trials.

Subepithelial rectal gastrointestinal stromal tumor \u2013 the use of endoscopic ultrasound-guided fine needle aspiration to establish a definitive cytological diagnosis: a case report

BackgroundGastrointestinal stromal tumors are the most common mesenchymal neoplasms affecting the gastrointestinal tract. The stomach is the most common location to be affected, and the rectum one of the rarest, but the whole gastrointestinal tract remains susceptible. Gastrointestinal stromal tumors account for only 0.1% of rectal tumors. Currently, endoscopic ultrasound plays an essential role in the diagnostic process of gastrointestinal stromal tumors, especially when the affected sites have a worse outcome and higher morbidity rates.Case presentationWe describe the case of a 68-year-old white Japanese man with a history of long-term mild rectal pain and tenesmus. A digital rectal examination revealed a right palpable solid mass ranging from 3 to 7 cm from his anal verge. A colonoscopy was performed and showed a 5 cm elevated lesion covered by normal mucosa, located 4 cm above the pectineal line. Endoscopic ultrasound confirmed the diagnosis of a homogeneous hypoechoic mass with areas of necrosis as a rectal subepithelial lesion originating at the fourth layer (muscularis propria). He then underwent endoscopic ultrasound-guided fine needle aspiration of the lesion, followed by cytological and immunohistochemistry evaluation. The evaluation showed spindle and epithelioid cells of variable sizes, in fascicles separated by stroma, which reacted firmly and consistently to CD117/c-kit and CD34, and negative to desmin and S-100 protein. There was weak staining for nuclear Ki-67 in the tumor cells. A diagnosis of rectal gastrointestinal stromal tumor was confirmed. After a multidisciplinary meeting, an abdominoperineal resection of his rectum was performed. The pathology of the specimen confirmed the diagnosis of rectal gastrointestinal stromal tumor. He is now asymptomatic after 3 months’ follow-up and is on adjuvant therapy with a tyrosine-kinase inhibitor.ConclusionsGastrointestinal stromal tumors are rare tumors, and among the variety of primary location sites, the rectum is one of the rarest. The localization of this type of tumor has worse outcomes and higher morbidity rates. We report this rare case to emphasize the need for precise diagnosis and the important role of endoscopic ultrasound-guided fine needle aspiration in such situations.

A systematic review of the effectiveness of palliative interventions to treat rectal tenesmus in cancer

Background: Rectal tenesmus is a distressing symptom in patients with advanced cancer and challenging to treat. There is lack of consensus on the appropriate management of tenesmus in this patient population. Aim: To identify and examine the effectiveness of interventions to palliate rectal tenesmus caused by advanced cancer when surgery, radiotherapy or chemotherapy are no longer treatment options. Design: A systematic review of the literature following standard systematic review methodology and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidance. Data sources: A comprehensive search of the electronic databases MEDLINE, EMBASE and the Cochrane Library was conducted from date of inception to April 2016. PubMed ‘related articles’ search, grey literature search and hand-searches of the bibliographies of relevant papers and textbooks were also performed. Non-cancer patients were excluded. Any studies involving surgery or radiotherapy to treat tenesmus were excluded. Studies involving interventions to treat pelvic pain syndromes without specific outcome measures on severity of tenesmus were excluded. The quality of the studies was assessed using a National Institute for Health and Clinical Excellence–recommended quality assessment tool. Results: From 861 studies, 9 met full criteria and were selected. All were case series investigating the use of pharmacological interventions (diltiazem, nifedipine, methadone, mexiletine hydrochloride, lidocaine and bupivacaine), anaesthetic interventions (lumbar sympathectomy, neurolytic superior hypogastric plexus block), and endoscopic laser interventions. The included studies showed substantial heterogeneity, and therefore, a meta-analysis was not feasible. Conclusion: From this review, we identified a significant gap in research into the palliation of rectal tenesmus. A multimodal approach may be necessary due to the complexity of the pathophysiology of tenesmus. Future research should focus on randomised controlled trials of drug therapies whose potential effectiveness is suggested by case series.

Restorative resection of radiation rectovaginal fistula can better relieve anorectal symptoms than colostomy only

BackgroundRadiation-induced rectovaginal fistula (RVF) is a severe and difficult complication after pelvic malignancy radiation. This study was to retrospectively compare the outcomes of restorative resection and colostomy only in remission of anorectal symptoms.MethodsWe enrolled a cohort of 26 consecutive cases who developed RVF after pelvic radiation. Two main procedures for these patients in our institution were used: one was restorative resection and pull-through coloanal anastomosis with a prophylactic colostomy, and another was a simple colostomy without resection. Thus, we divided these patients into these two groups. Anorectal symptoms including rectal pain, bleeding, tenesmus, and perineal mucous discharge were recorded and scored prior to surgery and at postoperative multiple time points.ResultsThe baseline was similar among the two groups. All patients acquired good efficacy with improved symptoms at postoperative 6, 12, and 24 months, when compared to baseline. In addition, the resection group showed a better remission of tenesmus (6 months 33.3 vs 0%; 12 months 66.7 vs 16.7%) and perineal mucous discharge (6 months 88.9 vs 6.7%; 12 months 77.8 vs 15.4%; 24 months 85.7 vs 25.0%). Furthermore, three (30%) patients in the resection group successfully reversed stomas while no stoma was closed in the simple colostomy group.ConclusionsBoth restorative resection procedure and colostomy only can improve anorectal symptoms of radiation-induced RVF, but restorative resection can completely relieve anorectal symptoms in selected cases.

Effect of diagnostic delay on survival in patients with colorectal cancer: a retrospective cohort study.

BackgroundDisparate and contradictory results make studies necessary to investigate in more depth the relationship between diagnostic delay and survival in colorectal cancer (CRC) patients. The aim of this study is to analyse the relationship between the interval from first symptom to diagnosis (SDI) and survival in CRC.MethodsRetrospective study of n = 942 CRC patients. SDI was calculated as the time from the diagnosis of cancer and the first symptoms of CRC.Cox regression was used to estimate five-year mortality hazard ratios as a function of SDI, adjusting for age and gender. SDI was modelled according to SDI quartiles and as a continuous variable using penalized splines.ResultsMedian SDI was 3.4 months. SDI was not associated with stage at diagnosis (Stage I = 3.6 months, Stage II-III = 3.4, Stage IV = 3.2; p = 0.728). Shorter SDIs corresponded to patients with abdominal pain (2.8 months), and longer SDIs to patients with muchorrhage (5.2 months) and rectal tenesmus (4.4 months).Adjusting for age and gender, in rectum cancers, patients within the first SDI quartile had lower survival (p = 0.003), while in colon cancer no significant differences were found (p = 0.282). These results do not change after adjusting for TNM stage.The splines regression analysis revealed that, for rectum cancer, 5-year mortality progressively increases for SDIs lower than the median (3.7 months) and decreases as the delay increases until approximately 8 months. In colon cancer, no significant relationship was found between SDI and survival.ConclusionsShort diagnostic intervals are significantly associated with higher mortality in rectal but not in colon cancers, even though a borderline significant effect is also observed in colon cancer. Longer diagnostic intervals seemed not to be associated with poorer survival. Other factors than diagnostic delay should be taken into account to explain this “waiting-time paradox”.

CC2 Does mycoplasma genitalium cause proctitis? A case report

Background/introduction Mycoplasma genitalium is an emerging sexually transmitted pathogen implicated in urethritis in men and cervicitis and pelvic inflammatory disease in women. The overall prevalence of rectal mycoplasma genitalium was 4.4% in one study of MSM. However, symptomatic disease is not well reported. Aims/objectives We describe a case of symptomatic rectal mycoplasma genitalium Methods Retrospective case not review Results A 19 year old MSM attended with a 2 week history of rectal bleeding, discharge and tenesmus. His last sexual contact was 6 weeks previously: condom-less receptive anal intercourse. On examination, he had no lymphadenopathy, no rash and no evidence of oral ulceration. On proctoscopy, he had erythematous mucosa and multiple small discrete rectal ulcers. Triple site swabs were taken including gonorrhoea culture, rectal swab for LGV and multiplex PCR (syphilis, HSV and mycoplasma genitalium). A full blood borne virus screen was performed. He was treated with ceftriaxone (500 g IM), azithromycin (1 g PO), doxycycline (100 mg PO BD for 7 days) and acyclovir (400 mg PO TDS for 5 days) but his symptoms did not resolve. All tests were negative except rectal multiplex PCR was positive for mycoplasma genitalium. He was diagnosed as having symptomatic mycoplasma genitalium infection and was treated with a prolonged course of azithromycin. His symptoms subsided. Discussion/conclusion Mycoplasma genitalium has been found in the rectum of MSM and is usually asymptomatic. We describe a case of proctitis which seems to be related to Mycoplasma genitalium. MSM with unresolved proctitis should be tested for Mycoplasma genitalium.

Perineal herniorrhaphy in a dog using a cone-shaped polypropylene mesh implant

A 10-year-old neutered male shih tzu was presented due to a history of rectal tenesmus, dyschezia and constipation for the previous two months. Physical assessment disclosed swelling on the left...

Heterotopic gastric mucosa in the rectum: Report of a case

Abstract Background Ectopic gastric mucosa has been described in different locations of the digestive tract, but that of the rectum is the least frequent. Clinical case The case is described of a 48 year-old woman being investigated by the gastrointestinal department due to rectal bleeding and rectal tenesmus. Colonoscopy showed a diverticular cavity 3 cm, which was reported by histology as fundic-type heterotopic gastric mucosa. Barium enema and abdominopelvic CT showed a diverticular image at level of the right posterolateral wall of the rectal ampulla. Trans-rectal diverticulectomy was performed with primary closure of the resulting mucosal defect. The surgical specimen showed areas of gastric epithelium with no signs of atypia. Conclusions It is not known whether the origin of heterotopic gastric mucosa occurs during foetal development or is the result of abnormal regeneration under inflammatory conditions. It is usually clinically asymptomatic or presents as haematochezia, especially in cases where gastric acid is being produced. In these cases there must be an initial treatment with proton pump inhibitors, although the definitive treatment is always surgical or endoscopic excision of the mucosa.

Anorectal melanoma and seborrheic dermatitis - a case report

Anorectal melanoma (ARM) is a rare and aggressive neoplasm with predisposition for early infiltration, distant spread, and unfavorable prognosis. It has been speculated that Malassezia yeasts could possibly have an impact on skin carcinogenesis and development of melanoma, especially in patients with seborrheic dermatitis (SD), due to production of aryl hydrocarbon receptor (AhR) agonists. A 52-year-old man with intensive SD complained of a four-month-long rectal bleeding, tenesmus, pain, and difficulty during defecation. On examination, a rectal tumor was detected and histopathology of tumor tissue revealed ARM with positive protein S100, melanoma antigen HMB45 and melan-A expression. After the diagnosis was established, abdominoperineal resection of the anus and rectum was performed, since the tumor was large, obstructive, and the anal sphincter was invaded. Because of the possible impact of intensive SD to the cross-link between Malassezia yeasts AhR agonists and skin carcinogenesis, we discussed on this matter and reviewed the literature data regarding ARM. In addition to “pathogenic” and “non-pathogenic” Malassezia subtypes based on AhR agonist production, future studies on Malassezia metabolites, their carcinogenic effect in the skin and development of melanoma are needed. If the cross-link between Malassezia AhR agonists and skin carcinogenesis exists, timely prevention of ARM could be done with Malassezia eradication, especially in patients with severe SD.

Pigmented perianal macules.

Primary mucosal melanoma occurs in under 2% of melanomas. Anorectal melanoma is a rare disorder, approximately accounting for 1% of all anorectal carcinomas. Primary anorectal melanoma presents predominantly in women, in the 4th-6th decade of life. Typical clinical manifestations include rectal bleeding and tenesmus. The prognosis remains poor.

Patient and Clinician Reported Acute Toxicity During Preoperative Chemoradiation for Locally Advanced Rectal Cancer

Preoperative pelvic radiation therapy (RT) with concurrent 5-Fluorouracil (FU)-based chemotherapy is the standard of care for patients with locally advanced rectal cancer. Pelvic RT is associated with significant acute toxicities that can adversely impact a patient’s quality of life. As opposed to 3D conformal RT (3DCRT), intensity modulated RT (IMRT) allows for more focal dose delivery, thus sparing normal tissues. We compared clinician reported acute toxicity profiles between patients treated with IMRT and 3DCRT and described patient reported outcomes (PROs) for IMRT patients. We retrospectively reviewed records of 335 consecutive rectal cancer patients treated with preoperative pelvic RT at our institution from 2007–2014. Clinical information, including weekly acute toxicity graded according to the CTCAE v3.0, was collected. Weekly PROs using a 7 or 14-item questionnaire based on the Bowel Problems Scale, and NCI PRO-CTCAE were also collected for 150 patients treated with IMRT from 2009–2014. Symptom frequency, severity and interference with daily activities were reported on a 5-point Likert-type scale between 1-“not at all” and 5-“very frequently” A clinically meaningful PRO score was defined as ≥3. Fisher exact test was used to test for statistical differences. The median age was 56 years (range, 22–93) and 202 (60%) patients were male. The majority of patients had clinical stage T3 (79%) and N+ (79%) disease. Of the 335 patients, 229 (68%) were treated with IMRT and 106 (32%) with 3DCRT. All patients received concurrent 5-FU-based chemotherapy with no significant difference in the median RT dose between the two cohorts. Significantly fewer patients experienced ≥grade 2 diarrhea in the IMRT group compared to the 3DCRT group (11% vs 22%, P = .02). While no grade 3 cystitis or proctitis occurred in either groups, fewer patients experienced grade 2 cystitis in the IMRT group (5% vs 12% 3DCRT, P = .02), and there was a trend towards decreased grade 2 proctitis in the IMRT group (19% vs 28% 3DCRT, P = .06). Of the 150 IMRT patients who completed PROs, a high proportion reported PRO scores ≥3 for diarrhea (65%) and urgency (73%). About half of the patients experienced rectal pain (53%) and tenesmus (49%), with fewer complaining of abdominal cramping (42%), rectal bleeding (34%) and loss of bowel control (30%). In this large cohort of patients undergoing preoperative chemoradiation for locally advanced rectal cancer, compared to the use of 3DCRT, the use of IMRT significantly reduced lower gastrointestinal and genitourinary toxicity during treatment as measured by clinicians. Patient reported outcomes show that lower gastrointestinal toxicity is experienced frequently amongst patients treated with IMRT. Further studies are needed to determine the best method to assess the impact of IMRT on treatment related toxicities.

Enfermedad pélvica inflamatoria: diagnóstico y complicaciones

El diagnóstico de la enfermedad pélvica inflamatoria (EPI) puede ser difícil por lo variable de su presentación, y abarca desde una paciente agudamente enferma hasta cuadros asintomáticos. El síntoma más común es el dolor abdominal bajo (90%), otros síntomas son dispareunia, flujo vaginal y sangrado vaginal anormal, urgencia miccional, náuseas, vómitos y tenesmo rectal, entre otros. Para el diagnóstico se necesita uno de los siguientes hallazgos: dolor a la movilización cervical, a la palpación del útero o en la palpación anexial. Algunos exámenes auxiliares mejoran el criterio diagnóstico: aumento de leucocitos en la secreción vaginal, aumento de la velocidad de eritrosedimentación y la identificación de N. gonorrhoeae o C. trachomatis a nivel cervical. Otras pruebas útiles son los estudios por imágenes: ultrasonido, tomografía computarizada y resonancia magnética. El estándar de oro es el examen laparoscópico, aunque existen comunicaciones que señalan que la biopsia de endometrio puede complementar el diagnóstico, cuando no existe evidencia de enfermedad durante el examen laparoscópico. Se recomienda tener un umbral bajo para el diagnóstico de EPI, para que las complicaciones agudas perihepatitis, periapendicitis o rotura del absceso tuboovárico- o las crónicas -dolor pélvico crónico, infertilidad y embarazo ectópico- comprometen la salud sexual y reproductiva de las pacientes.

A phase IIb trial of docetaxel concurrent with radiotherapy plus hormotherapy versus radio hormonotherapy in high-risk localized prostate cancer (QRT SOGUG trial): Preliminary report for design, tolerance, and toxicity.

15 Background: Docetaxel improves survival in patients (pts) with metastatic hormonosensitive prostate cancer (PC) and castration-resistant prostate cancer. The objective of this phase IIb trial was to assess the activity of low dose docetaxel concurrent with radiotherapy plus standard hormonal treatment in pts with high risk localized CaP. Methods: High-risk localized CaP was defined by ≥ 1 of the following criteria: T3-T4, Gleason score (GS) ≥ 8, PSA > 20 ng/mL, pN+. Pts were randomly assigned to either arm A (LH-RH analogs every 3 months for 3 years and radiotherapy 73.8 Gy [1.8 Gy x 41 fractions] or 74 Gy [2Gy x 37 fractions]) or arm B (LH-RH analogs every 3 months for 3 years, radiotherapy and concurrent weekly docetaxel at 20 mg/m2 for 9 weeks). Chemotherapy was started one week before of radiotherapy. Primary endpoint was PSA relapse according to the Phoenix definition. The planned number of pts was 130 to detect a 15% difference with a power of 80% and an alpha of 0.05 (two-sided). Results: From 12/2008 to 9/2012, 130 pts were accrued (Arm A: 64, Arm B: 66). Median age was 68 years (61-73). Patients had T3-T4 (82.6%), GS ≥ 8 (76.3%), PSA > 20 ng/mL (26.9%) and pN+ (18.9%). All characteristics were well-balanced between arms. Median dose of radiotherapy was 74 Gy (72–74.8) in arm A, and 73.8 Gy ( 72-75.6) in arm B. 75.7% of pts received the planned 9 treatments of docetaxel and median number of cycles delivered per patient was 9. After a median follow-up of 29.6 months (9.6-40.2), most common grade 1/2 toxicities (arm A and arm B) were: cystitis ( 12.5% vs 8.3%), diarrhea (35.9% vs 70%), proctitis (12.5% vs 13.3%), rectal tenesmus (3.1% vs 23.3%), asthenia (23.4% vs 61.6%) and dysuria ( 28.1% vs 30.0%). Toxicity G3/G4 diarrhea was reported in 8.3% of pts in arm B and 0% in arm A. G3/G4 lymphopenia occurred less often in arm A than in arm B (3.1% vs 23.3%). %). There was no toxicity-related death. Conclusions: The QRT SOGUG phase IIb trial met its accrual target and shows that concurrent weekly docetaxel can be administered with standard doses of radiotherapy and without increasing toxicity profile. Clinical trial information: 2008-003554-14.

終末期がん患者の直腸テネスムスに対して，アモキサピン内服とリドカイン持続静注が奏効した1例

終末期がん患者の直腸テネスムスに対して，アモキサピン内服とリドカイン持続静注が奏効した1例

The Impact of Race on Prostate-Cancer Specific Mortality Among Men With Low-Risk Disease: Potential Implications for Active Surveillance

Purpose/Objective(s): To report the efficacy and toxicity profile of highdose-rate (HDR) interstitial brachytherapy (BRT) as monotherapy in prostate cancer patients (pts) with localized disease. Materials/Methods: Between January 2009 and December 2012 78 patients (pts) with localized prostate cancer (T1 T2c) underwent conformal HDR monotherapy. The mean age of pts was 68 years (range 49-83), mean PSA level and Gleason score were 7,985 ng/ml and 6, respectively. Three fractions of 15Gy were delivered every 3 weeks using an Iridum-192 source and transrectal ultrasound (TRUS) guided treatment planning. Biochemical failure was defined according to the Phoenix consensus. Toxicity was evaluated using EORTC/RTOG scales. Results: The median follow-up time was 20,4 months. The 24and 48month biochemical control and metastases-free survival rates were 98 %, 95 % and 100%, 98%, respectively. Four-year overall survival was 100%. The most common acute urinary symptoms were: urinary urgency, urinary frequency, dysuria and nocturia (G1 50,2% and G2 17,6% of pts). The rectal symptoms (rectal urgency, frequency and tenesmus) were rare (4,3%). No grade 3 and 4 acute toxicities, both of genitourinary and gastrointestinal system, were reported. Two patients developed urethrostenosis needed urological intervention. Conclusions: Our results confirm that HDR-BRT as monotherapy is safe and effective modality for clinically localized prostate cancer. Author Disclosure: D. Kazberuk: None. T. Filipowski: None. A. Szmigiel-Trzcinska: None.M. Niksa: None. D. Hempel: None. B. PancewiczJanczuk: None. W. Nowik: None.

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Hemorrhoidal laser procedure: short- and long-term results from a prospective study

BackgroundWe report the results of 2-year regular use of the hemorrhoidal laser procedure (HeLP) in 97 patients with symptomatic second- to third-grade hemorrhoids with minimal or moderate internal mucosal prolapse. MethodsData on duration of the procedure, perioperative complications, postoperative pain, downgrading of hemorrhoids, resolution or persistency, and recurrence of hemorrhoidal disease (HD) were prospectively collected. ResultsNo significant intraoperative complications occurred. The median follow-up was 15 months. Postoperative pain was null in most patients. There were no cases of rectal tenesmus or alteration of defecation habits. Symptoms and HD downgrading reached a “plateau” at 3 to 6 months after the HeLP. At this evaluation, frequency of bleeding, pain, itching, and hemorrhoidal acute syndrome decreased by 76% to 79%. HD grade showed a significant reduction. HD recurrence rate was 5% at 2 years. ConclusionsOur study demonstrates that the HeLP is a safe, effective, and painless technique for the treatment of symptomatic second- to third-grade hemorrhoids with minimal or moderate mucosal prolapse, ideally suitable as ambulatory treatment.

Orphan symptoms in advanced cancer patients followed at home

Orphan symptoms are rarely assessed, particularly at home. The aim of this multicenter prospective study was to assess the prevalence of these symptoms and eventual factors possibly associated in advanced cancer patients at admission of a home care program. A prospective study was performed at three home care programs in Italy. Patients' data were collected, including age, sex, diagnosis, and Karnofsky status. Possible contributing factors were analyzed; preexisting neurological diseases, cerebral metastases, hyperthermia, diabetes, a state of dehydration clinically evident and/or oliguria, possible biochemical parameters when available, data regarding recent chemotherapy, opioids and doses, use of neuroleptics, benzodiazepine or anticonvulsants, corticosteroids, anti-inflammatory, and antibiotics were collected. Myoclonus, hiccup, sweating, pruritus, and tenesmus, either rectal or vesical, were assessed, according to a preliminary definition, at time of home care program admission. Three hundred sixty-two patients were surveyed at the three home care programs. Globally, 48 patients presented one or more orphan symptoms in the period taken into consideration, and 7 patients presented more than 1 symptom. One patient presented occasional and diffuse myoclonus. Nineteen patients presented sweating, 13 patients presented pruritus, and 14 patients presented hiccup. Finally, nine patients presented rectal or vesical tenesmus. There was a significant correlation between sweating and transdermal fentanyl use (P = 0.044), fever (P = 0.001), hiccup (P < 0.0005), and vesical tenesmus (P = 0.028). Pruritus was not associated to any factor. Hiccup was associated with gender (males, P = 0.006) and sweating (P < 0.0005). Vesical tenesmus was associated with fever (P = 0.019) and sweating (P = 0.028). Although the symptoms examined have a low prevalence in advanced cancer patients admitted to home care, the distress for patients may be high and deserve further analyses. Given the low prevalence of these symptoms, large studies are needed to find possible associated factors.

Marked Improvement in Severe and Refractory Formalin Colitis with Retinyl Palmitate Suppositories

Purpose: To describe clinical usage of retinyl palmitate suppositories for the treatment of severe formalin colitis. Description: An 80-year-old male developed chronic radiation proctopathy (CRP) after receiving external beam radiation for prostate cancer. This was characterized by periodic rectal bleeding that did not respond to 5-aminosalicylic acid suppositories or short-chain fatty acid enemas. Rectal instillation of formalin was performed under general anesthesia using two aliquots of 100 and 200 ml of unknown concentration with three-minute contact time for each instillation, followed by removal with irrigation and suctioning. Formalin instillation was immediately followed by hospitalization for fever and abdominal pain, requiring IV fluids and antibiotics. Sigmoidoscopy revealed diffuse severe inflammation of the rectum and sigmoid colon (Figure 1). A subsequent perforation occurred and was managed conservatively during a prolonged hospitalization. Despite 50 hyperbaric oxygen sessions and a laparoscopic diverting loop ileostomy, the patient continued to have debilitating rectal pain and tenesmus. He received retinyl palmitate suppositories 20,000 IU daily as part of an open-label study of this treatment for CRP. He had resolution of all symptoms with a decrease in Radiation Proctopathy Symptom Assessment Score from 21 to six. Sigmoidoscopy performed after 90 days of therapy revealed only mild colonic inflammation (Figure 2). No adverse events or change in serum vitamin A occurred during the trial. He has since undergone ileostomy closure and has remained symptom-free on daily suppository treatment. Retinyl palmitate suppositories represent a useful, well-tolerated therapy for formalin colitis.Figure 1Figure 2

Salvage Radiotherapy to the Prostatic Fossa Using Volumetric-modulated Arc Therapy: Early Results

Objectives: Volumetric-modulated arc therapy (VMAT) is better than intensity-modulated radiotherapy (IMRT) in terms of its plan qualities and efficiency for the treatment of prostate cancer. It remains unclear whether its use in salvage radiotherapy to prostatic fossae is safe and effective. Herein we report the dosimetric and clinical results of salvage radiotherapy to prostatic fossae using VMAT. Methods: Fifteen consecutive patients with a rising prostate-specific antigen after radical prostatectomy in our institution received salvage radiotherapy using VMAT. Prostate-specific antigen control and acute toxicities within 1 year after treatment were retrospectively reviewed. For comparison, IMRT plans were also generated for 12 of these patients and the quality of these plans in terms of organ-at-risk sparing (volume of bladder and rectum receiving 60 and 70 Gy), target coverage (conformation number and the prescribed dose of D90), and the number of monitor units. Results: After salvage radiotherapy using VMAT, all patients had a decrease in their prostate-specific antigen with a complete response rate of 87%. The recorded toxicities were rectal bleeding, tenesmus, urinary frequency, nocturia, and urinary incontinence. After a median follow-up of 20 months, two patients endured treatment failure. There was no significant difference between the VMAT and IMRT plans in terms of quality. The mean number of monitor units by VMAT (488) was significantly smaller than that used by IMRT (519) [p < 0.001]. The mean beam-on time was 171 (range, 92-228) seconds with treatment delivered by VMAT. Conclusions: It is efficient, effective, and safe to use VMAT as salvage radiotherapy to the prostatic fossa.