Treatment Of Radiation Proctitis Research Articles

Progress in multidisciplinary treatment of hemorrhagic radiation proctitis

With the development and wide application of radiotherapy technology, the incidence of radiation proctitis (RP) caused by radiotherapy for pelvic malignant tumors tends to increase, especially the treatment of hemorrhagic RP (HRP) is very difficult. Complications such as intestinal necrosis and perforation cause great pain and inconvenience to patients. How to effectively and safely treat HRP is an urgent clinical problem to be solved. This article reviews the progress of multidisciplinary treatment of RP, especially HRP, in recent years, and focuses on the progress of formalin in the treatment of hemorrhagic radiation proctitis.

Management of Long-Term Toxicity From Pelvic Radiation Therapy.

Pelvic radiation therapy is an integral component in the treatment of various gastrointestinal, gynecologic, and genitourinary cancers. As survival rates from these malignancies improve, the prevalence of toxicity secondary to pelvic radiation has increased. Gastrointestinal toxicities are the most common complications and greatly impact quality of life. Toxicities can present in acute or late stages; although symptoms may be similar during both, the management may differ. Acute toxicities represent an inflammatory reaction in response to the radiation exposure, whereas late toxicities may arise as a result of small vessel disease, ischemia, and fibrosis. Currently, there are no large clinical trials and only limited guidelines on the management of late gastrointestinal radiation toxicities. Therapy is generally approached in a stepwise manner from medical to endoscopic to surgical methods. Several endoscopic therapies, such as the treatment of radiation proctitis with argon plasma coagulation and dilation of radiation bowel strictures, may prevent the need for surgical intervention, which may be associated with high morbidity and mortality. Given that late toxicities can occur years after radiation therapy, they are often difficult to recognize and diagnose. Successful management of late toxicities requires recognition, an understanding of the underlying pathophysiology, and a multidisciplinary approach. More dedicated research could clarify the prevalence of gastrointestinal pelvic radiation toxicities, permit a better understanding of the efficacy and safety profile of current therapies, and allow for the development of novel therapeutic approaches.

Preliminary clinical analysis of radiation proctitis treated with argon plasma coagulation combined with submucosal injection

Objective To preliminarily evaluate the clinical efficacy of endoscopic argon plasma coagulation (APC) combined with sub-mucosal injection of norepinephrine saline in the treatment of radiation proctitis (RP), especially for refractory RP. Methods Clinical data of 22 RP patients were retrospectively analyzed. The severity of RP was evaluated by a modified endoscopy scoring system (A) or Sherman′s classification (B). The criteria of successful treatment are the improvement of clinical symptoms or the cessation of bleeding (or only occasional traces of blood on the stools that do not need further treatment). Results All 22 patients were successfully treated. Among them, 18 patients (82%) had no bleeding. According to the classification of A, 15 patients (68%) had mild proctitis and 7(32%) experienced severe proctitis. Based on B classification, 9 patients (41%) were categorized as mild proctitis and 13(59%) as severe proctitis. Using the classification of A, the number of treatment sessions was significantly correlated with the endoscopic grade (or endoscopic total score)(Spearman’s r=0.86, P<0.001). Conclusions Preliminary evidence demonstrates that endoscopic APC combined with sub-mucosal injection of norepinephrine saline is not only effective for mild and moderate RP, but also maintains long-term efficacy for refractory RP. Modified endoscopy scoring system (A) assessment is more suitable for clinical application compared with B assessment. Key words: Radiation proctitis/argon plasma coagulation; Radiation proctitis/combined therapy; Treatment outcome

Evaluation of prophylactic and therapeutic effects of ruscogenin on acute radiation proctitis: an experimental rat model.

PurposeRadiation proctitis (RP) is inflammation and damage to the rectum, manifested secondary to ionizing radiation utilized for treatment. In this study, we evaluated the anti-inflammatory therapeutical and protective effects of ruscogenin in a model of acute RP.MethodsThirty-two Sprague-Dawley rats were divided into 4 groups (n = 8) as sham, control, treatment, and prophylaxis groups. Prophylaxis group and treatment group were dosed ruscogenin by oral gavage for 14 days pre- and postradiation. At the end of the 28th day, all subjects were sacrificed.ResultsHistopathological analysis showed a significant increase in cryptitis abscess, cryptitis and reactive atypia, and depth of lymphocytic infiltration of the control group, compared to the other groups (P < 0.05), while treatment and prophylaxis groups showed significant decreases (P < 0.05). Immunohistochemical analysis indicated that immunoreactivity were significantly higher in control group (P < 0.05, P < 0.001, and P < 0.01, respectively), but vice versa for treatment and prophylaxis groups. There was not any significant difference for fibroblast growth factor 2 immunoreactivity. The epithelium of control rectums indicated an increase in TNF-α immunoreactivity while other groups had significant decrease (P < 0.01). Electron microscopical findings were parallel to light microscopy.ConclusionIn this study, ruscogenin was observed to be effective on prophylaxis or treatment of acute RP. Although there are various reports on the treatment of the rectum damaged by acute RP in the literature, this could be the first study since there is no research indicating the ultrastructural effect of ruscogenin.

Hyperbaric Oxygen in the Treatment of Radiation Proctitis and Cerebral Necrosis

Hyperbaric Oxygen in the Treatment of Radiation Proctitis and Cerebral Necrosis

Systematic evaluation on curative effects of traditional Chinese medicine retention enemas for patients with radiation proctitis

Objectives To systematically evaluate the curative effects of traditional Chinese medicine retention enemas for patients with radiation proctitis. Methods Reports on randomized controlled trials (RCTs) on traditional Chinese medicine retention enemas in the treatment of radiation proctitis were searched in the Cochrane Library, PubMed, EMBASE, EBSCO, ISI, CNKI, VIP, WanFang Data and CBM databases. The publication dates were from inception to May 2014, and a literature screening, data extraction, quality evaluation and cross checks were independently conducted by two reviewers in accordance with the inclusion and exclusion criteria. A meta-analysis was then carried out using RevMan 5.3 software. Results In total, 14 RCTs were included, and of these, only 10 RCTs involving 702 patients were included in the meta-analysis. The meta-analysis showed that the total efficacy of traditional Chinese medicine retention enemas was higher for patients with radiation proctitis compared with that in control group, RR = 4.83, 95% CI (2.98, 7.84), P < 0.000 01; the results from four studies indicated that the improvement of clinical symptoms due to traditional Chinese medicine retention enemas was higher than that of the control group. Conclusions The implementation of traditional Chinese medicine retention enemas could improve the total efficacy of treatment and provide relief in patients with radiation proctitis.

Radiation Induced Cystitis and Proctitis - Prediction, Assessment and Management.

Cystitis and proctitis are defined as inflammation of bladder and rectum respectively. Haemorrhagic cystitis is the most severe clinical manifestation of radiation and chemical cystitis. Radiation proctitis and cystitis are major complications following radiotherapy. Prevention of radiation-induced haemorrhagic cystitis has been investigated using various oral agents with minimal benefit. Bladder irrigation remains the most frequently adopted modality followed by intra-vesical instillation of alum or formalin. In intractable cases, surgical intervention is required in the form of diversion ureterostomy or cystectomy. Proctitis is more common in even low dose ranges but is self-limiting and improves on treatment interruption. However, treatment of radiation proctitis is broadly non-invasive or invasive. Non-invasive treatment consists of non-steroid anti-inflammatory drugs (NSAIDs), anti-oxidants, sucralfate, short chain fatty acids and hyperbaric oxygen. Invasive treatment consists of ablative procedures like formalin application, endoscopic YAG laser coagulation or argon plasma coagulation and surgery as a last resort.

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

Effects of human amnion–derived mesenchymal stromal cell transplantation in rats with radiation proctitis

Background aimsMesenchymal stromal cells (MSCs) have been reported to be a promising cell source in cell therapy, and large amounts of MSCs can easily be isolated from human amnion. Therapeutic irradiation for intra-pelvic cancer often causes radiation proctitis; however, there is currently no effective treatment. We therefore investigated the effect of transplantation of human amnion–derived MSCs (AMSCs) in rats with radiation proctitis. MethodsAmnion was obtained at cesarean delivery, and AMSCs were isolated and expanded. Sprague-Dawley rats were γ-irradiated (5 Gy/d) at the rectum for 5 days. On day 5, AMSCs (1 × 106 cells) were intravenously transplanted. Rats were killed on day 8. Histological analyses were performed, and messenger RNA expression of inflammatory mediators was measured. In vitro, after γ-irradiation of rat intestinal epithelial cells (IEC-6), the cells were cultured with AMSC-conditioned medium (CM). The effect of AMSC-CM was evaluated by measurement of caspase-3/7 activity, p53 transcription activity and quantitative reverse-transcription–polymerase chain reaction for p53-target genes. ResultsHistological examination demonstrated that epithelial injury and infiltration of inflammatory cells in the rectum were significantly suppressed by transplantation of AMSCs. In vitro, the cell injury in IEC-6 cells induced by γ-irradiation was inhibited by AMSC-CM, which also inhibited the upregulation of p53 transcription activity, caspase-3/7 activity and p21 expression. ConclusionsTransplantation of AMSCs improved radiation proctitis, possibly through inhibition of cell injury and inflammatory reactions. AMSC transplantation should be considered as a new treatment for radiation proctitis.

Radiofrequency ablation for the treatment of radiation proctitis.

The main endoscopic therapy for radiation proctitis is argon plasma coagulation (APC); however treatment is not always successful. Radiofrequency ablation (RFA) is a possible treatment for radiation proctitis but data are scarce. The aim of this study was to report on the safety and efficacy of RFA in the treatment of radiation proctitis. This study was an open-label, retrospective, multicenter study of patients with chronic hemorrhagic radiation proctitis who were treated with RFA. Data included a three-item symptom score, the number of packed red blood cell transfusions, the lowest hemoglobin concentration, and complications, during the 6 months prior to and after RFA. Clinical success was defined as a decrease in the symptom score. Biological success was defined as an increase in the hemoglobin rate with equal or decreased number of transfusions required. A total of 17 patients underwent a median of 2 RFA sessions (range 1 - 4), without perioperative complications. Symptom scores decreased in 16 patients (clinical success 94 %), from a mean score of 3.6 (median 4) to 1.4 (median 1) (P < 0.01). Two patients developed rectal ulceration, with no local symptoms. During the 6 months after RFA, hemoglobin concentration increased in all 17 patients (from mean 8.3 ± 2.8 g/dL [median 7.5] to 11.3 ± 2.2 g/dL [median 11.0]; P < 0.01). Among 13 patients who were transfusion dependent prior to RFA (mean 7.2 ± 7.7 transfusions [median 4]), 9 patients (69 %) were weaned off transfusions after RFA. A significant increase in the hemoglobin level was observed in this subgroup of patients (from mean 7.2 ± 1.4 g/dL [median 7.3] to 10.7 ± 1.5 g/dL [median 10.5]; P < 0.001). Biological success was 100 %. RFA seems to significantly decrease clinical symptoms and increase the hemoglobin concentration, thus reducing the need for transfusions.

Diagnosis and Treatment of Radiation Proctitis

Radiation proctitis (RP) is a common side effect of radiation therapy to the pelvis. It often manifests as rectal bleeding. Endoscopic argon plasma coagulation (APC) is considered the best treatment option for symptomatic patients. Herein, a case with classical diagnostic features in an 85-year-old male with recent treatment for prostate cancer including therapeutic intervention using APC has been presented. This article is part of an expert video encyclopedia.

Prevention and treatment of radiation proctitis by retention enema

Objective To study the effect of prevention and treatment for patients with radiation proctitis by retention enema.Methods According to the digital table,120 patients with pelvic tumor treated with radiotherapy were randomly divided into two groups.The observation group was taken retention enema 2 to 14 days after radiotherapy once a day.The control group was taken retention enema when the patients with radiation proctitis after radiotherapy.The severity and frequency of radiation proctitis were observed in the two groups.Results The incidence of radiation proctitis in the observation group was 35.0％,which was significantly lower than that of the control group (83.3％) (χ2 =47.623,P =0.000).The severity of radiation proctitis was also significantly lower than that of control group.The incidence of Ⅱ and Ⅲ degree of radiation proctitis in the observation group were 3.3％,0,respectively,which were significantly lower than those of the control group (26.7％,6.7 ％) (χ2 =12.810、4.138,P =0.000、0.042).The total efficiency rate was 100.0％,which was significantly higher than that of the control group (72.0％)(χ2 =32.558,P =0.000).Conclusion Retention enema can effectively treat the radiation proctitis and the effect will be more significant if the retention enema starts soon after radiotherapy. Key words: Radiativity, proctitis ; Enema

Mo1619 Radiofrequency Ablation Treatment of Radiation Proctitis: Results From an European Collaborative Study

Mo1619 Radiofrequency Ablation Treatment of Radiation Proctitis: Results From an European Collaborative Study

Early treatment and prevention of the radiation proctitis—composite enemas containing sodium butyrate

Early treatment and prevention of the radiation proctitis—composite enemas containing sodium butyrate

The role of endoscopy in patients with anorectal disorders

The role of endoscopy in patients with anorectal disorders

Clinical Spectrum of Disease in a Hundred Veteran Patients with Radiation Proctitis

Purpose: Pelvic radiation therapy (RT), in particular to the prostate, can predispose to the development of neovascularization in the rectal mucosa, commonly termed radiation proctitis (RP). The spectrum of this disease varies from asymptomatic to major rectal bleeding. RP is seen in up to 20% of irradiated patients, with the interval varying from 3 months to several years after RT. While majority of these patients have low grade hematochezia, significant bleeding resulting in anemia, transfusion needs, and/or definitive treatment for RP is not rare. Given the limited literature on the natural history and paucity of large case series, we investigated the spectrum of disease in our veterans; a population that has a high prevalence of prostate cancer, many of whom are treated with RT. Methods: All veterans diagnosed with RP in the VA New York Harbor Health Care System, Brooklyn campus from 2000 to 2009 were identified by a retrospective review of our endoscopy database. Electronic medical chart review was then conducted to record the demographics, type of RT, mean duration to diagnosis of RP and clinical spectrum of RP. The degree of bleeding was assessed based on the presence of anemia, requirement of iron or blood transfusions or the need for endoscopic therapy. Results: One hundred patients with RP, all male, were identified. 60 were African Americans, 33 were Whites (7 unknown). Mean age at the diagnosis was 74 yrs. 78 received external beam RT, 8 brachytherapy, 7 both modalities (7 unknown). Mean interval from completion of RT to diagnosis of RP was 32 months (range: 3-228 months with exception of one patient diagnosed 11th day of RT requiring discontinuation). At the time of diagnosis, 53 had hematochezia, 9 had occult bleeding and 38 were incidentally found to have proctitis during endoscopy for other reasons (primarily screening). 13% required blood transfusions. At endoscopy, 81 had non-bleeding neovascularities, 12 had friable mucosa, 4 ulcers and 3 had active hemorrhage. Overall, 42% required endoscopic therapy, half of whom received two or more treatment sessions (mean 2.3). 36 patients received argon plasma coagulation (APC), 1 radiofrequency ablation, 3 both modalities, 1 Nd:Yag laser and 1 APC and endoclip. Conclusion: Radiation proctitis is not an uncommon sequela of pelvic radiation and has a wide spectrum of presentation varying from asymptomatic state to major rectal bleeding. Endoscopic intervention to ablate the neovascularities is frequently needed for control of bleeding. Prospective studies are needed to determine the best endoscopic modality for treatment of radiation proctitis.

Algumas considerações sobre a retite actínica

The article “Rectal dose assessment in patients submitted to high-dose-ratebrachytherapy for uterine cervix cancer” published in the present issue of RadiologiaBrasileira deals with a relevant theme currently discussed in radiotherapy and oncology.Radiation proctitis is condition of the rectum caused by ionizing radiation. It maybe acute (arising during or right after radiation therapy), and in these case is generallyself-limited. Symptoms of acute proctitis are diarrhea, eventual bleeding, mucus lossor constipation.Histological changes are limited to the mucosa, and the cells with a more rapidturnover are the most sensitive ones.Late radiation proctitis may occur up to two years after radiation therapy withmore severe symptoms: mucus loss, pain, rectal urgency, bleeding, ulceration, stenosisand even rectovaginal fistulas. In late radiation proctitis, histological findingscorrespond to changes of vascular nature and fibrosis of the subintimal layer.Radiation proctitis severity is directly proportional to the dose received and dosevolume, as well as to the number of fractions and the length of the interval betweenthem. It is this dose limitation (both in radiotherapy and chemotherapy) that producesbetter or worst results in the management of cancer.Radiation proctitis has been known for more than one century, but factorsdetermining a worsening in the prognosis such as association with other diseases(diabetes, hypertension, collagen diseases, etc.) have only recently been confirmed.Wherever possible, the treatment for radiation proctitis should be conservative.In the acute phase of the disease, symptomatic medication is generally enough to relievethe symptoms. The discomfort can be relieved with corticoid retention enema, besidesthe utilization of sulphasalazine. Major bleedings can be managed with argon lasertherapy. Although criticized by some authors, the utilization of hyperbaric oxygentherapy may also be useful. Colostomy should be the last resource to be adopted, inmost resistant cases

Advances in treatment of radiation proctitis

Advances in treatment of radiation proctitis

W1307 The Role of Argon Plasma Coagulation (APC) in the Treatment of Chronic Radiation Proctitis

Radiation proctitis is a common complication of radiation treatment for pelvic malignancies. Approximately 5 to 20 % of patients who receive radiation treatment will develop chronic complications including bleeding, fistulae and stictures. To date there are no standard recommendations for the treatment of the chronic blood loss from radiation proctitis. Studied treatments, including hyperbaric oxygen, formaldehyde, 5-ASA have had varied results. Endoscopic treatment is gaining popularity in the treatment of radiation proctitis with both APC and bipolar heater probe being studied. A number of case reports suggest APC may be useful and safe in the treatment of chronic radiation proctitis. However none have utilized a validated scoring system for treatment effect.We plan to study both the endoscopic and the clinical response of APC in the treatment of rectal bleeding from radiation proctitis. Method: Patients referred from radiation oncology with chronic blood loss from suspected radiation proctitis were approached for consent to participate in this study. The patients baseline rectal bleeding was scored using a five point bleeding scale; the patient then underwent a colonoscopy to confirm the source of bleeding. The severity of radiation proctitis was scored using a validated scoring system the rectal telangiectasia density grading score (RTG). Patients were then treated with APC and then re-evaluated in 8 weeks time. At this time, baseline bleeding score was obtained and RTG score evaluated with sigmoidoscopy. If further treatment was required the patient was again re-evaluated in 8 weeks time. Results: There were 19 patients enrolled in this study. Mean age was 72.1 (STD=8.0) and mean Hb is 134.2 g/l(STD=21.7). Three of them did not complete the study. Among the 16 patients who underwent the APC treatment, both the clinical bleeding score and RTG score were reduced after the treatment. The bleeding score reduced 0.93±1.34 (Mean ±STD), while the RTG score reduced 0.81±0.98 (Mean ±STD). The p-values for comparing the pre and post treatment bleeding and RTG scores were 0.02 and <0.01 (Wilcoxon signed ranked test) respectively. Conclusion: In this small prospective trial, APC treatment for radiation proctitis improves the clinical bleeding score and the endoscopic outcomes.

Treatment of Radiation Proctitis

Late complications of pelvic radiotherapy occur in 5–20% of patients, particularly chronic radiation proctitis (CRP). Rectal bleeding is the most common symptom. Other symptoms include difficulty in defaecation or tenesmus because of loss of distensibility of the rectum or rectal structuring. Treatment options of CRP include oral therapy (5-aminosalicylates, metronidazole), rectal instillation therapy (hydrocortisone, sucralfate, 5-aminosalicylates, formalin), thermal therapy (argon plasma coagulation, heater probe or laser) and hyperbaric oxygen. It is difficult to recommend evidence-based therapy. There are no adequately powered studies of the treatment of CRP and most data are uncontrolled, non-blinded observation studies from single sites. There are no standard evaluation tools (including endoscopic grading, symptom scores and quality-of-life scores), adequate description of preceding radiotherapy dose or adequate follow-up in most studies. Many studies have poor documentation of complications and few are carried out prospectively. A pragmatic approach is to use sucralfate enemas and oral metronidazole. Thermal methods seem to be effective and safe. Simple heater probe treatment or argon plasma coagulation are the preferred methods due to their better safety profile. Intra-rectal formalin seems to be effective, but possibly has a higher rate of complications. For resistant disease, hyperbaric oxygen may be an option.