Joint Hospital Grand Round

Radiation ProctitisNancy NgColorectal TeamDepartment of SurgeryPrince of Wales HospitalThe Chinese University of Hong Kong

Why Important ?

Increasing no. of patients treated with radiotherapy for pelvic malignancies, mostly with curative intent. 12000 in UK annually

Rectum commonly injuredAcute radiation toxicity : up to 80% Self-limiting and resolve after RT

Occur 29-51% of patients Not entirely dose related Depends on physical, patient-related, treatment

and genetic factors Dearnaley D et al. Lancet 1999 Widmark A et al. Cancer 1994 Crook J et al. Urology 1996

Impaired QOL in 5% Gami B et al. Aliment Pharmacol Ther 2003

Manifest from months to years after RT median 8-13 months

Chronic radiation rectal bleeding

Histopathologic changes

Progressive obliterative endarteritis and submucosal fibrosisMucosal ischaemiaNeo-vascularization

Hasleton PS et al. Histopathology 1985 Haboubi NY et al. Am J Gastroenterol 1988

Endoscopic appearance

Severe radiation proctitis

Radiation proctitis with stricture

Diagnosis

Usually straightforward from history? Endoscopy : Yes Older patient and prior pelvic radiation Increased risk of malignancy, esp. rectal tumor

Pickles, Phililips, et al. Radiother Oncol 2002 Brenner A, Curtis R, et al. Cancer 2000 Kleinerman R, Boice J, et al. Cancer 1995 Boice J, Day N, et al. Cancer Inst 1985

Other pathologies H R T Williams, P Vlavianos, et al. Ali Phar & Thera 2005

Treatment

Medical therapy Oral and rectal steroid 5-aminosalicylates Sucralfate Short chain fatty acid enema

Ineffective in severe cases

Denton AS et al. Br J Cancer 2002 Hong JJ et al. Aliment Pharmocal Ther 2001

Tagkalidis PP et al. ANZ J Surg 2001

Treatment

Endoscopic treatment Local formalin applicationSurgical treatment Rarely response to colostomy alone High morbidity and mortality

Tagkalidis PP et al. ANZ J Surg 2001 Hong JJ et al. Aliment Pharmocal Ther 2001

Indicated for uncertain diagnosis and complications

Surgical specimen

Surgical specimen

Endoscopic treatment

Coagulation can be achieved by heat probe multipolar electrocoagulation laser argon plasma coagulator (APC)

APC

monopolar therapy, use argon gas to conduct radiofrequency energy to tissue

Instant superficial tissue coagulation over 3-4mm area

Non-contact nature minimize tissue sticking and bleeding

Require adequate colon cleansing

Deep injury include perforation can occur (depends on contact time and total energy delivered

References YearNo. of

patients

Gasflow

L/min Power Transfused

MeanNo. of

sessions

Completecessationof PRB

Persistent minorPRB

Overallefficacy Complications

Amedeo 1998 7 3 60W 0 2 100% 0 100% NilKaassis et al2000 16 0.6 40W 18.80% 3.7 43.80% 56.20% 100% Nil

Tam et al 2000 15 2 60W 20% 2 20% 80% 100%

2 asymptomaticstricture

Tjandra et al2001 12 1.5 40W 33% 2 50% 33% 83%

Taieb et al 2001 11 0.8-2 50W 63.60% 3.2 81.80% 18.20% 100%

1 rectal ulcerand 2 rectal

stricture

Villavicencio et al2002 21 1.2-240-

50W not a/v 1.7 95% 5% 100% 4 tenesmus

English literature on APC for radiation proctitis

PWH experience

From 1/2001 to 12/200420 (M:4, F:16) with radiation proctitis were treated by endoscopic APC in our hospitalCa prostate : 4Ca rectum : 1Gyn malignancy : 15Age 67.6 (+/-11.5) years

Radiation dosage : 6300 (+/-1197cGy)Onset of PRB : 15 mthHb before treatment : 10.02g/dl (+/-2)6 of them need repeated admission for transfusion

Result

Mean treatment session : 1.5 (1-4)Bleeding stopped 7 35%Bleeding improved 5 25%Bleeding unchanged 6 30%Bleeding worsened 2 10%Treatment efficacy : 60%Hb after treatment : 10.05g/dl (+/-2)No documented complications

Conclusions

APC is a safe treatment modality for radiation proctitis

Good result from literature not reproduced

Topical FormalinFormaldehyde mixed with methanol

Treatment for radiation cystitis since 1976

First described by Rubinstein et al in 1986

Mechanism Chemical cauterization by protein cross-linking, cell

necrosis and vessel sealing. Effect of 4% formalin was transient and confine to the

mucosa Myers et al . Dis Colon Rectum 1998

Completecessation of

rectalbleeding

Persistenceof minor

rectalbleeding

Number (%) Number (%)

Seow-Choenet al.

1993 8 4 1.1 8 (100) 0 (0) 100 1 w orseningof rectalstricture

Mathai andSeow-Choen

1995 29 12 1.1 22 (75.9) 5 (17.2) 93.1 1 w orseningof rectalstricture

Biswal et al. 1995 16 11 1.1 13 (81.3) 3 (18.8) 100 No

Chapuis etal.

1996 14 Not clear Not stated 10 (71.4) 1 (7.1) 78.6 Not clear

Salvati 1996 10 Not stated Not stated 10 (100) 0 (0) 100 No

Ismail andQ ureshi

2002 20 12 Not clear 18 (90) 0 (0) 90 No

Chautems etal.

2003 13 12 1.6 13 (100) 0 (0) 100 1 rectalstenosis

Parikh etal.20

2003 33 18 3.4 Not stated Not stated 88 No

de Paradeset al.

2005 33 27 1.3 13 (39.4) 10 (30.3) 69.7 4 anorectalulcers, 6anorectal

strictures, 9anal

incontinence

Meannumber of

sessions

O verallefficacy (%)

Complications

References Year Number ofpatients

Follow-up(months)

English literature on formalin dab for radiation proctitis

PWH experienceFrom 1/2001 to 12/200411 ( M:2, F:9) patient with refractory radiation proctitis failed to medical (11) and /or argon plasma coagulation (7) were includedAge 62.8 (+/-14.8)Radiation dosage 6723.6 (+/-980cGy)Ca prostate : 2Gyn. malignancy : 8Buttock sarcoma : 1

Onset of PRB after RT : 10.9mth(+/-3.8)Hb before treatment : 7.3g/dl(+/-2.4)8 need repeated admission for transfusion

Treatment was done in minor operating theater without anaesthesia or sedation

4% formalin solution was prepared by mixing 40ml of10% buffered formalin

Patient in left lateral position.Contact for 1 to 3min, till mucosa appears whitish and bleeding stops.

Before treatment Immediately after treatment

4 days later

11 days later 5 weeks later 4 months later

Onesession

Twosessions

Foursessions

Sixsessions

Complete cessationof bleeding (Number

of patients)

3 0 1 0

Bleeding improved(Number of patients)

2 2 1 1

Bleeding unchanged(Number of patients)

0 1 0 0

Bleeding worsened(Number of patients)

0 0 0 0

Result

Overall efficacy 90.9%

Result

Hb after treatment : 10.4g/dl (+/-2.2) P = 0.007

No major complications documented

Conclusion Formalin dab is an effective, safe and inexpensi

ve treatment modality for refractory radiation proctitis.

Summary

Radiation proctitis is one of the common cause of PRB

Colonoscopy is suggested before making this diagnosis

APC is safe but may not be effective for severe bleeding

Formalin dab is effective, save and inexpensive for refractory bleeding and can be considered as the first line treatment

Thank You!