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Joint Hospital Surgical Grand Round Radiation Proctitis. MF HO Yan Chai Hospital 20/4/2013. Background. Frequently observed after treatment of pelvic tumour, e.g. CA prostate, CA cervix Due to microvascular injury and disruption of mucosal blood flow Neovascularization plays a role - PowerPoint PPT Presentation
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MF HOYan Chai Hospital
20/4/2013
BackgroundFrequently observed after treatment of pelvic
tumour, e.g. CA prostate, CA cervixDue to microvascular injury and disruption of
mucosal blood flowNeovascularization plays a roleSeverity related to total dose, dose
frequency, area of exposure, source geometryAcute vs Chronic radiation change
Complications associated with of pelvic irradiation
ProctitisUlcerationStrictureIncontinenceFistula formation
PresentationFeverRectal painTenesmusConstipation / diarrhoeaMucus passagePR bleedingFistula formation
Clinical assessmentSubject symptoms
Bleeding, diarrhoea, tenesmus, pain, incontinence
Physical examinationRectal telangiectasia, ulceration, stricture
Endoscopic assessmentEndoscopy, endorectal ultrasound
Functional assessment: Anal manometry, defaecatory proctogram
Grading of severityLENT – SOMA ( Late Effect Normal Tissue –
Subjective Objective Management Analysis) Scale
National Cancer Institute Common Toxicity Criteria for Adverse Event Version 4
Various grading system employed across different studies
Frequency of symptoms and requirement of intervention
IncidenceVaries due to different classification systemVaries due to different scheme of RT use1
External beam irradiation : 8-39%Brachytherapy: 8-13%Combine 8-21%
May increase if patient has concomitant inflammatory bowel disease2
1. Nhue L. Do et al. Radiation proctitis: Current Strategies in management. Gastroenterology Research and Practice. Volume 2011.
2. C.G. Wilet et al. Acute and late toxicity of patients with inflammatory bowel disease undergoing irradiation for abdominal and pelvic neoplasms. Int J Rad Onc Bio Phy. Vol 46, No. 4 pp 995-998, 2000
Management strategyTopical treatment
Oral medications
Endoscopic treatment
Hyperbaric oxygen
Surgical intervention
Topic treatmentSulcrafateMesalazinePrednisolone / HydrocortisoneMisoprostolShort chain fatty acid enemaFormalin dab / instillation
Topic treatmentAdvantages
Easy to apply, patient directedMinimal complications
DisadvantagesLimited efficacyStudies using combination of oral and topical
agentsRelieve mainly bleeding symptoms
FormalinAdvantages
Higher efficacy1
Ablative effect by protein hydrolysis
DisadvantagesOffice procedureFurther injury to rectal mucosaHigher complication rate: anal pain, tenesmus,
fever, diarrhoeaKnown Human carcinogen - WHO International
Agency for Research on Cancer (IARC)
1. V.P. Nelamangala Ramakrishnaiah et al. Colorectal Disease 2012, Vol 14, 876-882.
Ref: V.P. Nelamangala Ramakrishnaiah et al. Colorectal Disease 2012, Vol 14, 876-882.
Oral medicationsAminosalicylic acidTransaminVitamin A / CAntibioticsLaxatives
Part of standard careUsually combined with other modalities of
treatmentNot useful in acute situations
Endoscopic treatmentArgon plasma coagulationCryotherapyRadiofrequency ablationLaser therapyHeater probeFormalin dab / irrigation
Argon plasma coagulation
Superficial ablative therapy – limited penetration
Useful in acute setting – haemostasisAllow assessment and treatment in same
sessionLess local side effect compared with Formalin
Not for “ultra-low” lesionColonic perforation has been reported
Argon plasma coagulationKaramanolis et al. Endoscopy 2009.
56 patients with radiation proctitis treated with APC
Average treatment session of 26/56 patients failed to response (extent of
telangiectasia and anaemia)38 patients followed > 1 yr24/38 (63% has no further bleeding symptoms)
Non comparative studyHigh drop out rate
Argon plasma coagulationAlfadhli et al. Cancer J Gastroenterology 2008.
22 patients treated with APC and /or formalin11 APC, 8 formalin, 3 APC + formalinAnaemia responded in :
11/14 patients with APC 7/11 patient with formalin
Side effects more prominent in formalin group (9 in formalin vs 2 in APC)
Only comparative study availableOverlapping treatment without intention to treat
analysisSmall group of patientsHighlighted lower in side effect in APC group
Hyperbaric oxygen (HBO)Treatment of choice in refractory radiation
proctitis before consideration of surgeryNNT = 31
Satisfactory response in documented series
Limited accessRisks of barotrauma / oxygen toxicity
1. R.E. Clake et al. Hyperbaric oxygen treatment of chronic refectory radiation proctitis: A randomized and controlled double blind crossover trial with long term follow up. Int J Rad Onc Bio Phy. Vol 72, No.1. pp 134-143, 2008.
Surgical interventionRefractory bleedingComplete obstructionFistula / abscess formation
Proctectomy +/- proximal diversion colostomyProximal diversion colostomyPerineal procedures
Comparing 50 patients with radiation proctitis using formalin dab vs tap water irrigation and antibiotics treatment from 2010 to 2012
Patients with other complications from radiation e.g. fistula, rectal ulcers, strictures were excluded
Patient was assessed 8 weeks after treatmentSymptoms, satisfaction, sigmoidoscopy findings
Results
Randomized studyComparing new treatment with current
standard of treatmentAdditional advantage of treating post
irritation constipation
Symptoms severity before treatment was not compared? Difference in baseline symptoms severity
Results are not presented well? Why comparing difference of difference
between 2 treatment groupsIrrigation was given with antibiotics
Cannot distinguish treatment effect from irrigation / antibiotics
Short duration of follow upRT change delay up to 2 years after RT
ConclusionRadiation proctitis is commonly encountered as
radiotherapy to pelvis is increasingly used
Topical and oral medication are more of maintenance therapy
Acute bleeding can be dealt with ablative therapyHyperbaric oxygen can be employed in refractory
case
Surgery is the last resort, risks needed to be considered
Reference Management of Radiation Proctitis. William M . Mendenhall et al. American Journal of Clinical
Oncology, 2012.
A randomized controlled trial comparing colonic irrigation and oral antibiotics administration versus 4% formalin application for treatment of haemorrhagic radiation proctitis. Chucheep Sahakitrungruang et al. Dis Colon rectum 2012; 55: 1053-1058.
Endoscopic and medical therapy for chronic radiation proctopathy: a systematic review. Brian Hanson et at. Dis Colon Rectum 2012; 55: 1081-1095
Nhue L. Do et al. Radiation proctitis: Current Strategies in management. Gastroenterology Research and Practice. Volume 2011.
C. G. Wilet et al. Acute and late toxicity of patients with inflammatory bowel disease undergoing irradiation for abdominal and pelvic neoplasms. Int J Rad Onc Bio Phy. Vol 46, No. 4 pp 995-998, 2000
V.P. Nelamangala Ramakrishnaiah et al. Colorectal Disease 2012, Vol 14, 876-882.
Alfadhli et al. Efficacy of argon plasma coagulation compared to topical formalin application for chronic radiation proctopathy. Cancer J Gastroenterology 2008.
Karamanolis et al. Argon plasma coagulation has a long-lasting therapeutic effect in patients with chronic radiation proctitis. Endoscopy 2009.
R.E. Clake et al. Hyperbaric oxygen treatment of chronic refectory radiation proctitis: A randomized and controlled double blind crossover trial with long term follow up. Int J Rad Onc Bio Phy. Vol 72, No.1. pp 134-143, 2008