Therapeutics in radiation-induced proctopathy: a systematic review

Malignant neoplasms are increasingly prevalent in the daily clinical practice. Up to 61% of patients with pelvic malignancies undergo pelvic radiotherapy in different doses, which may cause intestinal damage, and the rectum is the segment most frequently affected due to its fixed position in the pelvis. Currently, there are several strategies to minimize the effects of radiation on the tissues surrounding the neoplastic site; despite those strategies, radiotherapy can still result in serious damage to organs and structures, and these injuries accompany patients throughout their lives. One of the most common damages resulting from pelvic radiotherapy is acute proctitis.The diagnosis is confirmed by visualizing the rectal mucosa through rigid or flexible rectosigmoidoscopy and colonoscopy. The objective of the present study was to review the forms of radiation-induced proctopathytherapy, and to evaluate the results of each method to propose a standardization for the treatment of this pathology. Despite the prevalence of radiation-induced proctopathy, there is no definitive standardized treatment strategy so far. The first approach can be tried with local agents, such as mesalazine and formalin. For refractory cases, control can usually be achieved with argon plasma coagulation, hyperbaric oxygen, and radiofrequency ablation therapies. Regarding the study of radiation-induced proctopathy, there is a lack of robust studies with large samples and standardized therapies to be compared. There is a lack of double-blinded, randomized controlled studies to determine a definitive standard treatment algorithm. (AU)

Chronic radiation-induced rectal injury after adjuvant radiotherapy for pelvic malignant tumors: report based on a phase 3 randomized clinical trial / 中华胃肠外科杂志

Objective: Radiotherapy is one of the standard treatments for pelvic malignant tumors. However, researches associated with intestinal radiation injury and the quality of life (QoL) of patients receiving radiotherapy were lacking in the past. This study aims to analyze the occurrence of radiation-induced rectal injury after adjuvant radiotherapy for pelvic malignant tumors and call for more attention on this issne. Methods: A retrospectively observational study was conducted. Case data of cervical cancer patients from the database of STARS phase 3 randomized clinical trial (NCT00806117) in Sun Yat-sen University Cancer Center were analyzed. A total of 848 cervical cancer patients who received adjuvant radiation following hysterectomy and pelvic lymphadenectomy in Sun Yat-sen University Cancer Center from February 2008 to August 2015 were recruited. The pelvic radiation dosage was 1.8 Gy/day or 2.0 Gy/day, five times every week, and the total dosage was 40-50 Gy. Among 848 patients, 563 patients received radiation six weeks after surgery, of whom 282 received adjuvant radiation alone and 281 received concurrent chemoradiotherapy (weekly cisplatin); other 285 patients received sequential chemoradiotherapy (paclitaxel and cisplatin). Acute adverse events, chronic radiation damage of rectum, and QoL were collected and analyed. The digestive tract symptoms and QoL were evaluated based on EORTC QLQ-C30 questionnaires at one week after surgery (M0), during adjuvant therapy period (M1), and at 12 months and 24 months after the completion of treatments (M12 and M24), respectively. Higher scores in the functional catalog and overall quality of life indicated better quality of life, while higher scores in the symptom catalog indicated severe symptoms and worse QoL. Chronic radiation rectal injury was defined as digestive symptoms that were not improved within three months after radiotherapy. Grading standard of acute adverse events and chronic radiation rectal injury was according to the gastrointestinal part of National Cancer Institute Common Terminology Criteria for Adverse Events, version 4.0 (NCI-CTCAE Version 4.0). Results: The mean total radiation dosage of 848 patients was (47.8±4.6) Gy. During adjuvant therapy, the common symptoms of acute intestinal dysfunction were nausea (46.0%, 390/848), vomiting (33.8%, 287/848), constipation (16.3%, 138/848) and abdominal pain (10.3%, 87/848). At M12 and M24, the number of 0 QLQ-C30 questionnaires collected was 346 and 250, respectively. QLQ-C30 questionnaires showed that the scores of nausea or vomiting, appetite decrease, diarrhea, constipation, etc. were improved obviously at M12 or M24 compared with those at M0 or during M1 (all P<0.05). As the extension of the follow-up time, the score of the overall QoL of patients gradually increased [M0: 59.7 (0.0-100.0); M1: 63.1 (0.0-100.0); M12: 75.2 (0.0-100.0); M24: 94.1 (20.0-120.0); H=253.800, P<0.001]. Twelve months after the completion of treatments, the incidence of chronic radiation rectal injury was 9.8% (34/346), mainly presenting as abdominal pain, constipation, stool blood, diarrhea, mostly at level 1 to 2 toxicity (33/34, 97.1%). One patient (0.3%) developed frequent diarrhea (>8 times/d), which was level 3 toxicity. Twenty-four months after all treatments, the incidence of chronic radiation rectal injury was 9.6% (24/250), which was not decreased significantly compared to that in the previous period (χ(2)=0.008, P=0.927). The symotoms of one patient with level 3 toxicity was not relieved. Conclusions: The common symptoms of patients with pelvic maligant tumors during postoperative adjuvant radiotherapy include nausea, vomiting, constipation, abdominal pain and diarrhea. These symptoms are alleviated obviously at 12 and 24 months after adjuvant radiotherapy, and the QoL is significantly improved. However, a few patients may develop chronic radiation rectal injury which is not improved for years or even decades, and deserves attention in clinical practice.

Aplicación de formalina al 4 para el tratamiento de la rectitis actínica hemorragia refractaria: variantes, técnicas y resultados / Application of formalin to 4 for the treatment of actinic rectitis refractory hemorrhage: variants, techniques and results

Introducción: Varios tratamientos se utilizan para la rectitis actínica hemorrágica, entre ellos corticoides, sucralfato, mezalasina y distintas variantes de cauterización endoscópica, aunque ninguno puede considerarse de elección. En este contexto, la aplicación local de formalina al 4% ha demostrado ser efectiva y segura cuando han fracasado otros tratamientos conservadores. Objetivo: Comunicar nuestra experiencia en el tratamiento de la rectitis actínica sangrante con formalina, describiendo las variantes técnicas de su aplicación y los resultados. Diseño: Observacional retrospectivo. Lugar de aplicación: Hospital público de la Ciudad de Buenos Aires. Pacientes y Método: Se revisaron registros hospitalarios de 10 pacientes (7 mujeres) de edad promedio 61,1±15,6 (rango 28-81) años, con rectitis sangrante posterior a radioterapia pelviana. La dosis osciló entre 7400 y 8000 cGy y el sangrado comenzó en promedio 7,2±3,1 (rango 2-12) meses luego de finalizada la misma. Todos los pacientes presentaban anemia y habían recibido uno o más tratamientos conservadores previos sin respuesta, tres de los cuales habían requerido transfusiones. La terapia con formalina se realizó con dos modalidades: Grupo I: hisopo embebido en formalina al 4% a ph 7 puesto en contacto con la superficie sangrante durante 1-2 minutos. Grupo II: instilación de un volumen de 100-200 ml, en bolos de 30-40 ml por área sangrante, mantenidos en contacto durante 30-60 segundos con posterior aspiración y lavado con solución fisiológica entre los bolos y al final del procedimiento. La respuesta fue considerada completa cuando el sangrado cesó por completo o sólo hubo esporádicas y escasas pérdidas hemáticas, que no requirieron ningún tratamiento. La respuesta parcial se definió como la mejoría en frecuencia y magnitud del sangrado que no requirió otra terapia agresiva. Resultados: Se trataron 10 pacientes (Grupo I: 8 y Grupo II: 2)... (TRUNCADO)...

Background: Several treatments are used for radiation-induced hemorrhagic proctitis, among these corticosteroids, sucralfate, mezalasina, and cauterization endoscopic variants, but none can be considered of choice. With varying results are described. In this context, the local application of 4% formalin has proven to be effective and safe when other conservative treatments have failed. Objective: To report on our experience in the treatment of radiation-induced hemorrhagic proctitis, describing the technical variants of its implementation and results. Design: Observational retrospective study. Setting: Public Hospital of the City of Buenos Aires. Patients and Methods: Hospital records of 10 patients (7 women), average age 61.1 ± 15.6 (range 28-81) years, with radiation-induced hemorrhagic proctitis after pelvic radiotherapy were reviewed. The doses ranged from 7400 to 8000 cGy and the bleeding started on average 7.2 ± 3.1 (range 2-12) months after it ended. All patients had anemia and had received one or more previous conservative treatments with no response, and three of them had required transfusions. Formalin therapy was performed in two ways: Group I: swab with 4% formalin at pH 7 in contact with the bleeding surface for 1-2 minutes. Group II: instillation of a volume of 100-200 ml, in 30-40 ml bolus by bleeding area, maintained in contact with that area for 30-60 seconds, with subsequent aspiration and washing with saline solution between the boluses and the end of the procedure. Treatment response was considered complete when the bleeding stopped completely or there was sporadic and limited blood loss not merequiring any treatment. Partial response was defined as improvement in the frequency and magnitude of bleeding not requiring other aggressive therapy... (TRUNCATED)...

Dosimetria in vivo com uso de detectores semicondutores aplicada ao tratamento de câncer na região pélvica e de cabeça e pescoço

Entre os tipos de tratamentos utilizados no tratamento do câncer, a radioterapia é um procedimento terapêutico que se utiliza da radiação ionizante. Devido a sua importância no sistema de saúde, torna-se necessário um controle rigoroso das diversas etapas que devolvem o planejamento radioterápico até a entrega da dose ao paciente. O trabalho apresentado avalia, por meio da dosimetria in vivo, a dose de radiaçãoadministrada aos pacientes do Instituto Nacional de Câncer (INCA) do Rio de Janeiro, submetidos aos tratamentos radioterápicos da região pélvica e de cabeça e pescoço, utilizando detectores diodos semicondutores Isorad-p e Qed de 1-4 MV e 6-12 MV respectivamente. Aplicando os protocolos recomendados pela International Atomic Energy Agency (IAEA), os diodos Isorad-p e Qed foram testados quanto ao seu desempenho para as medidas in vivo no simulador antropomórfico Rando Alderson eadaptados para serem utilizados na medição de dose nos pacientes. Com um total de 68 medidas in vivo dentro do limite máximo de ±5% de dose, recomendada pela International Comission on Radiation Units and Measurements (ICRU), entre a doseabsorvida num dado ponto do tumor e a dose prescrita pelo radioterapeuta para o mesmo, estes diodos passam a ser uma segurança a mais na administração da dose ao paciente, pois oferecem a vantagem de uma leitura imediata e a possibilidade de intervenção no caso de uma discordância entre a dose prescrita e a dose administrada.

Comparison of the radiation dose absorbed to the testes of men undergoing pelvis radiotherapy for cancer

The objective of this study was to measure the radiation dose absorbed by testes in those men receiving pelvic radiotherapy in order to provide appropriate shielding. Thermo luminescence dosimeter [TLD] which is in small tablet forms was used for this study. Patients were selected and were advised of the procedure. The TLD tablets were positioned in the appropriate places over the gonads and then the absorbed dose was determined. In this study the correlations between the absorbed dose of the gonads and factors such as the radiotherapy system energy, variation in the source skin distance [SSD] of the instrument, the pelvic area and the radiation direction were determined. Results showed significant association of the radiotherapy system energy, SSD variation, and pelvic area with the absorbed dose of the gonads [P < 0.05]. Our findings show that in pelvic radiotherapy the gonads are exposed to high radiation energy. This is an important issue for young men in order to protect their fertility. Therefore, it is very important to protect the gonads from the ionizing radiation with the best possible shielding

Radioterapia: lesões inflamatórias e funcionais de órgãos pélvicos / Radiotherapy: inflammatory and functional lesions of pelvic organs

A radioterapia pélvica tem sido cada vez mais indicada, em doses crescentes,como coadjuvante no tratamento das neoplasias pélvicas, com resultados cada vez melhores, mas com efeitos colaterais significativos. O advento da radioterapia tridimensional conformal estabelece um método que permite a mais precisa seleção de direção e de intensidade de raios emitidos para alvos pontuais, objetivando quase que exclusivamente o tumor, com a conseqüente preservação dos tecidos vizinhos, portanto com maior efetividade e com o mínimo de efeitos colaterais crônicos e insolúveis. Essas são as possibilidades teóricas que precisam ser comprovadas na prática.Elas envolvem um campo de observação cujos resultados reais tem sido subestimados, principalmente quando referidos a efeitos adversos. Esses não se limitam exclusivamente às mucosites, mas, também, a aspectos funcionais envolvendo incapacidades que vão, quando se trata do reto, além do que sempre foi atribuído à suposta síndrome da ressecção anterior 58, para abranger danos diretos da radiação sobre os complexos esfincterianos e os nervos dos plexos lombo-sacrais 21,22,59-63. Por enquanto, seja para o câncer de reto, para o câncer ginecológico e para o câncer de próstata, somos conclamados a investir no modelo mais preventivo do que curativo, ainda que o preventivo signifique apenas a mais precoce ação, pois para essas doenças de altas incidências e mortalidades "prevenir" no sentido de ação mais precoce é, sem dúvida, bem melhor que remediar, principalmente quando se faz uso das terapias neo-adjuvantes que poderiam ser dispensadas, em casos selecionados, para não somar ao desconforto emocional do portador do câncer todas as impossibilidades das iatrogenias inerentes ao tratamento que objetiva a cura. Assim, precisamos encontrar os fatores preditivos que nos permitam escolher os pacientes com probabilidade de cura apenas com o tratamento cirúrgico, para que eles fiquem livres da radioterapia e, por outro lado, buscar o...

Radiotherapy reducing local failure rates and improving overall survival has a favorable impact on the primary treatment of rectal cancer. However, radiation as an adjuvant therapy for that purpose and other pelvic malignances has been shown to increase long-term morbidity causing severe rectal or vesical mucositis, sometimes stenosis, undistensibler rectum with reduced capacity and/or anorectal dysfunction due lombosacralneuropathy with physiologic changes whose interaction remains poorly understood 60,63. Those iatrogenic outcomes stress the need for finding predictive factors for local recurrence to exclude patients with very high probability for cure with surgery alone and to use optimized radiation techniques22,64.

Overexposure of radiation therapy patients in Panama: problem recognition and follow-up measures

This report summarizes and analyzes the responses of various organizations that provided assistance to the National Oncology Institute (Instituto Oncológico Nacional, ION) of Panama following the overexposure of 28 radiation therapy patients at the ION in late 2000 and early 2001. The report also looks at the long-term measures that were adopted at the ION in response to the overexposure incident, as well as implications that the incident has for other cancer treatment centers worldwide. In March 2001, the director of the ION was notified of serious overreactions in patients undergoing radiation therapy for cancer treatment. Of the 478 patients treated for pelvic cancers between August 2000 and March 2001, 3 of them had died, possibly from an overdose of radiation. In response, the Government of Panama invited international experts to carry out a full investigation of the situation. Medical physicists from the Pan American Health Organization (PAHO) were among those invited. They ascertained that 56 patients treated with partially blocked teletherapy fields for cancers of the uterine cervix, endometrium, prostate, or rectum, had had their treatment times calculated using a computerized treatment planning system. PAHO's medical physicists calculated the absorbed doses received by the patients and found that, of these 56 patients, only 11 had been treated with acceptable errors of ±5 percent. The doses received by 28 of the 56 patients had errors ranging from +10 to +105 percent. These are the patients identified by ION physicists as overexposed. Twenty-three of the 28 overexposed patients had died by September 2005, with at least 18 of the deaths being from radiation effects, mostly rectal complications. The clinical, psychological, and legal consequences of the overexposures crippled cancer treatments in Panama and prompted PAHO to assess radiation oncology practices in the countries of Latin American and the Caribbean. ION clinicians...

Este informe resume y analiza la respuesta de varias organizaciones que brindaron asistencia al Instituto Oncológico Nacional (ION) de Panamá después de la sobreexposición de 28 pacientes sometidos a radioterapia que ocurrió en el ION a finales de 2000 y principios de 2001. Además, se examinan las medidas de largo plazo adoptadas en el ION en respuesta al accidente de sobreexposición y las implicaciones que tiene este accidente para todos los centros de tratamiento oncológico en el mundo. En marzo de 2001 se le comunicaron al director del ION las reacciones adversas graves sufridas por algunos pacientes sometidos a radioterapia contra el cáncer. De los 478 pacientes tratados entre agosto de 2000 y marzo de 2001 por cánceres localizados en la región pélvica, tres habían fallecido, presumiblemente por sobredosis de radiación. A raíz de ello, el Gobierno de Panamá invitó a expertos internacionales a realizar una investigación a fondo de la situación. Entre los especialistas invitados se encontraban físicos médicos de la Organización Panamericana de la Salud (OPS), quienes comprobaron que 56 pacientes con cáncer cérvico-uterino, de endometrio, de próstata o de recto tratados mediante campos de teleterapia parcialmente bloqueados recibieron dosis calculadas mediante un sistema computarizado de planificación de tratamientos. Los físicos médicos de la OPS comprobaron que solo 11 de esos 56 pacientes recibieron una dosis absorbida dentro de los límites aceptables de ±5 por ciento. Veintiocho de los 56 pacientes recibieron dosis con errores entre +10 y +105 por ciento. De esos 28 pacientes que fueron sobreexpuestos, según los físicos del ION, 23 murieron antes de septiembre de 2005; de ellos, 18 murieron a causa de los efectos de las radiaciones, principalmente complicaciones rectales. Las consecuencias clínicas, psicológicas y jurídicas de esta sobreexposición menoscabaron gravemente los tratamientos contra el cáncer en Panamá y llevaron...

Transposição ovariana em pacientes com neoplasia pélvica / Ovarian transposition in patients with pelvic neoplasms

Os Autores apresentam revisão da literatura e concluem que a transposição ovariana laparoscópica é procedimento efetivo de preservação ovariana e que deve ser oferecido a pacientes jovens submetidas à radioterapia pélvica. É frequente a utilização de irradiação pélvica no tratamento de neoplasias em mulheres jovens, incluindo neoplasias ginecológicas, neoplasias de reto e ânus, doença de Hodgkin e outras de apresentação mais rara. Dependendo da extensão e sítio da doença esta terapêutica pode ser bastante deletéria, causando infertilidade e falência ovariana. A transposição de ovários previamente à irradiação pélvica tem sido realizada para minimizar estes efeitos no aparelho reprodutor feminino e até possibilitar gestação futura

Atualizaçäo: complicaçöes actínicas do sistema genital e urinário / Atualization: actinics complications of genitourinary system

A radioterapia é empregada em várias neoplasias malignas pélvicas. Näo infreqüentemente, verifica-se complicaçöes actínicas em vários órgäos dos sistemas genital e urinário com intensidade variável. Nos casos mais graves, os pacientes mesmo com câncer controlado podem ter comprometidas de maneira significativa sua qualidade de vida e suas funçöes sexuais e reprodutivas. O risco da ocorrência de um segundo tumor primário, radioinduzido, deve ser lembrado. Os autores discutem de maneira individualizada essas complicaçöes, enfatizando aspectos de seu tratamento.