Download Topic discussion 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
 Severity related to total dose, dose frequency, area of
exposure, source geometry
 Acute vs Chronic radiation change
Complications associated with of
pelvic irradiation
 Proctitis
 Ulceration
 Stricture
 Incontinence
 Fistula formation
Presentation
 Fever
 Rectal pain
 Tenesmus
 Constipation / diarrhoea
 Mucus passage
 PR bleeding
 Fistula formation
Clinical assessment
 Subject symptoms
 Bleeding, diarrhoea, tenesmus, pain, incontinence
 Physical examination
 Rectal telangiectasia, ulceration, stricture
 Endoscopic assessment
 Endoscopy, endorectal ultrasound
 Functional assessment:
 Anal manometry, defaecatory proctogram
Grading of severity
 LENT – 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
Incidence
 Varies due to different classification system
 Varies 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.
2.
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
Management strategy
 Topical treatment
 Oral medications
 Endoscopic treatment
 Hyperbaric oxygen
 Surgical intervention
Topic treatment
 Sulcrafate
 Mesalazine
 Prednisolone / Hydrocortisone
 Misoprostol
 Short chain fatty acid enema
 Formalin dab / instillation
Topic treatment
 Advantages
 Easy to apply, patient directed
 Minimal complications
 Disadvantages
 Limited efficacy
 Studies using combination of oral and topical agents
 Relieve mainly bleeding symptoms
Formalin
 Advantages
 Higher efficacy1
 Ablative effect by protein hydrolysis
 Disadvantages
 Office procedure
 Further injury to rectal mucosa
 Higher complication rate: anal pain, tenesmus, fever,
diarrhoea
 Known 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 medications
 Aminosalicylic acid
 Transamin
 Vitamin A / C
 Antibiotics
 Laxatives
 Part of standard care
 Usually combined with other modalities of treatment
 Not useful in acute situations
Endoscopic treatment
 Argon plasma coagulation
 Cryotherapy
 Radiofrequency ablation
 Laser therapy
 Heater probe
 Formalin dab / irrigation
Argon plasma coagulation
 Superficial ablative therapy – limited penetration
 Useful in acute setting – haemostasis
 Allow assessment and treatment in same session
 Less local side effect compared with Formalin
 Not for “ultra-low” lesion
 Colonic perforation has been reported
Argon plasma coagulation
 Karamanolis et al. Endoscopy 2009.
 56 patients with radiation proctitis treated with APC
 Average treatment session of 2
 6/56 patients failed to response (extent of telangiectasia and
anaemia)
 38 patients followed > 1 yr
 24/38 (63% has no further bleeding symptoms)
 Non comparative study
 High drop out rate
Argon plasma coagulation
 Alfadhli et al. Cancer J Gastroenterology 2008.
 22 patients treated with APC and /or formalin
 11 APC, 8 formalin, 3 APC + formalin
 Anaemia 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 available
Overlapping treatment without intention to treat analysis
Small group of patients
Highlighted lower in side effect in APC group
Hyperbaric oxygen (HBO)
 Treatment of choice in refractory radiation proctitis
before consideration of surgery
 NNT = 31
 Satisfactory response in documented series
 Limited access
 Risks 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 intervention
 Refractory bleeding
 Complete obstruction
 Fistula / abscess formation
 Proctectomy +/- proximal diversion colostomy
 Proximal diversion colostomy
 Perineal 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 treatment
 Symptoms, satisfaction, sigmoidoscopy findings
Results
 Randomized study
 Comparing new treatment with current standard of
treatment
 Additional 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 groups
 Irrigation was given with antibiotics
 Cannot distinguish treatment effect from irrigation /
antibiotics
 Short duration of follow up
 RT change delay up to 2 years after RT
Conclusion
 Radiation 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 therapy
 Hyperbaric 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