Joint Hospital Grand Round Radiation Proctitis
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Transcript of Joint Hospital Grand Round Radiation Proctitis
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!