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PubMed2004

Dosimetric factors predicting severe radiation-induced bowel complications in patients with cervical cancer: combined effect of external parametrial dose and cumulative rectal dose.

OBJECTIVE: The purpose of this study was to analyze dosimetric factors of radiation-induced severe bowel complications among patients with cervical cancer. METHODS: We reviewed 297 patients of stage IB-IVA cervical cancer managed by curative-intent radiotherapy from May 1993 through December 1997. Whole-pelvic irradiation of external beam radiation therapy (EBRT) (34.2-48.6 Gy/19-27 fractions) was delivered to all patients. Two hundred and three patients received additional bilateral parametrial boost (3.6-18 Gy/2-10 fractions). High dose-rate (HDR) intracavitary brachytherapy (ICBT), 16-24 Gy/5 fractions to Point A, was given after external irradiation. Cumulative rectal biologically effective dose (CRBED) at rectal reference point was determined by summation of EBRT and ICBT component. RESULTS: The 5-year incidences of Grade 3-4 enterocolitis and proctitis were 10% and 7%, respectively. Both complications were associated with external parametrial dose (PMD) and CRBED. Interaction of CRBED and PMD was noted in multivariate analysis of enterocolitis (P < 0.001) and proctitis (P < 0.001). In CRBED > or = 100 Gy(3) group, PMD was an independent factor in enterocolitis (P = 0.010) and proctitis (P = 0.039). In PMD > or = 54 Gy group, CRBED was an independent factor in enterocolitis (P = 0.003) and proctitis (P = 0.036). Patients with both PMD > or = 54 Gy and CRBED > or = 100 Gy(3) had higher incidence of 5-year enterocolitis (26%) (P < 0.001) and proctitis (17%) (P < 0.001) than other dose groups. CONCLUSION: Radiation-induced severe bowel complications are association on both high PMD and high CRBED. We do not suggest both external PMD > or = 54 Gy and CRBED > or = 100 Gy(3) for treatment of cervical cancer due to unacceptably high incidence of severe bowel complications.

Adult↗
PubMed1990

The fate of the forgotten rectal pouch after Hartmann's procedure without reconstruction.

The rectal pouches of 45 patients who underwent Hartmann's procedure and were not scheduled to have a colostomy closure were examined with an endoscope at least 1 year after operation. Twenty-five patients had no symptoms related to the rectal pouch. The rest had pain, mucous discharge, moderate-to-severe bleeding, or discharge of small bowel contents. Endoscopic findings included moderate-to-severe proctitis in 20 patients, 10 of whom had no symptoms. Polyps were found in four patients (two asymptomatic) and carcinoma in seven (one asymptomatic). Of 24 patients operated upon for diverticulitis, 12 had proctitis and 2 had polyps. Of 14 patients with carcinoma, 4 had proctitis, 1 polyps, and 5 carcinoma. Of two patients with benign polyps, one had polyps and one, carcinoma and of five patients with inflammatory bowel disease, four had proctitis and one, carcinoma. The treatment of polyps and carcinoma is the same as for other patients with these conditions. Proctitis should be treated with reanastomosis. The frequent presence of abnormality in the rectal pouch indicates the need for regular follow-up examinations of these patients.

Anal Canal↗
PubMed2002

Using the magnitude of PSA bounce after MRI-guided prostate brachytherapy to distinguish recurrence, benign precipitating factors, and idiopathic bounce.

PURPOSE: To identify events that precipitated a prostate-specific antigen (PSA) bounce and characterize the magnitude, duration, and time to PSA bounce after MRI-guided prostate brachytherapy. METHODS AND MATERIALS: Between 1997 and 2001, 186 patients with low-risk prostate cancer underwent MRI-guided permanent 125I source implantation, with or without external beam radiotherapy. A PSA bounce was defined as a >or=15% elevation in PSA compared with the most recent value, followed by a decline to a level at or less than the prebounce value. At the time of PSA measurement, data were prospectively collected on whether the patient had recent ejaculation, ongoing radiation proctitis, or recent instrumentation. RESULTS: A total of 115 patients (61.8%) had a total of 156 PSA bounces. Of these, 36 patients had PSA bounces associated with ejaculation, proctitis, or instrumentation, and 79 experienced idiopathic PSA bounces (not associated with a precipitating event). The magnitude of the PSA bounce was significantly lower for the idiopathic PSA bounce (0.6 ng/mL) compared with that associated with ejaculation (p = 0.003), proctitis (p <0.0001), or instrumentation (p = 0.007). Patients with biopsy-proven local recurrence had a median PSA elevation of 1.2 ng/mL, significantly higher (p = 0.006) than the magnitude of the idiopathic PSA bounce, but not significantly different from the magnitude of the PSA bounce due to ejaculation, proctitis, or instrumentation. CONCLUSION: In patients treated with MRI-guided prostate brachytherapy, recent ejaculation, instrumentation, or ongoing radiation proctitis can cause a transient increase in PSA, the magnitude of which is significantly higher than that for idiopathic PSA bounce, but is similar to that in patients with recurrent disease.

Aged↗
PubMed2000

Rectal bleeding after radiation therapy for prostate cancer: endoscopic evaluation.

PURPOSE: To analyze the frequency and clinical importance of proctitis and hematochezia after radiation therapy for prostate cancer. MATERIALS AND METHODS: Of 63 patients with prostate cancer treated with curative intent by a single radiation oncologist between July 1, 1993, and December 31, 1997, 30 were asymptomatic, but 33 had heme-positive digital rectal examination (DRE) results or hematochezia at routine follow-up. Twenty-six of these patients underwent endoscopy of the sigmoid colon or colon for evaluation of these symptoms. Median doses of 60.0 Gy at postoperative radiation therapy and 68.4 Gy at definitive radiation therapy were delivered to four fields daily by using blocking customized on the basis of computed tomographically documented evidence of disease. The Fisher exact test and the Kaplan-Meier method were used to analyze the results. RESULTS: The frequency of rectal bleeding approached 80% at 3 years after radiation therapy in definitively treated patients. Only 14 patients had proctitis: eight as the only sign, and six in association with other disease. Six patients had other disease without proctitis, and four patients had normal examination findings. The frequency of rectal bleeding in the presence of proctitis was similar to that in the presence of other disease (Fisher exact test, P =.68). CONCLUSION: Hematochezia or positive DRE findings are frequent sequelae of definitive radiation therapy for prostate cancer; however, causes other than proctitis are often documented at endoscopy. Symptomatic individuals warrant rigorous evaluation to rule out serious coexistent disease.

Adult↗
PubMed1990

Late radiation damage in prostate cancer patients treated by high dose external radiotherapy in relation to rectal dose.

A retrospective analysis of the incidence of radiation proctitis was performed in 154 patients with carcinoma of the prostate treated with external radiotherapy assisted by CT-scan planning from 1983 to 1985. An attempt was made to assess a dose-response relationship for proctitis. Multivariate Cox regression analysis showed that previous bowel disease or surgery, anterior rectal dose, and average rectal dose contributed to a higher risk of proctitis. The anterior rectal dose was the most important indicator. No statistically significant correlation was found for the posterior rectal dose. The actuarial 2-year incidence of moderate or severe proctitis was 22% for anterior rectal doses less than 70 Gy and 20% for anterior rectal doses between 70 and 75 Gy, but increased to 60% when the dose was more than 75 Gy. A dose effect relation was evident, with a sharp dose-response gradient around 75 Gy at the anterior rectal wall.

Aged↗
PubMed2000

[Surgical treatment of Crohn's disease of the large intestine: do rectal complications influence the results of ileorectal anastomosis?].

STUDY AIM: The purpose of this retrospective study was to compare the morbidity and long-term outcome of patients undergoing total colectomy and ileorectal anastomosis (IRA) performed for Crohn's colitis with or without associated proctitis. PATIENTS AND METHODS: Thirty-nine patients with a mean age of 35 years (17-72 years) underwent total colectomy with IRA. Patients were retrospectively classified into two groups; group 1 (28) without rectal involvement; group 2 (11) with proctitis. Follow-up data were obtained during 1998, by reviewing all patients. Mean postoperative follow-up was 10.6 years (1.5-22). RESULTS: There were no postoperative deaths. Six (15%) patients experienced postoperative complications, with no difference between the two groups. Sixteen patients (41%) developed recurrence requiring surgery: 9 in group 1 (32%) and 7 in group 2 (64%) (p > 0.05). The IRA had to be removed or was no longer functional in 12 patients: 6 in group 1 (21.5%) and 6 in group 2 (54.5%) (p < 0.05). CONCLUSION: Moderate proctitis does not increase the morbidity of total colectomy with IRA for Crohn's disease. The risk of reoperation and secondary protectomy is higher when proctitis was present, but the IRA was still functional in one-half of patients after more than 10 years of follow-up.

Adolescent↗
PubMed2006

Hyperbaric oxygen therapy for radiation induced proctopathy in men treated for prostate cancer.

PURPOSE: Radiation proctitis is a common complication following external beam radiation therapy and brachytherapy for prostate cancer. While 95% percent of radiation induced proctitis is temporary and self-limiting, up to 5% of patients experience toxicities that are refractory to conservative management. Hyperbaric oxygen has a well-defined role in treating chronic wounds, osteomyelitis, hemorrhagic cystitis and necrotizing fasciitis. We reviewed our experience with hyperbaric oxygen therapy for radiation induced proctitis in patients undergoing radiation treatment for prostate cancer. MATERIALS AND METHODS: From October 1998 to December 2003, 27 patients with radiation induced proctitis secondary to brachytherapy (4), external beam radiation therapy (16) or combined modality (7) for prostate cancer were treated with hyperbaric oxygen therapy at Virginia Mason Medical Center in Seattle, Washington. In all patients primary medical or endoscopic management had failed. Patients received 100% oxygen in a multiplace hyperbaric chamber at a pressure of 2.4 atmospheres absolute for 90 minutes 5 to 7 days weekly for an average of 36 sessions (range 29 to 60). Data were collected from a retrospective review of medical records following approval by the Institutional Review Board at Virginia Mason Medical Center. RESULTS: All 27 men completed the planned course of therapy. Of patients with bleeding 48% showed complete resolution after therapy, while 28% reported significantly fewer bleeding episodes. Of patients 50% noted complete resolution of fecal urgency. Six of the 8 patients (75%) with pain noticed some improvement after therapy, although no patients reported complete resolution of rectal pain. Of patients with rectal ulceration 21% showed complete resolution of the ulcer on posttreatment endoscopy, while 29% showed evidence of improvement. Six patients (43%) had no change or worsening of rectal ulcers. Overall 67% of patients had a partial to good response, while 33% showed no response or disease progression. CONCLUSIONS: This series of patients showed a good overall response rate to hyperbaric oxygen for radiation induced proctopathy after other attempts at management had failed. Hyperbaric oxygen is generally well tolerated and it remains an important treatment option for managing this common and difficult disease.

Aged↗
PubMed2001

Argon plasma coagulation for rectal bleeding after prostate brachytherapy.

PURPOSE: To better define the efficacy and safety of argon plasma coagulation (APC), specifically for brachytherapy-related proctitis, we reviewed the clinical course of 7 patients treated for persistent rectal bleeding. Approximately 2-10% of prostate cancer patients treated with 125I or 103Pd brachytherapy will develop radiation proctitis. The optimum treatment for patients with persistent bleeding is unclear from the paucity of available data. Prior reports lack specific dosimetric information, and patients with widely divergent forms of radiation were grouped together in the analyses. METHODS AND MATERIALS: Seven patients were treated with APC at the Veterans Affairs Puget Sound Health Care System and the University of Washington from 1997 to 1999 for persistent rectal bleeding due to prostate brachytherapy-related proctitis. Four patients received supplemental external beam radiation, delivered by a four-field technique. A single gastroenterologist at the Veterans Affairs Puget Sound Health Care System treated 6 of the 7 patients. If the degree of proctitis was limited, all sites of active bleeding were coagulated in symptomatic patients. An argon plasma coagulator electrosurgical system was used to administer treatments every 4-8 weeks as needed. The argon gas flow was set at 1.6 L/min, with an electrical power setting of 40-45 W. RESULTS: The rectal V100 (the total rectal volume, including the lumen, receiving the prescription dose or greater) for the 7 patients ranged from 0.13 to 4.61 cc. Rectal bleeding was first noticed 3-18 months after implantation. APC (range 1-3 sessions) was performed 9-22 months after implantation. Five patients had complete resolution of their bleeding, usually within days of completing APC. Two patients had only partial relief from bleeding, but declined additional APC therapy. No patient developed clinically evident progressive rectal wall abnormalities after APC, (post-APC follow-up range 4-13 months). CONCLUSIONS: Most patients benefited from APC, and no cases of clinically evident progressive tissue destruction were noted. Although APC appears to be efficacious and safe in the setting of the rectal doses described here, caution is in order when contemplating APC for brachytherapy patients.

Argon↗
PubMed2004

Review article: The medical treatment of Crohn's perianal fistulas.

Perianal fistulas are a frequent manifestation of Crohn's disease. The correct application of the newer diagnostic and therapeutic agents for treating perianal Crohn's disease are beginning to be better defined. In general, a combined medical and surgical approach is preferred. The perianal disease process should first be fully delineated with endoscopy and either MRI or EUS before treatment is begun. Patients are then stratified into one of three groups: simple fistulas and no proctitis; simple fistulas and concomitant proctitis; and complex fistulas. Patients with simple fistulas and no proctitis can be treated medically with a combination of antibiotics and an immunosuppressive agent (azathioprine or mercaptopurine). Patients with simple fistulas and concomitant proctitis should have infliximab added to their treatment plan. Complex fistulas require surgical intervention first prior to medical treatment. A combination of antibiotics, immunosuppressive therapy and infliximab are then initiated to facilitate fistula healing.

Anti-Bacterial Agents↗
PubMed1992

Epidemiological study of ulcerative proctocolitis in Indian migrants and the indigenous population of Leicestershire.

A retrospective epidemiological study of ulcerative colitis (UC) and proctitis was performed in Leicestershire from 1972-89. Potential cases were identified from hospital departments of pathology, endoscopy, and medical records and from general practitioners. The county population includes more than 93,000 South Asians. There were 573 cases of UC and 286 of proctitis in Europeans and 115 cases of UC and 29 of proctitis in South Asians. The standardised incidence of UC in Europeans and South Asians was stable, except in Sikhs in whom it had increased rapidly. The relative risk of UC to South Asians was 2.45. The standardised incidences of UC in South Asians during the 1980s were: 10.8/10(5)/year in Hindus (95% confidence interval (CI) 7.4-14.1 cases/10(5)/year) 16.5/10(5)/year in Sikhs (95% CI 7.9-25.2 cases/10(5)/year), and 6.2/10(5)/year in Muslims (95% CI 1.6-10.9 cases/10(5)/year). There was no difference in incidence between Asians from East Africa and India. The standardised incidence of UC in Europeans was 5.3/10(5)/year (95% CI 4.3-6.3 cases/10(5)/year). The standardised incidences of proctitis were 3.1/10(5)/year (95% CI 1.9-2.5 cases/10(5)/year) in South Asians and 2.3/10(5)/year (95% CI 1.8-2.4 cases/10(5)/year) in Europeans. Ethnic groups had a similar disease distribution, except Sikhs in whom it was less extensive. Despite the similar disease distribution, South Asians had fewer operations and complications from UC than Europeans. There was a bimodal age specific incidence in Europeans, but not in other ethnic groups. First and second generation South Asians were at similar risk. Hindus and Sikhs have a significantly higher incidence of UC than Europeans in Leicestershire.

Adolescent↗
PubMedDate not supplied

The gay bowel syndrome: clinico-pathologic correlation in 260 cases.

The clinical and pathological findings in a group of 260 homosexual men comprising 10% of a private proctologic practice are reviewed. A clinical pattern of anorectal and colon diseases encountered with unusual frequency in these homosexual patients is termed the gay bowel syndrome. The clinical diagnoses in decreasing order of frequency include condyloma acuminata, hemorrhoids, nonspecific proctitis, anal fistula, perirectal abscess, anal fissure, amebiasis, benign polyps, viral hepatitis, gonorrhea, syphilis, anorectal trauma and foreign bodies, shigellosis, rectal ulcers and lymphogranuloma venereum. 60 anorectal and sigmoid biopsies from 51 patients failed to disclose evidence of specific infection other than condyloma acuminata. Of 21 patients with biopsy diagnosis of nonspecific proctitis, 8 had a specific infection which was detected by other means,--5 cases of shigellosis and one case each of gonorrheal proctitis, amebiasis and lymphogranuloma venereum. In evaluating proctologic problems in the gay male, all of the known sexually transmitted diseases should be considered. Shigellosis, amebiasis and viral hepatitis should be included. Microbiological evaluation is essential. Concurrent infections with 2 or more pathogens should be anticipated. Chlamydia trachomatis, an important cause of nonspecific urethritis in the general population, is high on the list of possible causes of the nonspecific proctitis present in 31 of the 260 patients.

Abscess↗
PubMed2004

Clinical comparison of two linear-quadratic model-based isoeffect fractionation schemes of high-dose-rate intracavitary brachytherapy for cervical cancer.

PURPOSE: Two linear-quadratic model-based isoeffect fractionation schemes of high-dose-rate intracavitary brachytherapy (HDR-IC) were used to treat cervical cancer in two consecutive periods. Patient outcomes and complications were analyzed and compared. METHODS AND MATERIALS: Between November 1987 and December 1996, a total of 541 women diagnosed with cervical cancer were treated with curative-intent radiotherapy. Patients were categorized into two groups according to the two isoeffect schemes used. Group 1 consisted of 254 patients treated with external beam radiotherapy (EBRT) plus 7.2 Gy HDR-IC to Point A for three fractions in the first period. Group 2 consisted of 284 patients treated with EBRT plus 4.8 Gy HDR-IC for five fractions in the second period. The goal of the new scheme for the latter group was to deliver an isoeffect dose that maintained similar tumor control but reduced normal tissue complications. The calculated biologically effective dose (BED(10), assuming an alpha/beta ratio = 10) of EBRT plus HDR-IC for tumor and acute responding tissue in Groups 1 and 2 was 90 Gy(10) (52.8 + 37.2 Gy) and 88.6 Gy(10) (53.1 + 35.5 Gy), respectively. The corresponding BED(3) for late responding tissue (assuming an alpha/beta ratio = 3) in Groups 1 and 2 was 146.7 Gy(3) (73.3 + 73.4 Gy) and 134.4 Gy(3) (72 + 62.4 Gy), respectively. Patients were followed for 6.1-15.2 years (median, 9.8 years). RESULTS: Overall, 66 patients (12.2%) developed pelvic recurrence. Of these, 53 patients had central recurrence. Of the 53 patients with central recurrence, 24 (9.4%) were in Group 1 and 29 (10.1%) in Group 2 (p = 0.722). The actuarial pelvic control rate for Groups 1 and 2 was 88.2% and 86.3% at 5 years and 87.3% and 85.5% at 10 years, respectively (p = 0.504). The actuarial overall survival rate for Groups 1 and 2 was 63.5% and 56.1% at 5 years and 47.8% and 49.3% at 10 years, respectively (p = 0.734). The actuarial proctitis rate for Groups 1 and 2 was 49.7% and 32.7% at 5 years and 50.5% and 32.7% at 10 years, respectively (p <0.001). Most of the decrease in the rate of proctitis was a result of a decrease in the incidence of low-grade proctitis (38% vs. 22%). The incidence of high-grade complications remained unchanged, 8% vs. 7%. The actuarial cystitis rate for Groups 1 and 2 was 14.3% vs. 11.4% at 5 years and 24.1% vs. 15% at 10 years, respectively (p = 0.134). Multivariate analysis revealed that the fractionation scheme (three fractions vs. five fractions) was a significant factor influencing the proctitis rate (p = 0.004, hazard ratio = 0.807; 95% confidence interval, 0.697-0.934), but not the local pelvic control rate, overall survival rate, or cystitis rate. CONCLUSION: The treatment results of the two groups maintained similar outcomes, while the complications decreased. The linear-quadratic model correctly predicted this outcome. Biologically, the manipulation of the fraction size in our study suggested that the sensitivity of the late responding tissue to the fractional change from 7.2 Gy to 4.8 Gy in HDR-IC is high and detectable clinically. The success, however, had its limitations, and the improvement was confined to low-grade complications.

Adult↗
PubMed2003

Combination external beam radiotherapy and high-dose-rate intracavitary brachytherapy for uterine cervical cancer: analysis of dose and fractionation schedule.

PURPOSE: To determine an appropriate dose and fractionation schedule for a combination of external beam radiotherapy (EBRT) and high-dose-rate intracavitary brachytherapy (HDR-ICBT) for uterine cervical cancer. METHODS: Eighty-eight patients with uterine cervical squamous cell carcinoma treated with EBRT and HDR-ICBT were analyzed. Twenty-five patients were classified as early disease (nonbulky Stage I/II, less than 4-cm diameter) and 63 patients as advanced disease (greater than 4 cm diameter or Stage IIIB) according to the American Brachytherapy Society definition. Tumor diameter was measured by MRI. Pelvic EBRT was delivered before applications of ICBT. HDR-ICBT was performed once a week, with a fraction point A dose of 6 Gy. Source loadings corresponded to the Manchester System for uterine cervical cancer. No planned optimization was done. A Henschke-type applicator was mostly used (86%). Median cumulative biologic effective dose (BED) at point A (EBRT + ICBT) was 64.8 Gy(10) (range: 48-76.8 Gy(10)) for early disease, and 76.8 Gy(10) (range: 38.4-86.4 Gy(10)) for advanced disease. Median cumulative BED at ICRU 38 reference points (EBRT + ICBT) was 97.7 Gy(3) (range: 59.1-134.4 Gy(3)) at the rectum, 97.8 Gy(3) (range: 54.6-130.4 Gy(3)) at the bladder, and 324 Gy(3) (range: 185.5-618 Gy(3)) at the vagina. Actuarial pelvic control rate and late complication rate were analyzed according to cumulative dose and calculated BED. RESULTS: The 3-year actuarial pelvic control rate was 82% for all 88 patients: 96% for those with early disease, and 76% for advanced disease. For pelvic control, no significant dose-response relationship was observed by treatment schedules and cumulative BED at point A for both early and advanced disease. The 3-year actuarial late complication rates (Grade > or =1) were 12% for proctitis, 11% for cystitis, and 14% for enterocolitis. There were significant differences on the incidence of proctitis (p < 0.0001) and enterocolitis (p < 0.0001), but not for cystitis by the treatment schedules and cumulative point A BED. All 4 patients treated with 86.4 Gy(10) at point A suffered both proctitis and enterocolitis. Patients with cumulative BED at rectal point of > or =100 Gy(3) had significantly higher incidence of proctitis (31% vs. 4%, p = 0.013). CONCLUSIONS: In view of the therapeutic ratio, cumulative BED 70-80 Gy(10) at point A is appropriate for uterine cervical cancer patients treated with a combination of EBRT and HDR-ICBT. Present results and data from other literatures suggested that cumulative BED at the rectal point should be kept below 100-120 Gy(3) to prevent late rectal complication.

Adult↗
PubMed2002

Preliminary toxicity and prostate-specific antigen response of a Phase I/II trial of neoadjuvant hormonal therapy, 103Pd brachytherapy, and three-dimensional conformal external beam irradiation in the treatment of locally advanced prostate cancer.

PURPOSE: Standard therapies for locally advanced prostate cancer have resulted in suboptimal disease control rates. A Phase I/II trial was designed for patients with positive seminal vesicle biopsies, prostate-specific antigen (PSA) >15 ng/ml, Gleason score > or =8 or clinical classification T2c-T3 to improve local control and to test the tolerance of the prostate to high-dose radiation by using neoadjuvant hormonal therapy, 103Pd brachytherapy, and conformal three-dimensional external beam radiation therapy (EBRT). This article outlines treatment-related morbidity and PSA response to this regimen and analyzes the effect of escalating doses of brachytherapy. METHODS AND MATERIALS: Forth-three patients with T1c-T3 prostate cancer were enrolled in a Phase I/II trial from March 1994 through September 1997. Follow-up ranged from 12 to 64 months (median, 32 months). Pretreatment PSA ranged from 2.1 to 202 ng/ml (median, 16 ng/ml). Seventy-seven percent (33 of 43) of patients had high-grade tumors (score > or =7). Seventy-four percent (32 of 43) had stage > or =T2c. A total of 21 (49%) patients had positive seminal vesicle biopsies. Treatment consisted of hormonal therapy for 3 months with leuprolide and flutamide followed by a 103Pd implant and, 2 months later, 59.4 Gy of three-dimensional EBRT. Hormonal therapy was continued for 9 months. The planned 103Pd dose was escalated from 57 Gy (13 patients) to 77 Gy (13 patients) to 86 Gy (17 patients). RESULTS: The actuarial freedom from PSA failure (PSA>0.5 ng/ml) at 4 years was 74%. There were no significant differences found when analyzing patients by presenting PSA or seminal vesicle status. There was a trend toward improved outcome with higher doses delivered to the prostate via the implant. Patients receiving doses > or =65 Gy (31 patients) had a freedom from PSA failure rate at 4 years of 89.5%, compared with 52.5% for those receiving doses <65 Gy (10 patients; p=0.08). The last PSA values for those patients free from PSA failure were < or =0.1 ng/ml in 25 (69%), >0.1-0.2 ng/ml in 5 (14%), and >0.2-0.5 ng/ml in 6 (17%). The actuarial freedom from developing Grade 2 proctitis was 75% at 4 years. There was a trend toward increased proctitis with increasing prostate implant doses. Patients with doses < or =70 Gy (n=12) had a 92% freedom from Grade 2 proctitis compared with 67.5% for those with doses delivered to 90% of the gland from a dose-volume histogram of >70 Gy (n=29) (p=0.15). There were no cases of Grade 3 or 4 proctitis. The 3-year actuarial preservation of sexual potency rate was 43%. CONCLUSIONS: The preliminary results from this regimen show an improvement in PSA control for this group of locally advanced prostate cancer patients over more standard therapies. To maximize control while minimizing toxicity, doses of 65-70 Gy of 103Pd should be used when 59.4 Gy of three-dimensional EBRT is delivered. Longer follow-up will be needed to further substantiate these findings.

Aged↗
PubMed2000

Mucosal cytokine production in radiation-induced proctosigmoiditis compared with inflammatory bowel disease.

OBJECTIVE: We measured the mucosal levels of interleukin 1beta (IL-1beta), IL-2, IL-6, and IL-8 in affected segments of radiation-induced proctosigmoiditis and compared these with the levels in normal controls and inflammatory bowel disease (IBD) patients. METHODS: Thirteen patients with histologically proven radiation proctosigmoiditis, 32 patients with active ulcerative colitis (UC), 35 patients with Crohn's disease, and 15 normal subjects undergoing routine colonoscopy were included in the study. All patients underwent colonoscopy and mucosal biopsies were obtained from both diseased and normal-appearing areas. Mucosal levels of IL-1beta, IL-2, IL-6, and IL-8 were determined by solid-phase enzyme-linked immunosorbent assay (ELISA) using the Quantikine method (R&D Systems, Minneapolis, MN). All the data were statistically analyzed using Student's t test. RESULTS: The mucosal levels of IL-2, IL-6, and IL-8 were significantly higher in both diseased segments (5.62 +/- 0.13, 1.60 +/- 0.31, and 21.45 +/- 4.03 pg/ml, respectively) and normal-appearing segments (3.83 +/- 0.78, 1.36 +/- 0.34, and 13.45 +/- 3.18 pg/mg) in the radiation proctitis group compared to those of normal control subjects (1.74 +/- 0.23, 0.67 +/- 0.09, and 4.99 +/- 1.39 pg/mg). These differences were statistically significant (p < 0.05). In the UC group, IL-1beta, IL-6, and IL-8 levels in diseased segments were 4.98 +/- 0.53, 2.22 +/- 0.28, and 88.85 +/- 8.05 pg/mg, respectively. In Crohn's disease patients, IL-1beta, IL-6, and IL-8 levels were 5.45 +/- 0.93, 2.88 +/- 0.58, and 61.68 +/- 10.02 pg/mg, respectively. All these levels were significantly higher (p < 0.05) compared with IL-1beta, IL-6, and IL-8 levels from normal segments of IBD patients. Compared with the radiation proctitis patients, the levels of IL-6 and IL-8 were significantly higher in the IBD group. CONCLUSIONS: The mucosal levels of IL-2, IL-6, and IL-8 were significantly higher in both diseased and normal segments of colon in patients with radiation proctitis, compared with normal controls. Only IL-1beta levels were significantly higher in diseased segments, compared with endoscopically normal-appearing segments in radiation proctitis. These results indicate that there is a similarity in the activation of mucosal cytokines between IBD and radiation proctosigmoiditis. This may partly explain the beneficial effects of similar topical and systemic agents such as steroids and mesalamine compounds when used in radiation-induced proctosigmoiditis.

Colitis, Ulcerative↗
PubMed1981

The prognosis of ileorectal anastomosis in Crohn's disease.

A total of 105 patients have been treated with colectomy and ileorectal anastomosis from 1958 to 1978 in Birmingham, England (48) and in Leiden, Netherlands (57). At the end of 1978 the mean follow-up was 7.6 years (6 months-20 years). Mild or moderate degrees of proctitis were not considered as contraindications for ileorectal anastomosis. The presence or absence of ileal disease or perianal disease at the time of ileorectal anastomosis did not effect the long term prognosis but patients with sigmoidoscopic proctitis appeared to fare less well (69 per cent still functioning) than those with an apparently normal rectum (87 per cent). However, no statistical significance was obtained. The risk of reoperation for recurrence of Crohn's disease after ileorectal anastomosis calculated by actuarial methods shows a 50 per cent cumulative reoperation rate after 16-20 years. This result suggests that ileorectal anastomosis is a safe and useful procedure for most patients with Crohn's colitis who did not have severe proctitis.

Adolescent↗
PubMed1981

Gastrointestinal tract complications following radiotherapy of uterine cervical cancer: past and present.

A retrospective analysis of the gastrointestinal tract complications in 298 patients with cervical cancer treated with radiotherapy at the State University of New York at Buffalo and Albert Einstein College of Medicine affiliated hospitals was carried out. Fifty-two patients had pretreatment surgical staging (39 transperitoneal and 13 extraperitoneal). Twenty-four percent had varying degrees of radiation sickness. They all responded to conservative therapy. Seven percent developed Stage I radiation proctitis. In the clinical staging group late complications consisted of: Three small bowel injuries, 4% persistent Stage I, 3% Stage III, and one patient with Stage II radiation proctitis. Among 39 patients who had transperitoneal surgical staging, two small bowel injuries, one case of gastric ulcer, and three cases of radiation proctitis were encountered. Only one of 13 patients who had extraperitoneal surgical staging developed intestino-vesico-vaginal fistula. A literature search was conducted, and prophylactic and therapeutic measures are discussed. The importance of careful selection of patients for radiotherapy and recognition of high risk clinical factors is reemphasized.

Adult↗
PubMed1991

Surgical management of intestinal radiation injury.

The management of 14 cases of radiation injury to the intestinal tract over a 4-year period is evaluated. The longest latent interval between radiation treatment and symptoms was 30 years. Eight patients were treated surgically; six were treated conservatively by laser therapy or application of formalin to the affected mucosa. The indications for surgery were rectovaginal fistula (four), rectal stricture (one), radiation proctitis (eight), and small bowel obstruction (one). Seven patients underwent large bowel resection. These consisted of four anastomoses with coloanal J-reservoirs, two low anterior resections, and one coloanal anastomosis without reservoir. There was no perioperative mortality. Morbidity occurred in one of the eight surgical cases. Radical resection of the radiation-damaged rectum has been shown to be a safe and reliable treatment for rectovaginal fistulas, rectal strictures, and proctitis unresponsive to medical measures. Coloanal J-reservoir is the procedure of choice to avoid urgency and frequency symptoms associated with coloanal sleeve anastomosis. Laser therapy for hemorrhagic proctitis can achieve an important place in the management of this problem without recourse to surgery.

Adult↗