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PubMed2006

Preoperative chemoradiation in rectal cancer: Retrospective comparison between capecitabine and continuous infusion of 5-fluorouracil.

BACKGROUND: We compared the efficacy and toxicity of oral capecitabine and continuous infusion of 5-fluorouracil (5-FU) in the preoperative chemoradiation treatment of patients with rectal cancer. PATIENTS AND METHODS: The files of 89 patients with rectal cancer, 43 treated preoperatively with oral capecitabine and 46 with intravenous 5-FU, were reviewed, and the outcome of the groups was compared. RESULTS: There was no statistically significant difference in the complete pathological response rate between the capecitabine and the 5-FU groups (30% vs. 17%, P = 0.15). The downstaging rate was higher in the capecitabine group (77% vs. 50%, P = 0.009). Toxicity was mild in both groups. The rate of Grade 3 gastrointestinal toxicity was similar in the two groups (diarrhea 2% vs. 4%, proctitis 5% vs. 7%), except for one patient in the 5-FU group (2%) who developed a rectovaginal fistula. In the capecitabine group, one patient (2%) had Grade 3 hand-foot syndrome, and another had an acute myocardial infarction. In the 5-FU group, two patients (4%) had Grade 3 hematological toxicity, and three (6%) had complications from Port-a-Cath insertion. CONCLUSION: Preoperative chemoradiation with oral capecitabine appears to be safe and well tolerated, and at least as good as continuous 5-FU.

Administration, Oral↗
PubMed1983

Combined external radiotherapy and hormonal therapy for localized carcinoma of the prostate.

Forty-nine patients with localized carcinoma of the prostate were treated by external radiotherapy together with hormonal manipulation and were followed up to six years. Hormonal manipulation included bilateral orchiectomy and diethylstilbestrol, 3 mg/day. The cumulative five-year survival for the 49 patients was 87.6%, with 11% progression rate to stage D during that period. In 40 patients (81.6%), a decrease in the size of the prostate was noted. In none of the patients was there local recurrence of the tumor during the period of follow-up. Transient gastrointestinal and/or urinary symptoms occurred following radiotherapy in 11 patients (22.4%), and in four patients severe cystitis or proctitis appeared. Complications related to hormonal therapy occurred in 11 patients (22.4%). The high survival rates reported herein, together with the low progression rate to stage D during six years of follow-up, may justify the early institution of radiotherapy in combination with hormonal manipulation for patients with localized carcinoma of the prostate. A randomized study with an extended number of patients is underway to further evaluate this mode of therapy.

Aged↗
PubMed1994

Chemotherapy followed by radiotherapy versus radiotherapy alone in locally advanced cervical cancer: a randomized study.

Between August 1990 and January 1992, 184 patients with squamous cell carcinoma of the cervix, FIGO stage IIB-IVA, were randomized to receive either two cycles of bleomycin, ifosfamide-mesna, and cis-platinum (BIP) chemotherapy (CT) followed by radiotherapy (RT) ("CT-RT group," n = 94) or RT alone (RT group, n = 90). In the CT-RT group, of 89 evaluable patients, 64 responded: complete response (CR) 4 (4.5%) and partial response 60 (67.5%). Of the remaining 25 patients, 23 had stable disease and 2 progressed. Eighty of 89 patients completed RT as planned. Following RT 56 (70%) achieved CR, 19 (23.7%) had residual disease, and 5 (6.3%) had progressed. CT responders had a better response to RT: 83% (49/59) vs 33.3% (7/21), P < 0.01). The stage of disease, histologic grade, duration of symptoms, and history of smoking had no influence on the response to CT. Patients aged > 45 years and those with Hb > 10 g/dl had significantly better response. Nausea/vomiting, alopecia, grade I-II myelosuppression, diarrhea, and mucositis were the major side effects of CT. Two patients died of CT toxicity. In the RT group, 88 patients were evaluable: 61 (69.3%) patients achieved CR, 25 had residual disease, and 2 progressed. The side effects of RT were cystitis, proctitis, and local skin reaction. These were equally distributed between the two groups. There was no significant difference in overall and disease-free survival in the two groups.

Adult↗
PubMed1994

Laparoscopic descending colostomy in three patients with cervical carcinoma.

Three patients with cervical carcinoma underwent laparoscopic descending colostomy. The indications for colostomy included severe radiation proctitis, enterovaginal fistula secondary to progressive pelvic tumor, and large bowel obstruction from progressive pelvic tumor. Two patients were treated with laparoscopic descending end colostomy with creation of a Hartman's pouch, and the third patient underwent laparoscopic descending loop colostomy. The techniques utilized are discussed.

Colostomy↗
PubMed1996

Bolus mitomycin C and 5-FU with sequential radiation for poor-prognosis locally advanced cervical cancer.

Forty patients with locally advanced cervical carcinoma were entered into a protocol utilizing the bolus administration of both mitomycin C (10 or 15 mg) on Day 1 and 5-fluorouracil (400 mg) on Day 1-5 followed by sequential pelvic irradiation on Day 6 between September 1980 and October 1985. All patients had poor-prognosis FIGO stage IB, IIB, IIIB, or IVA disease. Only patients with poor prognosis factors such as bulky tumor masses of 5 cm or greater noted on the initial physical exam (37 patients) or poorly differentiated histology (3 patients) were eligible for this study. There were three severe side effects seen in the 24 patients receiving 15 mg mitomycin C. One patient developed thrombocytopenia, one patient developed acute radiation enteritis, and the third patient developed radiation proctitis requiring laser therapy. Only 1 of 16 patients receiving 10 mg mitomycin C developed a complication (thrombocytopenia). Neutropenia was mild in all patients. No infections were seen. Thrombocytopenia never warranted platelet transfusion. No patients developed therapy-related bowel obstruction or fistulae. Median follow-up was 11.3 years with a range of 6.2-14.2 years. A complete response rate of 63%, a local control rate of 58%, and a 5-year survival rate of 44% were obtained. This does not appear to offer any benefit over radiation alone. This present study supports the superiority of higher dose concurrent infusional chemotherapy and radiation over low-dose sequential bolus chemotherapy and radiation.

Antibiotics, Antineoplastic↗
PubMed1996

High complete response rate of concomitant chemoradiotherapy for locally advanced squamous cell carcinoma of the uterine cervix.

A prospective study with a newly designed schedule of concomitant chemoradiotherapy was initiated for 42 patients with previously untreated squamous cell carcinoma of the uterine cervix. Their ages ranged from 34 to 77 years, median 57 years. There were 13 FIGO stage IIB, 1 IIIA, 27 IIIB, and 1 IVA. Radiotherapy was administered using 1.8 Gy/day, 5 days a week, to the whole pelvis (50.4 Gy/28 fractions) with local boost if indicated. Intracavitary brachytherapy of 5 Gy for five times was delivered after 1-2 weeks of rest. The first 21 patients received concomitant chemotherapy of biweekly PEB regimen (100 mg/m2 etoposide + 50 mg/m2 cisplatin + 50 mg/m2 bleomycin) for two to three cycles during external irradiation. The chemotherapy for the latter 21 patients was modified to weekly PEBF (50 mg/m2 etoposide + 20 mg/m2 cisplatin + 10 mg/m2 bleomycin + 800 mg/m2 5-FU, mixed in normal saline, 24-hr continuous iv infusion) for five to six cycles. All except 1 patient achieved complete response (97.6%) and sustain so after a median follow-up time of 30 months. There were three relapses--one with persistent pelvic disease and two with distant metastasis. Two-year overall survival and disease-free survival rates were 97.6 and 92.9%, respectively. Myelosuppression was moderate but fully recovered. Other acute toxicities were tolerated except for 1 patient who encountered grade IV radiation colitis with cecum perforation and required surgery. As to late morbidity, the incidence of radiation proctitis was high (21.4%) but of a mild degree, with 1 patient needing repeated transfusion. One patient developed chronic cystitis with an acontractile bladder. Our preliminary results show that concomitant chemoradiotherapy for advanced cervical carcinoma is both feasible and effective with acceptable toxicities. Further follow-up is mandatory to ensure whether this high complete response protocol will translate into long-term local control and survival.

Adult↗
PubMed1999

Interstitial brachytherapy for vaginal recurrences of endometrial carcinoma.

OBJECTIVE: The aim of this study was to evaluate the efficacy of interstitial brachytherapy in the management of vaginal recurrences of endometrial carcinoma. METHODS: Thirty patients received interstitial irradiation, with or without external beam radiotherapy. They were followed for a minimum of 5 years or until death. RESULTS: The median age was 66 years at initial diagnosis of endometrial cancer. FIGO stages included Stage I (n = 18), Stage II (n = 7), and Stage III (n = 5). All patients were treated originally by total abdominal hysterectomy and bilateral salpingo-oophorectomy, with or without lymphadenectomy, and 13 (43%) also received postoperative adjuvant whole pelvis radiotherapy as part of their primary treatment. Vaginal recurrences were diagnosed at a mean interval of 29 months after hysterectomy (range, 3-119 months). No patient had clinical evidence of pelvic sidewall extension or of distant metastatic disease. All patients were treated with interstitial brachytherapy; each implant delivered a mean maximal tumor dose of 25.5 Gy. Eighteen patients (60%) also received external beam radiotherapy (mean dose, 48 Gy) as part of their treatment for vaginal recurrence. Twenty-eight patients (93%) experienced a complete clinical response. Ten patients relapsed in the vagina (n = 5) or at distant sites (n = 5). Eleven patients are dead of disease. From the time of vaginal recurrence, the median overall survival was 60 months and the cause of death adjusted 5-year survival rate was 65%. Major morbidity included radiation proctitis (n = 2), fistula (n = 2), and radiation stricture (n = 1). CONCLUSION: Interstitial irradiation resulted in favorable local control as well as a 5-year survival rate and morbidity comparable to that reported previously for conventional brachytherapy.

Aged↗
PubMed2002

Evaluation of patients after extraperitoneal lymph node dissection and subsequent radiotherapy for cervical cancer.

OBJECTIVE: The presence of nodal metastases is the most important prognostic factor in cervical cancer. To adjust our therapy based on the true extent of the patient's disease, we performed an extraperitoneal lymph node dissection (EPLND) in all patients with cervical cancer prior to radiotherapy (RT) or radical hysterectomy. METHODS: Thirty-three patients with carcinoma of the cervix underwent EPLND. The value of this procedure as a diagnostic tool for monitoring the extension of the disease was determined. Additionally, EPLND/RT-associated treatment complications were monitored. RESULTS: The combined treatment approach of EPLND with RT or chemotherapy/RT was without major complications. Nineteen patients showed a temperature elevation, but only one patient had a fever of greater than 39.0 degrees C. Fourteen (48.3%) of 29 patients experienced some degree of proctitis or diarrhea and 3 (10.3%) experienced cystitis during the course of RT. No grade 3 or 4 acute or late genitourinary or gastrointestinal toxicities were noted. EPLND changed the clinical management for 6 patients from a radical hysterectomy to RT and for 7 patients from standard-field RT to extended-field RT. Without EPLND these 7 patients would have received RT with standard pelvic fields that would not have treated involved lymph node areas at high risk for subsequent failure. CONCLUSION: Thirteen (44.8%) of 29 patients received a different treatment than would otherwise have been administered with standard treatment planning. Therefore, we suggest that EPLND should be performed in all patients with cervical cancer prior to radical surgery or RT.

Adult↗
PubMed2002

Pelvic insufficiency fracture after pelvic irradiation in uterine cervix cancer.

OBJECTIVES: Pelvic insufficiency fractures (IF) are well known but uncommon and are frequently misinterpreted sequelae. The clinical features were investigated. METHODS: Four hundred sixty-three patients, who were treated between 1994 and 2000 for uterine cervix cancer, were clinically examined. All patients had been treated with 10 or 15 MV photons, with 50.4-55.8 Gy in 28 fractions with adjuvant intent (n = 235) in addition to high-dose-rate brachytherapy 24 Gy in 6 fractions for curative treatment (n = 228). The median follow-up was 38 months. RESULTS: Eight patients (8/463, 1.7%) developed pelvic IF 7-19 months (median, 12 months) after the treatment. Among these, seven patients (7/228, 3.1%) were treated with curative intent and one (1/235, 0.4%) was treated with adjuvant intent. All patients were postmenopausal and complained of moderate to severe pelvic pain, which resolved after 1-11 months with conservative therapy in all patients. Two of these patients also had radiation proctitis. CONCLUSION: In women who present with pelvic pain after radiotherapy for cervical cancer, bony destruction and fractures may be indicative of a late radiation effect rather than osseous metastasis. IF are more common in the curative treatment group than in the postoperative adjuvant group.

Aged↗
PubMed1996

Laparoscopic colorectal surgery: analysis of 140 cases.

BACKGROUND: This study was performed to prospectively assess the results of our first 140 consecutive patients who underwent laparoscopic or laparoscopic-assisted colorectal operations. METHODS: The parameters studied included the type and length of procedure, intra- and postoperative complications, conversion to open surgery, and length of ileus and hospitalization. RESULTS: 140 laparoscopic and laparoscopic-assisted procedures were performed between May 1991 and January 1995. The mean patient age was 48 (range 12-88) years; there were 78 males and 62 females. Indications for surgery included inflammatory bowel disease in 47, colorectal carcinoma in 19, diverticular disease in 17, polyps in 16, familial polyposis in 7, colonic inertia in 7, fecal incontinence in 11, sigmoidocele in 3, irradiation proctitis in 3, rectal prolapse in 2, intestinal lymphoma in 2, and miscellaneous conditions in 6. The procedures included 38 total abdominal colectomies (TAC) (ileoanal reservoir 28, ileorectal anastomosis 8 and end ileostomy 2); 70 segmental resections of the colon, small bowel, and rectum; 18 diverting stoma creations; 10 reversal of Hartmann's procedures; and 4 other procedures. In 15 cases, the laparoscopic procedure was converted to a laparotomy (11%); 31 patients (22%) sustained 37 complications, which included: enterotomies(7), hemorrhage(10), intraabdominal abscess(4), prolonged ileus(6), wound infection(4), intestinal obstruction(2), anastomotic leak(1), aspiration(1), cardiac arrhythmia(1), and upper intestinal bleeding(1); there was no mortality. The overall complication rate in TAC cases was significantly higher (42%) when compared to that of all other procedures (segmental resection 17%, others 9%), P < 0.05. The mean length of operating time was 4 (range 2.5-6.5) h for TAC, 2.6 (range 1.5-5.5) h for segmental colonic resections, and 1.7 (range 0.7-4) for all other procedures. The length of ileus was 3.5 (range 2-7) days after TAC, 3 (range 2-7) after the segmental resections and 2 (range 1-4) after the other procedures. The mean length of hospital stay was 6.8 (2-40) days (8.4, 6.5, and 6.3 days for the TAC, segmental resections, and other procedures, respectively). CONCLUSION: The feasibility of laparoscopic colorectal surgery has been well established. TAC is associated with a higher complication rate compared to other laparoscopic colorectal procedures.

Adolescent↗
PubMed1993

Treatment of anovaginal fistulas with an anocutaneous flap in patients with Crohn's disease.

We report on a new and simple operative technique for closure of anovaginal fistulas with an anocutaneous flap in patients with Crohn's disease. From January 1989 till December 1990 this operation was performed in 10 women with Crohn's disease. Seven of the ten patients suffered from Crohn's proctitis. In these patients a protective enterostomy was applied before the operative closure of the fistula. All fistulas healed primarily. Within a median follow up of 18 months (7-24 months) a relapse occurred in 3 patients; two of these were treated successfully with fibrin injection in one case and a further operative closure of the fistula using the same procedure in the second case. In the third patient a seton was placed into the recurrent fistula track, which is still present after 4 weeks.

Adult↗
PubMed1995

Management of rectourethral fistulas in Crohn's disease.

We report the thirteenth case of a recto-urethral fistula in Crohn's disease. The patient, a 37-year-old white male, had a 20-year history of intestinal Crohn's disease and had undergone numerous bowel resections. His symptoms were fecaluria, urorrhea and passing of urine from an orifice just outside the base of the scrotum. He had urinary infection and severe ileocolitis. He underwent a diagnostic evaluation (cystourethroscopy, proctoscopy, retrograde pyelography, intravenous urography, voiding cystourethrography) that revealed a fistula comprising the membranous urethra, the rectum, the perineum and the scrotum. He was treated with Metronidazole (20 mg/kg/day/12 mo). At 1 year no signs of intestinal disease and urinary sepsis were noted. The external orifice and the perineal fistulous network were closed, and the drainage from the rectum and the urethra had improved. No side effects limited use of the drug. No relapse was observed in the 3 months, after the therapy was discontinued. We present a review of the literature on the management of rectourethral fistulas in Crohn's disease. Surgeons have used successfully several approaches in the repair of this lesion, but no single procedure has proved optimal or even universally applicable. We emphasize, as the literature suggests, that the management must be individualized. Medical therapy with metronidazole has an important role in a patient with rectourethral fistula and concomitant proctitis, ileocolitis, urinary sepsis and multiple previous surgical procedures.

Adult↗
PubMed1994

Unexpected radiation protection with 13-cis-retinoic acid plus interferon alpha-2a.

A recent clinical protocol combining retinoic acid, interferon, and radiotherapy for advanced cervical cancer produced proctitis severe enough to necessitate dose reductions. In an attempt to model this biological response to multimodality therapy, we used a murine model to study the response of the colonic epithelium. Mice were treated with retinoic acid (100 micrograms/day) and interferon (3 x 10(4) units/day) for 5 days before undergoing whole-body irradiation. The functional response of the bowel was assessed by the ability to maintain body weight, and reproductive cell survival was quantified by the colon crypt assay. Both assays indicated a moderate protective effect of treatment with retinoic acid and interferon prior to irradiation. Protection factors in the range of 1.1-1.4 were observed.

Animals↗
PubMed1983

Stromal cell changes in human colorectal adenomas and carcinomas. An ultrastructural study of fibroblasts, myofibroblasts, and smooth muscle cells.

Structural changes in stromal cells during the development of human colorectal carcinomas were studied by light and electron microscopy. The results were as follows: Stromal cells of the lamina propria in control subjects consisted principally of resting fibroblasts. Stromal fibroblasts were mildy activated in adenomas with mild -moderate atypia, and more markedly in adenomas with severe atypia (carcinoma in situ). In invasive adenocarcinomas, (a) desmoplastic reaction was induced, (b) stromal fibroblasts proliferated significantly and were activated showing enlarged nuclei and abundant rough endoplasmic reticulum, and (c) some smooth muscle cells were endowed with well-developed rough endoplasmic reticulum in their axial cytoplasm, resulting in a similar appearance to "myofibroblasts". Stromal fibroblasts in ulcerative colitis and proctitis were also activated. Morphometric analysis revealed that activated fibroblasts significantly increased the areas of their nuclei and cytoplasm, and the perimeter of rough endoplasmic reticulum. These activated fibroblasts suggested a higher production of collagen and other connective tissue proteins. Bundles of microfilaments of actin type were readily found in fibroblasts in all cases examined. These filaments were most remarkable in the fibroblasts in the desmoplastic stroma of invasive adenocarcinoma and were considered to be one of the basic components of these cells. Relationships between fibroblasts, "myofibroblasts", and smooth muscle cells are discussed.

Adenocarcinoma↗
PubMed1980

Staphylococcal pelvic and rectal infection in a neonate.

An infant with neonatal staphylococcal infection had evidence of pelvic inflammation, peritonitis and proctitis which resulted in narrowing of the rectosigmoid, uterectasis, pyelocaliectasis, and partial obstruction of the inferior vena cava. Appropriate treatment resulted in resolution of these findings.

Colon↗
PubMed1986

Idiopathic chronic watery diarrhea from excluded rectosigmoid with goblet cell hyperplasia cured by restoration of large bowel continuity.

A 73-year-old woman developed abnormal electrolyte and water loss from an excluded rectosigmoid segment after surgical treatment of a volvulus of the sigmoid colon. Rectal discharges lasted almost for a year, until it spontaneously resolved after restoration of large bowel continuity. Despite extensive investigation, including endoscopic, radiologic, microscopic, bacteriologic and parasitic examinations, no satisfactory explanation of the diarrhea could be found. The histologic pattern of the excluded segment showed a striking increase in mucosal thickness and in number and height of goblet cells. These abnormalities disappeared after closure of the colostomy. Electrolyte composition of the rectal fluid, which contained 134 mmol potassium and 22 mmol sodium per liter was remarkable and similar to that of normal stool water and anal discharges of patients with ulcerative proctitis.

Aged↗
PubMed1991

Radiation-induced proctosigmoiditis. Prospective, randomized, double-blind controlled trial of oral sulfasalazine plus rectal steroids versus rectal sucralfate.

In a prospective study, 37 consecutive patients with radiation-induced proctosigmoiditis were randomized to receive a four-week course of either 3.0 g oral sulfasalazine plus 20 mg twice daily rectal prednisolone enemas (group I, N = 18) or 2.0 g twice daily rectal sucralfate enemas plus oral placebo (group II, N = 19). The two groups were comparable with respect to demographic features, duration of symptoms, and clinical and endoscopic staging of the disease. Fifteen patients in group I and 17 in group II completed the trial. At four weeks, both groups showed significant clinical improvement (P less than 0.01 for group I and P less than 0.001 for group II) and endoscopic healing (P less than 0.01 for group I and P less than 0.001 for group II). When the two groups were compared, sucralfate enemas showed a significantly better response as assessed clinically (P less than 0.05), although endoscopically the response was not statistically different (P greater than 0.05). We conclude that both treatment regimens are effective in the management of radiation proctitis. Sucralfate enemas give a better clinical response, are tolerated better, and because of the lower cost should be the preferred mode of short-term treatment.

Administration, Oral↗
PubMed1988

New enema treatments for inflammatory bowel disease.

Two new preparations are under clinical trial for use in the treatment of ulcerative proctitis and left-sided colitis. One is 5-aminosalicylate, a component of sulfasalazine. This substance has virtually no immunomodulating capabilities. Evidence for efficacy equal to that of sulfasalazine in acute colitis has been obtained but its role in preventing recurrences is unknown. The other substance is tixocortol, a rapidly metabolized steroid, which has local antiinflammatory activity. Specific procedures of preparation and dosage remain to be established. Both preparations are administered as enemas.

Aminosalicylic Acids↗