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PubMed2004

Mesalazine-induced reversible infertility in a young male.

Mesalazine is a well-established treatment for ulcerative colitis. A young man treated with mesalazine for proctitis was found to have pathological semen with a count of only 3 x 10(6) sperm cells/ml. He failed to achieve conception with his wife. When mesalazine treatment was stopped, semen analysis returned to near normal and pregnancy ensued. Due to recurrent disease activity, mesalazine treatment was reinstituted. This was followed by deterioration of the patient's semen.

Adult↗
PubMed2005

Technological advances in radiotherapy for the treatment of localised prostate cancer.

There is good evidence that radiation dose escalation in localised prostate cancer is associated with increased cell kill. The traditional two-dimensional (2D) technique of treatment planning and delivery is limited by normal tissue toxicity, such that the dose that can be safely delivered to the prostate by external beam radiotherapy is 65-70 Gy. Several technological advances over the last 20 years have enhanced the precision of external beam radiotherapy (EBRT), and have resulted in improved outcomes. The three-dimensional conformal radiotherapy (3D-CRT) approach reduces the dose-limiting late side-effect of proctitis and has allowed for dose escalation to the whole prostate to 78 Gy. More recently, intensity modulated radiotherapy (IMRT), an advanced form of conformal therapy, has resulted in reduced rectal toxicity when using doses greater than 80 Gy. In addition, IMRT can potentially escalate the dose to specific parts of the prostate where there are resistant subpopulations of tumour clonogens, or can be used to extend the high-dose region to pelvic lymph nodes. The addition of androgen deprivation to conventional radiotherapy has an impact on survival and local control. Initial hormone therapy causes cytoreduction of the prostate cancer allowing for a reduction in radiotherapy volume as well as an additive effect on cell kill. Long-term adjuvant androgen deprivation has been shown to improve overall survival in more advanced tumours. Prostate brachytherapy is now a recognised treatment for those with low-risk disease. It achieves similar long-term outcome to other treatment modalities. Brachytherapy can be used as monotherapy for localised disease, or as boost treatment following conventional EBRT for locally advanced disease. New techniques are available to improve the precision of both target definition and treatment verification. This so-called image-guided radiotherapy will help to enhance the accuracy of dose delivery by correcting both for inter-fraction positional variation and for intra-fraction movement of the prostate in real-time and will allow for tighter tumour margins and avoidance of normal tissues, thereby enhancing the safety of treatment.

Androgen Antagonists↗
PubMed2006

Colitis cystica profunda and solitary rectal ulcer syndrome-polypoid variant: Two confusing clinical conditions.

Colitis cystica profunda and solitary rectal ulcer syndrome-polyoid variant are related chronic benign disorders with characteristic histological features. However, the clinical and endoscopic settings are confusing and misleading, suggesting other rectal conditions. We report a case of colitis cystica profunda and solitary rectal ulcer syndrome-polypoid variant that was misdiagnosed initially as an ulcerative proctitis. Since an occult malignancy could not be ruled out by superficial biopsies, the mass was removed by full-thickness transanal excision.

Journal Article↗
PubMed2004

Long-term treatment results of invasive cervical cancer patients undergoing inadvertent hysterectomy followed by salvage radiotherapy.

PURPOSE: To evaluate the long-term results of salvage radiotherapy for patients of invasive cervical cancer after inadequate surgery. METHODS AND MATERIALS: Between October 1975 and January 1994, 90 patients were treated with radiotherapy for invasive cervical carcinoma after simple hysterectomy. The inadequate surgery was performed for a variety of reasons. All patients had postoperative external beam irradiation or intravaginal brachytherapy, or both. The end points of this study were local control, survival, and treatment-related toxicity. RESULTS: The patients' age varied between 33 and 76 with a median of 53 years. The most common histopathology was squamous cell carcinoma, which accounted for 91% of the patients. The most frequent reason for inadvertent hysterectomy was understaged disease with preoperative diagnosis as carcinoma in situ for 51 patients (57%). Malignancy was not suspected before surgery in 28 patients (31%). After surgery, 72 patients (80%) were restaged as Ib, 12 patients (13.3%) as IIa, and 6 patients (6.7%) as IIb. Median follow-up time was 83 months. Seventy-three patients had follow-up times of 5 years or more. The overall 5-year and 10-year survival rates of 90 patients were 85.5% and 74.1%, respectively. Disease-specific 5-year and 10-year survival rates were 85.5% and 80.5%, respectively. All 16 patients with either locoregional or distant failure eventually died of disease. Fourteen patients (15.5%) had late morbidities. Radiation proctitis developed in 6 patients, intestinal obstruction in 4 patients, and hemorrhagic cystitis in 3. There was only 1 patient (1%) with terminal ileum stenosis and severe intestinal obstruction requiring surgical intervention. CONCLUSIONS: Most cases of inadequately treated invasive cervical cancer were the result of suboptimal preoperative workups. Patients who had early tumors and no gross residual tumor after inadequate hysterectomy can have excellent prognoses when given postoperative radiotherapy. The severe long-term complication related to salvage radiotherapy is rare.

Adult↗
PubMed2004

The efficacy of hyperbaric oxygen therapy in the treatment of radiation-induced late side effects.

PURPOSE: We investigated the efficacy of hyperbaric oxygen therapy (HBOT) in the management of patients with radiation-induced late side effects, the majority of whom had failed previous interventions. METHODS AND MATERIALS: Of 105 eligible subjects, 30 had either died or were not contactable, leaving 75 who qualified for inclusion in this retrospective study. Patients answered a questionnaire documenting symptom severity before and after treatment (using Radiation Therapy Oncology Group criteria), duration of improvement, relapse incidence, and HBOT-related complications. RESULTS: The rate of participation was 60% (45/75). Improvement of principal presenting symptoms after HBOT was noted in 75% of head-and-neck, 100% of pelvic, and 57% of "other" subjects (median duration of response of 62, 72, and 68 weeks, respectively). Bone and bladder symptoms were most likely to benefit from HBOT (response rate, 81% and 83%, respectively). Fifty percent of subjects with soft tissue necrosis/mucous membrane side effects improved with HBOT. The low response rate of salivary (11%), neurologic (17%), laryngeal (17%), and upper gastrointestinal symptoms (22%) indicates that these were more resistant to HBOT. Relapse incidence was low (22%), and minor HBOT-related complications occurred in 31% of patients. CONCLUSION: Hyperbaric oxygen therapy is a safe and effective treatment modality offering durable relief in the management of radiation-induced osteoradionecrosis either alone or as an adjunctive treatment. Radiation soft tissue necrosis, cystitis, and proctitis also seemed to benefit from HBOT, but the present study did not have sufficient numbers to reliably predict long-term response.

Adolescent↗
PubMed2005

A dose-escalation trial with the adaptive radiotherapy process as a delivery system in localized prostate cancer: analysis of chronic toxicity.

PURPOSE: To evaluate the validity of the chosen adaptive radiotherapy (ART) dose-volume constraints while testing the hypothesis that toxicity would not be greater at higher tumor dose levels. MATERIALS AND METHODS: In the ART dose escalation/selection trial, treatment was initiated with a generic planning target volume (PTV) formed as a 1-cm expansion of the clinical target volume (CTV). After the first week of therapy, the patient was replanned with a patient-specific PTV, constructed with CT and electronic portal images obtained in the first 4 days of treatment. A new multileaf collimator beam aperture was used. A minimum dose prescribed to the patient-specific PTV, ranging 70.2-79.2 Gy, was determined on the basis of the following rectal and bladder constraints: <5% of the rectal wall has a dose >82 Gy, <30% of the rectal wall has a dose >75.6 Gy, <50% of the bladder volume has a dose >75.6 Gy, and the maximum bladder dose is 85 Gy. A conformal four-field and/or intensity-modulated radiotherapy (IMRT) technique was used. Independent reviewers scored toxicities. The worst toxicity score seen was used as per the Common Toxicity Criteria grade scale (version 2). We divided the patients into three separate groups: 70.2-72 Gy, >72-75.6 Gy, and >75.6-79.2 Gy. Toxicities in each group were quantified and compared by the Pearson chi-squared test to validate our dose escalation/selection model. Grades 0, 1, 2, and 3 were censored as none vs. each category and none vs. any. RESULTS: We analyzed patients with follow-up greater than 1 year. The mean duration of follow-up was 29 months (range, 12-46 months). We report on 280 patients, mean age 72 years (range, 51-87 years). Only 60 patients received adjuvant hormones. Mean pretreatment prostate-specific antigen level was 9.3 ng/mL (range, 0.6-120 ng/mL). Mean Gleason score was 6 (range, 3-9). The lowest dose level was given to 49 patients, the intermediate dose to 131 patients, and 100 patients received the highest dose escalation. One hundred eighty-one patients (65%) were treated to a prostate field only and 99 patients (35%) to prostate and seminal vesicles. Chronic genitourinary and/or gastrointestinal categories were incontinence, persistent urinary retention, increased urinary frequency/urgency, urethral stricture, hematuria, diarrhea, rectal pain, bleeding, ulcer, fistula, incontinence, and proctitis. Toxicity at the high dose level was not different from toxicity at the intermediate or lower dose levels. No significant difference was observed in any of the individual toxicity categories. CONCLUSIONS: By applying the ART process--namely, developing a patient-specific PTV--to prostate cancer patients, significant dose escalation can be achieved without increases in genitourinary or gastrointestinal toxicity. Our data validate the rectal and bladder dose-volume constraints chosen for our three-dimensional conformal and IMRT prostrate radiotherapy planning.

Aged↗
PubMed2005

Preoperative chemoradiation with oral tegafur within a multidisciplinary therapeutic approach in patients with T3-4 rectal cancer.

PURPOSE: The aim of this study was to evaluate the activity in terms of downstaging histologic patterns of residual tumor and clinical tolerance of a neoadjuvant chemoradiation program with oral tegafur for rectal cancer. METHODS AND MATERIALS: From May 1998 to May 2001, 62 consecutive patients with cT(3-4) or cN(+) rectal cancer, or both, were treated with 45-50 Gy (1.8 Gy/day; 25 fractions) and oral tegafur 1200 mg/day. Surgery was performed 6 weeks after the completion of chemoradiation. All patients received a boost with intraoperative electron beam radiotherapy (IOERT) over the presacral space. RESULTS: Grade 3-4 hematologic toxicity consisted on Grade 3 anemia in 1 patient. Nonhematologic toxicity was mild. Fifteen patients (23%) had Grade 3 dermatitis, 16 (25%) had Grade 3, and 2 (3%) had Grade 4 proctitis. The median dose of radiotherapy was 50.4 Gy. Surgery consisted on anterior resection in 38 patients (61%) and abdominoperineal amputation in 24 (39%). Five complete pathologic responses were observed (8%), and 29 patients (47%) had a minimal microscopic residual tumor (mic category). The total downstaging rate was 68%. With a median follow-up of 46 months, the pelvic control rate was 95%, disease-free survival 74.1%, and overall survival 76.5%. CONCLUSIONS: Neoadjuvant chemoradiation with oral tegafur is feasible, well tolerated, and active, with the additional advantage of offering the convenience of oral chemotherapy.

Adult↗
PubMed2005

Phase II dose escalation study of image-guided adaptive radiotherapy for prostate cancer: use of dose-volume constraints to achieve rectal isotoxicity.

PURPOSE: In our Phase II prostate cancer Adaptive Radiation Therapy (ART) study, the highest possible dose was selected on the basis of normal tissue tolerance constraints. We analyzed rectal toxicity rates in different dose levels and treatment groups to determine whether equivalent toxicity rates were achieved as hypothesized when the protocol was started. METHODS AND MATERIALS: From 1999 to 2002, 331 patients with clinical stage T1 to T3, node-negative prostate cancer were prospectively treated with three-dimensional conformal adaptive RT. A patient-specific confidence-limited planning target volume was constructed on the basis of 5 CT scans and 4 sets of electronic portal images after the first 4 days of treatment. For each case, the rectum (rectal solid) was contoured in its entirety. The rectal wall was defined by use of a 3-mm wall thickness (median volume: 29.8 cc). The prescribed dose level was chosen using the following rectal wall dose constraints: (1) Less than 30% of the rectal wall volume can receive more than 75.6 Gy. (2) Less than 5% of the rectal wall can receive more than 82 Gy. Low-risk patients (PSA < 10, Stage < or = T2a, Gleason score < 7) were treated to the prostate alone (Group 1). All other patients, intermediate and high risk, where treated to the prostate and seminal vesicles (Group 2). The risk of chronic toxicity (NCI Common Toxicity Criteria 2.0) was assessed for the different dose levels prescribed. HIC approval was acquired for all patients. Median follow-up was 1.6 years. RESULTS: Grade 2 chronic rectal toxicity was experienced by 34 patients (10%) (9% experienced rectal bleeding, 6% experienced proctitis, 3% experienced diarrhea, and 1% experienced rectal pain) at a median interval of 1.1 year. Nine patients (3%) experienced grade 3 or higher chronic rectal toxicity (1 Grade 4) at a median interval of 1.2 years. The 2-year rates of Grade 2 or higher and Grade 3 or higher chronic rectal toxicity were 17% and 3%, respectively. No significant difference by dose level was seen in the 2-year rate of Grade 2 or higher chronic rectal toxicity. These rates were 27%, 15%, 14%, 17%, and 24% for dose levels equal to or less than 72, 73.8, 75.6, 77.4, and 79.2 Gy, respectively (p = 0.3). Grade 2 or higher chronic rectal bleeding was significantly greater for Group 2 than for Group 1, 17% vs. 8% (p = 0.035). CONCLUSIONS: High doses (79.2 Gy) were safely delivered in selected patients by our adaptive radiotherapy process. Under the rectal dose-volume histogram constraints for the dose level selection, the risk of chronic rectal toxicity is similar among patients treated to different dose levels. Therefore, rectal chronic toxicity rates reflect the dose-volume cutoff used and are independent of the actual dose levels. On the other hand, a larger PTV will increase the rectal wall dose and chronic rectal toxicity rates. PTV volume and dose constraints should be defined, considering their potential benefit.

Aged↗
PubMed2005

Rectal toxicity profile after transperineal interstitial permanent prostate brachytherapy: use of a comprehensive toxicity scoring system and identification of rectal dosimetric toxicity predictors.

PURPOSE: To better understand rectal toxicity after prostate brachytherapy, we employed the National Cancer Institute Common Terminology Criteria for Adverse Events (CTCAE version 3.0), a comprehensive system with distinct and separately reported gastrointestinal adverse event items (unlike Radiation Therapy Oncology Group morbidity scoring), to evaluate item-specific postimplant rectal toxicities. METHODS AND MATERIALS: We analyzed 135 patients treated with brachytherapy +/- hormonal therapy, using CTCAE v3.0 to score acute/late rectal toxicities (median follow-up, 41 months). Dosimetric parameters were evaluated for ability to predict toxicities. RESULTS: Use of CTCAE yielded a novel rectal toxicity profile consisting of diarrhea, incontinence, urgency, proctitis, pain, spasms, and hemorrhage event rates. No item had a < 5% Grade 1-2 acute toxicity rate (except spasms). Rectal dosimetry predicted late toxicities: for diarrhea, 5% Grade 1 toxicity rate for %V25 (percent of rectal volume receiving 25% of prescribed prostate dose) < or = 25% vs. 60% for %V25 > 25% (p < 0.001); for maximum toxicity, 10% Grade 1 toxicity rate for %V10 < or = 40% vs. 44% for %V10 > 40% (p = 0.007). CONCLUSIONS: A comprehensive understanding of item-specific postimplant rectal toxicities was obtained using CTCAE. Rectal %V25 > 25% and %V10 > 40% predicted worse late diarrhea and maximum toxicity, respectively.

Aged↗
PubMed2006

Low-dose rate prostate brachytherapy is well tolerated in patients with a history of inflammatory bowel disease.

PURPOSE: We report on the follow-up of 24 patients with a prior history of inflammatory bowel disease (IBD) treated with brachytherapy for early-stage prostate cancer. METHODS AND MATERIALS: Twenty-four patients with a history of inflammatory bowel disease (17 with ulcerative colitis (UC), 7 with Crohn's disease [CD]) underwent prostate brachytherapy between 1992 and 2004. Fifteen patients were treated with I-125 implantation and 6 patients were treated with Pd-103 alone or in combination with 45 Gy external beam radiation. Charts were reviewed for all patients, and all living patients were contacted by phone. National Cancer Institute common toxicity scores for proctitis were assigned to all patients. Actuarial risk of late toxicity was calculated by the Kaplan-Meier method. Statistical analysis was performed using SPSS software. Follow-up ranged from 3 to 126 months (median, 48.5 months; mean, 56.8 months). RESULTS: None of the patients experienced Grade 3 or 4 rectal toxicity. Four patients experienced Grade 2 late rectal toxicity. The 5-year actuarial freedom from developing late Grade 2 rectal toxicity was 81%. At a median follow-up of 48.5 months, 23 patients were alive and had no evidence of disease with a median prostate-specific antigen for the sample of 0.1 ng/mL (range, <0.05-0.88 ng/mL). One patient died of other causes unrelated to his prostate cancer. CONCLUSIONS: Prostate brachytherapy is well tolerated in patients with a history of controlled IBD. Therefore, brachytherapy should be considered a viable therapeutic option in this patient population.

Brachytherapy↗
PubMed2006

Locally advanced prostate cancer treated with concomitant radiation and 5-fluorouracil: Southwest Oncology Group Study 9024.

PURPOSE: Radiation is considered the standard treatment for locally advanced (T3 and T4) prostate cancer but cure with radiation alone is infrequent. Studies have shown that adding androgen ablation improves the results but there is still much room for improvement. We performed a phase II multi-institutional study to explore the feasibility of concomitant chemoradiotherapy. MATERIALS AND METHODS: Eligible patients had prostate cancer with clinical evidence of invasion through the prostatic capsule or into the seminal vesicles without evidence of nodal or distant metastasis. Prior prostatectomy was not allowed and patients could not be candidates for surgical resection due to medical reasons or refusal of surgery. Radiation consisted of 7,020 cGy in 39 fractions. Continuous infusion 5-fluorouracil at a dose of 200 mg/m2 daily was started on day 1 and continued 7 days weekly until the last day of radiation. RESULTS: All 30 eligible patients were evaluated for toxicity. Diarrhea was the most common toxicity with grade 3 and 4 diarrhea in 2 and 1 patients, respectively. The only other grade 4 toxicity was hemorrhagic cystitis in 1 patient. There was 1 incident each of grade 3 stomatitis, congestive heart failure, edema, proctitis and hematuria. No patient with grade 3 or 4 toxicity required treatment delay. Ten patients (33%) achieved a negative biopsy and 13 (43%) achieved prostate specific antigen less than 1.0 ng/ml. Six patients (20%) achieved a complete response, defined as negative biopsy and prostate specific antigen less than 1.0 (95% CI 8 to 39). Patients without any biopsies or without prostate specific antigen followup were assumed to be nonresponders. CONCLUSIONS: Toxicity was acceptable. The modest response rate indicates that better chemotherapy that improves local and systemic failure is necessary to improve the results. This study confirms the feasibility of a combined chemoradiotherapy approach.

Adenocarcinoma↗
PubMed2004

Reducing the toxicity associated with the use of radiotherapy in men with localized prostate cancer.

The risk for serious complications associated with modern radiotherapy is relatively low. Compared with conventional radiotherapy, 3DCRT and IMRT allow higher doses to be given more safely. The use of IMRT increases the time and effort required by physicians and physicists. Although there is a clear move toward IMRT, 3DCRT is considered standard. The quality assurance procedures for and fundamental questions regarding IMRT are evolving, including the radiobiologic consequences of altered time-dose fractionation and the greater dose heterogeneity in the target. Defining an accurate target volume and routinely correcting for set-up error and organ movement before each treatment promise to reduce the complications associated with EBRT in the next 5 years. Complications following prostate brachytherapy are better understood now than 10 years ago. Dosimetric or patient selection factors that correlate with a higher risk for complications, such as acute retention, strictures, severe prolonged urinary symptoms, fistulas, proctitis, and impotence, often can be accounted for or avoided. Finally, the role of radiation protectors is beginning to be addressed. It is hoped that these advances will eliminate toxicity associated with radiotherapy and increase cure rates.

Aged↗
PubMed2005

Concurrent chemoradiotherapy using high-dose-rate intracavitary brachytherapy for uterine cervical cancer.

OBJECTIVE: We retrospectively reviewed our experience with concurrent chemoradiotherapy (CCRT) using high-dose-rate intracavitary brachytherapy (HDR-ICBT) to assess its feasibility and efficacy in the treatment of patients with uterine cervical cancer. METHODS: Forty patients with uterine cervical squamous cell carcinoma treated with CCRT using HDR-ICBT were analyzed. The median cervical tumor size assessed by MRI was 63 mm (range: 40-86 mm). Eighteen patients (45%) had enlarged pelvic nodes on MRI (> or =10 mm). Cisplatin (20 mg/m2/day) was concurrently administered with radiotherapy for 5 days at 21-day intervals for a median of three courses (range: 1-5 courses). Thirty-eight (95%) patients received whole pelvic external beam radiotherapy (EBRT) with 40 Gy/20 fractions followed by HDR-ICBT with 18 Gy/3 fractions to point A. Subsequently, additional pelvic EBRT with 10 Gy/5 fractions was delivered with a midline block. The cumulative biological effective dose (BED) at point A of this schedule was 77 Gy10. The median follow-up period for all 40 patients was 37 months (range: 8-71 months). RESULTS: Grade 3/4 leukopenia was the most common acute side effect (83%). The actuarial 3-year pelvic control rate, disease-free survival rate, and overall survival rate were 91%, 67%, and 79%, respectively. Eight (20%) patients suffered late gastrointestinal complications (all grades). No patient suffered radiation cystitis (all grades). Only one patient experienced grade 3 complication (enterocolitis). The actuarial 3-year late complication rate (all grades) was 9% for proctitis and 15% for enterocolitis. CONCLUSION: This preliminary study suggests that CCRT using HDR-ICBT is feasible and efficacious for patients with locoregionally advanced uterine cervical cancer.

Adult↗
PubMed1998

Differential effect of radiation on endothelial cell function in rectal cancer and normal rectum.

BACKGROUND: Chronic radiation injury of the intestine is associated with significant underexpression of a potent physiological anticoagulant, endothelial cell thrombomodulin (TM). This study compared early and late radiation-induced changes in endothelial TM, urokinase plasminogen activator (uPA), and transforming growth factor beta (TGF-beta) in normal rectum and tumors. METHODS: Rectal resection specimens from 27 patients were analyzed: Nine patients underwent primary resection of rectal cancer, 11 tumors were resected after neo-adjuvant radiotherapy, and 7 because of local recurrence after prior resection and adjuvant radiotherapy. TM, uPA, and extracellular matrix-associated TGF-beta, immunoreactivity were assessed using computerized image analysis. RESULTS: Multivariate analysis revealed that tumors had more TM-positive vessels (P = 0.003), more uPA-positive cells (P <0.001), and higher TGF-beta immunoreactivity levels (P <0.001) than normal rectum. Preoperative irradiation was associated with decreased proportions of TM-positive vessels in tumors (P = 0.003) and normal rectum (P <0.001). Irradiated tumors had fewer uPA-positive cells (P = 0.003) and less TGF-beta immunoreactivity (P = 0.001) than unirradiated tumors. The proportion of TM-positive vessels in irradiated rectum from patients with recurrence was decreased (P = 0.03), whereas the recurrent (ie, unirradiated) tumors did not differ from primary tumors in terms of TM, TGF-beta, or uPA immunoreactivity. CONCLUSIONS: The results support a role for endothelial dysfunction in the pathogenesis of radiation proctitis. Maintaining endothelial cell anticoagulant function may be a potential method to optimize the therapeutic ratio of adjuvant radiotherapy of rectal cancer.

Aged↗
PubMed2000

How gastroenterologists screen for colonic cancer in ulcerative colitis: an analysis of performance.

BACKGROUND: The aim of this study was to assess the colorectal cancer surveillance practices of British gastroenterologists for patients with ulcerative colitis. METHODS: A questionnaire that investigated aspects of surveillance in patients with ulcerative colitis was mailed to all consultant gastroenterologists in the U.K. (n = 413). RESULTS: Three hundred forty-one questionnaires were returned (response rate 83%). Ninety-four percent of consultants practice cancer surveillance in ulcerative colitis, with 35% maintaining a registry of patients in surveillance programs. All gastroenterologists perform surveillance in patients with pancolitis, 24% in those with left-sided colitis and 2% in patients with proctitis. The mean duration of disease before surveillance is commenced is 9.2 years for pancolitis and 12.4 years for left-sided colitis (p < 0.0001). Only 4% of gastroenterologists routinely offer patients with disease of more than 10 years' duration a prophylactic colectomy. Colonoscopies are conducted by an accredited gastroenterologist in 65% of cases and biopsies are reviewed by specialists in gastrointestinal pathology in 45%. When histology reveals low-grade dysplasia only 4% advise colectomy and when high-grade dysplasia is found 53% recommend colectomy. Sixteen percent of gastroenterologists were unaware of the significance of a dysplasia associated lesion or mass. CONCLUSION: The majority of gastroenterologists practice surveillance on a disorganized basis. There is inconsistency in the management of patients with dysplasia and education of gastroenterologists is needed.

Biopsy↗
PubMed1981

Colonoscopy in ischemic colitis.

Fifteen patients with ischemia of the colon are presented. The majority showed a similar clinical presentation with hematochezia, abdominal pain, and diarrhea in an elderly patient population having associated disease. Colonoscopy was abnormal in all patients studied. Three endoscopic stages were recognized; (1) acute stage characterized by petechiae, pallor, and hyperemia; (2) subacute stage consisting of ulceration and exudation; and (3) chronic stage characterized by stricture, decrease in haustrations, and mucosal granularity. Conventional barium enemas were abnormal and suggested ischemic colitis in six of 15 patients. Rigid proctoscopy was normal or demonstrated nonspecific proctitis in 12 of 15 patients studied. Colonoscopic biopsies demonstrated superficial inflammatory changes in all patients. Thirteen patients had complete mucosal healing endoscopically in 2 weeks to 3 months with stricture developing in four patients. Because ischemic colitis is a distinct subtype of ischemic bowel disease most often limited to the superficial mucosa, colonoscopy is an alternative and usually safe modality in the diagnosis of this entity and proved more accurate that conventional x-ray and proctoscopy.

Aged↗
PubMed1999

Appendiceal orifice inflammation as a skip lesion in ulcerative colitis: an analysis in relation to medical therapy and disease extent.

BACKGROUND: Although several reports have claimed that the appendix can be involved as a skip lesion in ulcerative colitis, they do not exclude the possibility that this skip lesion occurs as a result of medical therapy. Also, little is known about the relation between the presence of appendiceal orifice inflammation and the extent of the disease. METHODS: The presence of appendiceal orifice inflammation was prospectively assessed both endoscopically and histologically in 94 patients with active ulcerative colitis, the extent of whose disease had not been beyond the hepatic flexure. To evaluate the effect of prior medical therapy on the prevalence of appendiceal orifice inflammation, all cases were divided into two groups. Group A consisted of 66 patients who had been treated before inclusion; group B was composed of 28 patients newly diagnosed at inclusion. RESULTS: Appendiceal orifice inflammation was diagnosed in 24 (26%) of 94 patients with active subtotal ulcerative colitis, with no statistical difference observed between group A (23%) and group B (32%). In all 94 patients, the frequency of appendiceal orifice inflammation decreased significantly as the extent of disease increased, i.e., 37% in proctitis (n = 49), 17% in left-sided colitis (n = 36), and 0% in extensive colitis (n = 9) (p < 0.05). CONCLUSIONS: Appendiceal orifice inflammation as a skip lesion of ulcerative colitis is not rare, is more frequently observed in patients with less extensive disease, and is not the result of patchy improvement due to medical therapy.

Adult↗
PubMed1995

Chronic constipation as a symptom of cow milk allergy.

Twenty-seven consecutive infants (mean age, 20.6 months) with chronic "idiopathic" constipation were studied to investigate the possible relation between constipation and cow milk protein allergy (CMPA). The infants were initially observed on an unrestricted diet, and the number of stools per day was recorded. Subsequently the infants were put on a diet free of cow milk protein (CMP) for two periods of 1 month each, separated by two challenges with CMP. During the CMP-free diet, there was a resolution of symptoms in 21 patients; during the two consecutive challenges, constipation reappeared within 48 to 72 hours. In another six patients the CMP-free diet did not lead to improvement of constipation. Only four of the patients who improved on the CMP-free diet had concomitant symptoms of suspected CMPA, but a medical history of CMPA was found in 15 of the 21 patients cured and in only one of the six patients whose condition had not improved (p < 0.05); in addition, in 15 of the 21 cured patients, results of one or more laboratory tests (specific IgE, IgG, anti-beta-lactoglobulin, circulating eosinophils) were positive at the time of diagnosis, indicating hypersensitivity, compared with one of the six patients whose condition did not improve (p < 0.05). The endoscopic and histologic findings at the time of diagnosis showed proctitis with monocytic infiltration in two patients cured with the CMP-free diet; after 1 month on this diet, they were completely normal. We conclude that constipation in infants may have an allergic pathogenesis.

Animals↗