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Chronic radiation proctitis, although relatively rare, can be the source of severe comorbidity in patients who had undergone prior radiotherapy for pelvic malignancy. Although current treatments for radiation proctitis include argon plasma coagulation, heater probe, bipolar neodymium/yttrium aluminum garnet (Nd: YAG) lasers, these interventions are often burdened by the frequent occurrence of rectal ulcerations and stenosis. Since radiofrequency ablation (RFA) is frequently used to ablate esophageal malignancy and pre-malignancy, we report the efficacy of RFA using through the scope system in two patients with rectal bleeding due to radiation proctitis. In both cases, the procedure was well-tolerated with hemostasis achieved after 1 or 2 sessions of RFA. Mucosal re-epithelialization was observed in areas of previous bleeding with no stenosis or ulceration observed at follow-up.
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OBJECTIVE: We retrospectively evaluated the efficacy of combining the SpaceOAR (SOAR) hydrogel with prostate brachytherapy, using colonoscopy findings to assess for radiation proctitis. METHODS: Among 731 patients undergoing iodine-125 low-dose-rate prostate brachytherapy (LDR-BT), SOAR was utilized in 394 patients (53.9%). Colonoscopy was performed for 97 patients (13.3%) to assess the presence, location, condition, and treatment of radiation proctitis. We also investigated treatment factors associated with the occurrence of radiation proctitis. RESULTS: Radiation proctitis was observed in 57 patients (7.8%) and 17 (2.3%) were treated with argon plasma coagulation (APC). The incidence of radiation proctitis was 12.2% in the non-SOAR and 4.1% in the SOAR group (p < 0.001). In the non-SOAR group, the incidence of radiation proctitis was 6.6% for LDR-BT monotherapy and increased to 22.0% when combined with external beam radiation therapy (EBRT) (p = 0.001). However, in the SOAR group, these rates significantly decreased to 3.3% and 5.7% for monotherapy and combination therapy, respectively (p = 0.035, p < 0.001). With SOAR, inflammation was observed directly above the DL in most patients (87.5%), and only one patient (6.3%) required APC. The absence of SOAR (p < 0.001, HR = 0.29) and the concurrent use of EBRT (p = 0.018, HR = 2.87) were identified as significant risk factors for the occurrence of radiation proctitis. CONCLUSION: The use of SOAR significantly reduced the incidence of radiation proctitis in patients undergoing LDR-BT monotherapy and combined EBRT. Inflammation primarily occurred directly above the DL; further examination is necessary to clarify its cause.
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Braquiterapia , Radioisótopos de Yodo , Proctitis , Neoplasias de la Próstata , Traumatismos por Radiación , Humanos , Masculino , Braquiterapia/efectos adversos , Braquiterapia/métodos , Neoplasias de la Próstata/radioterapia , Proctitis/etiología , Proctitis/diagnóstico , Estudios Retrospectivos , Anciano , Traumatismos por Radiación/etiología , Traumatismos por Radiación/epidemiología , Traumatismos por Radiación/diagnóstico , Persona de Mediana Edad , Radioisótopos de Yodo/efectos adversos , Radioisótopos de Yodo/administración & dosificación , Radioisótopos de Yodo/uso terapéutico , Hidrogeles , Incidencia , Colonoscopía/efectos adversos , Colonoscopía/métodos , Dosificación Radioterapéutica , Anciano de 80 o más Años , Coagulación con Plasma de Argón/métodos , Coagulación con Plasma de Argón/efectos adversosRESUMEN
Radiation therapy is one of the main treatment option for prostate cancer used either independently or as a component of combined and complex treatment of the disease. Modern achievements make it possible to deliver doses of radiation that match the exact dimensions of the tumor for greater efficacy, with minimal exposure of the surrounding tissues, however, does not eliminate them. In most patients, clinical manifestations of chronic radiation proctitis occur during the first 2 years after radiation therapy. The article summarizes the current knowledge about pathophysiology, clinical manifestations, diagnostics and treatment options for this condition. In this paper, we present a case of complicated of chronic radiation proctitis.
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Proctitis , Neoplasias de la Próstata , Traumatismos por Radiación , Masculino , Humanos , Recto , Proctitis/diagnóstico , Proctitis/etiología , Proctitis/terapia , Enfermedad Crónica , Neoplasias de la Próstata/diagnóstico , Neoplasias de la Próstata/radioterapia , Neoplasias de la Próstata/complicaciones , Traumatismos por Radiación/diagnóstico , Traumatismos por Radiación/etiología , Traumatismos por Radiación/terapiaRESUMEN
BACKGROUND: Radiation proctitis (RP) is the most common complication of radiotherapy for pelvic tumor. Currently there is a lack of effective clinical treatment and its underlying mechanism is poorly understood. In this study, we aimed to dynamically reveal the mechanism of RP progression from the perspective of RNomics using a mouse model, so as to help develop reasonable therapeutic strategies for RP. RESULTS: Mice were delivered a single dose of 25 Gy rectal irradiation, and the rectal tissues were removed at 4 h, 1 day, 3 days, 2 weeks and 8 weeks post-irradiation (PI) for both histopathological assessment and RNA-seq analysis. According to the histopathological characteristics, we divided the development process of our RP animal model into three stages: acute (4 h, 1 day and 3 days PI), subacute (2 weeks PI) and chronic (8 weeks PI), which could recapitulate the features of different stages of human RP. Bioinformatics analysis of the RNA-seq data showed that in the acute injury period after radiation, the altered genes were mainly enriched in DNA damage response, p53 signaling pathway and metabolic changes; while in the subacute and chronic stages of tissue reconstruction, genes involved in the biological processes of vessel development, extracellular matrix organization, inflammatory and immune responses were dysregulated. We further identified the hub genes in the most significant biological process at each time point using protein-protein interaction analysis and verified the differential expression of these genes by quantitative real-time-PCR analysis. CONCLUSIONS: Our study reveals the molecular events sequentially occurred during the course of RP development and might provide molecular basis for designing drugs targeting different stages of RP development.
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Proctitis , Traumatismos por Radiación , Animales , Modelos Animales de Enfermedad , Perfilación de la Expresión Génica , Proctitis/genética , Proctitis/metabolismo , Traumatismos por Radiación/etiología , Traumatismos por Radiación/patología , Recto/metabolismo , Recto/patología , Recto/efectos de la radiación , TranscriptomaRESUMEN
Pelvic radiation is increasingly being used for the neoadjuvant and definitive treatment of pelvic organ malignancy. While this treatment can be highly effective, and may assist in organ sparing, it is also associated with significant toxicity and devastating adverse events that need to be considered. In broad terms, pelvic radiation disease affects both the primary target organ as well as adjacent organs and soft tissue structures, with complications that can be classified and graded according to consensus criteria. The complication grade is often modality, dose, and area dependent. The most common manifestations are proctitis, cystitis, recto-urethral fistula, ureteric stricture, and bone involvement. Toxicity can be misdiagnosed for many years, resulting in significant management delays. Complications can be difficult to prevent and challenging to treat, requiring specialized multi-disciplinary input to achieve the best possible strategy to minimize impact and improve patient quality of life.
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OBJECTIVES: Radiation therapy is a main method for female pelvic malignancies, which can cause some adverse reactions, such as radiation proctitis (RP). The incidence of RP is highly positively correlated with radiation dose. There is an urgent need for a scientific method to accurately predict the occurrence of RP to help doctors make clinical decisions. In this study, based on the clinical data of female pelvic tumor patients and dosimetric parameters of radiotherapy, the random forest method was used to screen the hub features related to the occurrence of RP, and then a machine learning algorithm was used to construct a risk prediction model for the occurrence of RP, in order to provide technical support and theoretical basis for the prediction and prevention of RP. METHODS: A total of 100 female patients with pelvic tumors, who received static three-dimensional conformal intensity-modulated radiation therapy in the Department of Radiation Oncology of the Affiliated Hospital of Xiangnan University from January 2019 to December 2020, were retrospectively collected, and their clinically relevant data and radiotherapy planning system data were collected. During radiotherapy and 18 months after radiotherapy, 35 cases developed RP (RP group), and the remaining 65 cases had no RP (non-RP group). The clinical and dosimetric characteristics of patients were ranked by the importance of random forest algorithm, and the independent prognostic characteristics associated with the occurrence of RP were selected for machine learning modeling. A total of 6 machine learning algorithms including support vector machines, random forests, logistic regression, lightweight gradient boosting machines, Gaussian naïve Bayes, and adaptive enhancement were used to build models. The performance of the model was evaluated by the area under the receiver operating characteristic curve (AUC), accuracy, sensitivity, specificity, positive predictive value, negative predictive value, and F1 score. Finally, the random forest model was determined as the prediction model, and the calibration curve and decision curve of the prediction model were drawn to evaluate the accuracy and clinical benefit of the model. RESULTS: The parameters for random forest prediction model in the training set were as follow: AUC, 1.000, accuracy, 0.988, sensitivity, 1.000, specificity, 1.000, positive predictive value, 1.000, negative predictive value, 0.981, and F1 score, 1.000. In validation set, AUC was 0.713, accuracy was 0.640, sensitivity was 0.618, specificity was 0.822, positive predictive value was 0.500, negative predictive value was 0.656, and F1 score was 0.440. Random forest showed high predictive performance. Moreover, the Brief of the calibration curve for the prediction model was 0.178, the prediction accuracy was high, and the decision curve showed that the prediction model could benefit clinically. CONCLUSIONS: Based on the clinical and dosimetric parameters for the female pelvic tumor patients, the prediction model of radiation proctitis constructed by random forest algorithm has high predictive ability and strong clinical usability.
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Neoplasias Pélvicas , Proctitis , Oncología por Radiación , Teorema de Bayes , Femenino , Humanos , Aprendizaje Automático , Neoplasias Pélvicas/radioterapia , Proctitis/etiología , Estudios RetrospectivosRESUMEN
OBJECTIVE: To investigate the incidence of colorectal cancer and chronic radiation proctitis after prostate radiotherapy using periodic total colonoscopy screening. METHODS: From February 2013 to January 2018, 270 patients who underwent external beam radiation therapy for prostate cancer were advised to receive periodic total colonoscopy screening annually. We evaluated the incidence and characteristics of colorectal cancer and chronic radiation proctitis. RESULTS: First, second, third, fourth and fifth total colonoscopy were performed in 256 (95%), 151 (56%), 60 (22%), 23 (8.5%) and 7 (2.6%) patients at a median of 14, 31, 42, 54 and 72 months after radiotherapy, respectively. The prevalence proportion of colorectal cancer in the first colonoscopy since radiotherapy was 3.9%. Twelve (4.4%) patients were diagnosed with colorectal cancer, including four invasive cancers, during a follow-up period. Eight of these 12 patients had not experienced rectal bleeding. The median time to diagnosis of colorectal cancer was 21 months. Chronic radiation proctitis was observed in 136 (50%) patients, including 67 (25%) patients with symptomatic bleeding. CONCLUSIONS: The high detection rate of asymptomatic radiation proctitis suggests the utility of total colonoscopy to screen for early-stage colorectal cancer prior to or following radiotherapy for prostate cancer. Considering the longevity after localized prostate cancer treatment, the awareness of chronic radiation-induced proctitis and the risk of colorectal cancer masked by bleeding is needed in treatment decision -making.
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Neoplasias Colorrectales , Neoplasias Inducidas por Radiación , Proctitis , Neoplasias de la Próstata , Traumatismos por Radiación , Colonoscopía , Detección Precoz del Cáncer , Humanos , Masculino , Neoplasias Inducidas por Radiación/diagnóstico , Neoplasias Inducidas por Radiación/etiología , Proctitis/diagnóstico , Proctitis/etiología , Neoplasias de la Próstata/radioterapia , Traumatismos por Radiación/diagnóstico , Traumatismos por Radiación/etiologíaRESUMEN
PURPOSE: The impact of acute histopathological changes (HC) of the rectum on development of late clinical proctitis (LCP) after external radiotherapy (RT) for prostate cancer is poorly explored and was the primary end point of this prospective study. METHODS: In 70 patients, 15 HC of early rectal biopsies after RT were identified, whereby RT was conventional 2D RT in 41 cases and conformational 3D RT in 29. Associations of HC in anterior and posterior rectal walls (ARW, PRW) with LCP, acute endoscopic (AEP) and acute clinical proctitis (ACP) were statistically evaluated considering as explicative variables the patient general characteristics and the HC. RESULTS: The mean patients' follow-up was 123.5 months (24-209). The median prostatic dose was 72â¯Gy (2â¯Gy/fraction). For the 41 and 29 patients the ARW and PRW doses were 64 and 49â¯Gy vs. 63 and 50â¯Gy, respectively. The incidence of LCPâ¯≥ grade 2â¯at 10 years was 12.9%. The univariate (pâ¯= 0.02) and Kaplan-Meyer methods (pâ¯= 0.007) showed that the gland (or crypts) loss in the ARW was significantly associated with LCP. AEP and ACP occurred in 14.3 and 55.7% of cases. At multivariate level AEP significantly correlated with hemorrhoids (pâ¯= 0.014) and neutrophilia in ARW (pâ¯= 0.042). CONCLUSIONS: Early after RT, substantial gland loss in ARW is predictive of LCP. To reduce this complication with conventional fractionation, we suggest keeping the mean dose to ARW ≤48-52â¯Gy.
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Adenocarcinoma/radioterapia , Órganos en Riesgo/efectos de la radiación , Proctitis/patología , Neoplasias de la Próstata/radioterapia , Traumatismos por Radiación/patología , Radioterapia Conformacional/efectos adversos , Radioterapia de Alta Energía/efectos adversos , Recto/efectos de la radiación , Enfermedad Aguda , Adenocarcinoma/cirugía , Anciano , Terapia Combinada , Fraccionamiento de la Dosis de Radiación , Relación Dosis-Respuesta en la Radiación , Estudios de Seguimiento , Humanos , Incidencia , Estimación de Kaplan-Meier , Masculino , Persona de Mediana Edad , Órganos en Riesgo/patología , Proctitis/diagnóstico , Proctitis/epidemiología , Proctitis/etiología , Proctoscopía , Estudios Prospectivos , Prostatectomía , Neoplasias de la Próstata/cirugía , Traumatismos por Radiación/diagnóstico , Traumatismos por Radiación/epidemiología , Traumatismos por Radiación/etiología , Protección Radiológica/instrumentación , Dosificación Radioterapéutica , Radioterapia Conformacional/métodos , Radioterapia de Intensidad Modulada/efectos adversos , Recto/patología , Factores de TiempoRESUMEN
BACKGROUND: Chronic radiation proctitis (CRP) with rectal ulcer is a common complication after pelvic malignancy radiation, and gradually deteriorating ulcers will result in severe complications such as fistula. The aim of this study was to evaluate effect of colostomy on ulcerative CRP and to identify associated influence factors with effectiveness of colostomy. METHODS: Between November 2011 to February 2019, 811 hospitalized patients were diagnosed with radiation-induced enteritis (RE) in Sun Yat-sen University Sixth Affiliated Hospital, among which 284 patients presented with rectal ulcer, and 61 ulcerative CRP patients were retrospectively collected and analyzed. RESULTS: The overall effective rate of colostomy on ulcerative CRP was 49.2%, with a highest effective rate of 88.2% within 12 to 24 months after colostomy. 9 (31.1%) CRP patients with ulcers were cured after colostomy and 12 (19.67%) patients restored intestinal continuity, among which including 2 (3.3%) patients ever with rectovaginal fistula. 100% (55/55) patients with rectal bleeding and 91.4% (32/35) patients with anal pain were remarkably alleviated. Additionally, multivariable analysis showed the duration of stoma [OR 1.211, 95% CI (1.060-1.382), P = 0.005] and albumin (ALB) level post-colostomy [OR 1.437, 95% CI (1.102-1.875), P = 0.007] were two independent influence factors for the effectiveness of colostomy on the rectal ulcer of CRP patients. CONCLUSIONS: Colostomy was an effective and safe procedure for treating rectal ulcer of CRP patients, and also a potential strategy for preventing and treating fistula. Duration of stoma for 12-24 months and higher ALB level could significantly improve the effectiveness of colostomy on ulcerative CRP patients.
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Colostomía/métodos , Neoplasias Pélvicas , Proctitis , Radioterapia Adyuvante/efectos adversos , Anciano , Enfermedad Crónica , Femenino , Humanos , Persona de Mediana Edad , Neoplasias Pélvicas/radioterapia , Proctitis/etiología , Proctitis/cirugía , Fístula Rectal/etiología , Fístula Rectal/prevención & control , Estudios Retrospectivos , Úlcera/etiología , Úlcera/cirugíaRESUMEN
Lower gastrointestinal bleeding (LGIB) is an increasingly common problem in patients with comorbid medical conditions that place them at higher bleeding risk. This discussion of some special considerations in the GI bleeding patient encompasses an overview of the elderly patient, and selects comorbid conditions that place patients at higher risk of developing intestinal bleeding. The discussion lends itself to exploring the challenges of and new advancements in anticoagulation therapy. Radiation induced proctitis and rectal varices as sources of LGIB will also be addressed.
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PURPOSE: To compare relative and absolute dose-volume parameters (DV) of the rectum and their clinical correlation with acute and late radiation proctitis (RP) after radiotherapy (RT) for prostate cancer (PCa). PATIENTS AND METHODS: 366 patients received RT for PCa. In total, 49.2% received definitive RT, 20.2% received postoperative RT and 30.6% received salvage RT for biochemical recurrence. In 77.9% of patients, RT was delivered to the prostate or prostate bed, and additional whole pelvic RT was performed in 22.1%. 33.9% received 3D-RT, and 66.1% received IMRT. The median follow-up was 59.5 months (18.0-84.0 months). The relative (in %) and absolute (in ccm) rectal doses from 20-75â¯Gy including the receiver operating characteristics curves (rAUC) from 30-65â¯Gy (in % and ccm) and several other clinical parameters were analyzed in univariate and multivariate analyses. We performed the statistical analyses separately for the entire cohort (nâ¯= 366), patients with (nâ¯= 81) and without (nâ¯= 285) pelvic RT, comparing RP vs. RPâ¯≥ grade I. RESULTS: With the exception of the V50Gyccm (pâ¯= 0.02) in the univariate analyses for acute RP in the entire patient cohort, no absolute DV parameter (in ccm) was statistically significant associated with either acute or late RP. In the multivariate analyses, 3D-RT (pâ¯< 0.008) and rAUCV30-50â¯Gy% (pâ¯= 0.006) were significant parameters for acute RP for the entire cohort, and the V50Gy% (pâ¯= 0.01) was the significant parameter for patients with pelvic RT. The rAUCV40-50â¯Gy% (pâ¯= 0.004) was significant for RT to the prostate/prostate bed. Regarding the statistical analysis for late RP, the rAUCV30-65â¯Gy% (pâ¯= 0.001) was significant for the entire cohort, and rAUCV30-50â¯Gy% (pâ¯= 0.001) was significant for RT of the prostate/prostate bed. No parameter was significant in patients with pelvic RT. CONCLUSION: Absolute DV parameters in ccm are not required for RT in PCa patients.
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Proctitis/etiología , Neoplasias de la Próstata/radioterapia , Traumatismos por Radiación/etiología , Enfermedad Aguda , Anciano , Anciano de 80 o más Años , Correlación de Datos , Humanos , Masculino , Persona de Mediana Edad , Recurrencia Local de Neoplasia/radioterapia , Recurrencia Local de Neoplasia/cirugía , Neoplasias de la Próstata/cirugía , Dosis de Radiación , Radioterapia Adyuvante , Estudios Retrospectivos , Terapia RecuperativaRESUMEN
BACKGROUND AND AIM: Although argon plasma coagulation is the current standard endoscopic treatment for chronic radiation proctitis (CRP), radiofrequency ablation (RFA) has emerged as an attractive alternative. The aim of this study is to evaluate the efficacy and safety of RFA for the treatment of CRP. METHODS: Searches of PubMed, EMBASE, Web of Science, and Cochrane Library databases were performed from 2004 through March 2018. Review and data abstraction were performed independently by two authors. Measured outcomes included hemoglobin, transfusion dependence, number of treatment sessions, RFA settings, and serious adverse events. RESULTS: Six studies (n = 71; mean age 73.41 ± 1.88 years; 90.14% male) were included. Thirty-eight percent of patients failed prior treatment with argon plasma coagulation. Patients underwent a mean of 1.71 ± 0.34 RFA sessions with 24.54 ± 16.47 RFA applications per session. Pooled clinical and endoscopic success of RFA was 99% (95% confidence interval [CI]: 90-100; P < 0.001) and 100% (95% CI: 94-100; P < 0.001), respectively. Serious adverse events were reported in one patient-pooled rate of 0% (95% CI: 0-3; P < 0.001). Mean pre-procedure hemoglobin was 10.38 ± 1.82 g/dL with significant improvement observed post-RFA [weighted mean difference 2.49 g/dL (95% CI: 2.16-2.82; P < 0.001)]. Among transfusion-dependent patients, 85% (95% CI: 68-97; P < 0.001) became transfusion-free post-RFA. Pooled mean follow-up was 19.73 ± 9.72 months. CONCLUSION: Despite limited long-term data on RFA for CRP, available evidence suggests RFA is an effective and safe treatment.
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Proctitis/cirugía , Traumatismos por Radiación/cirugía , Ablación por Radiofrecuencia , Anciano , Enfermedad Crónica , Femenino , Humanos , Masculino , Complicaciones Posoperatorias/etiología , Proctitis/etiología , Traumatismos por Radiación/etiología , Ablación por Radiofrecuencia/efectos adversos , Factores de Riesgo , Resultado del TratamientoRESUMEN
AIM: Chronic radiation proctitis (CRP) develops in 5-15% of patients after pelvic radiation therapy, with rectal bleeding being the main symptom. Reports suggest that argon plasma coagulation (APC) can be an effective therapy for CRP following radiotherapy for prostate cancer, but there is less information about how useful it is after radiotherapy for gynaecological malignancy. The aim of this work therefore was to study the efficacy of APC for CRP after radiotherapy for gynaecological malignancy. METHOD: This was a prospective study of consecutive patients with CRP following radiotherapy for gynaecological malignancy at IPGME&R, SDLD, Kolkata, India; symptoms included rectal bleeding grade (RBG) ≥ 2. APC was performed at monthly intervals to a maximum of four treatment sessions. Severity of disease at baseline was graded (endoscopically) by the total colonoscopic severity score (TCSS) and treatment response was assessed by reduction in RBG from ≥ 2 to ≤ 1 measured at > 6 months after cessation of APC. RESULTS: Seventy patients [90% with cervical cancer, 10% with endometrial cancer; mean age 51.93 ± 9.15 years; median RBG 3 (range 2-4)] received APC. Seven patients died due to underlying malignancy and seven patients were lost to follow-up. Fifty-six (85.7%) patients responded to therapy after a median of 2 (range 1-4) treatment sessions. Multivariate analysis demonstrated that a lower haemoglobin at the start of treatment predicted failure of therapy (P < 0.05). CONCLUSION: APC is an effective management option for CRP in female patients with gynaecological malignancy. However, the more anaemic the patient the less likely it is to be successful.
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Coagulación con Plasma de Argón/métodos , Hemorragia Gastrointestinal/terapia , Neoplasias de los Genitales Femeninos/radioterapia , Proctitis/terapia , Traumatismos por Radiación/terapia , Enfermedad Crónica , Femenino , Hemorragia Gastrointestinal/etiología , Humanos , Persona de Mediana Edad , Proctitis/etiología , Estudios Prospectivos , Traumatismos por Radiación/etiología , Resultado del TratamientoRESUMEN
AIM: The aim of this study was to assess the expression of vascular endothelial growth factor (VEGF) as a key proangiogenic factor and determine whether there is any correlation between its expression and clinical symptoms or endoscopic changes in patients with chronic radiation proctitis (ChRP). METHOD: Fifty patients who had all undergone radiotherapy for prostate, cervical or uterine cancer were included in the study (37 women, 13 men). There was a control group of 20 patients (9 women, 11 men). The Radiation Therapy Oncology Group/European Organization for Research and Treatment of Cancer (RTOG/EORTC) scoring system was used for grading the severity of the proctitis. Endoscopic scoring of late rectal mucosal damage was performed using Gilinsky's classification. Serum levels of VEGF were analysed by the enzyme-linked immunosorbent assay method. RESULTS: Most patients presented with Grade 1 symptoms. Endoscopic assessment showed that most patients had Grade 1 late rectal mucosal damage. The predominant endoscopic finding was the presence of telangiectasia. Assessment of VEGF correlation between the control group and the degrees of endoscopic changes showed statistically significant differences for all three degrees (P < 0.0001, P = 0.0251 and P = 0.0005, respectively). Due to the small numbers of patients with Grades 2 and 3 symptoms using the RTOG/EORTC scoring system, they were grouped with Grades 1 and 4 respectively forming two groups for statistical purposes. VEGF expression differed significantly between controls and group I and between controls and group II (P = 0.0001, P = 0.0009, respectively). CONCLUSION: A significant increase in VEGF expression was found to correlate with clinical symptoms and endoscopic rectal mucosa changes in patients with ChRP, suggesting that it may play an important role in pathological angiogenesis.
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Mucosa Intestinal/efectos de la radiación , Proctitis/sangre , Traumatismos por Radiación/sangre , Recto/efectos de la radiación , Factor A de Crecimiento Endotelial Vascular/sangre , Adulto , Anciano , Anciano de 80 o más Años , Endoscopía del Sistema Digestivo , Femenino , Humanos , Mucosa Intestinal/irrigación sanguínea , Masculino , Persona de Mediana Edad , Proctitis/etiología , Proctitis/patología , Neoplasias de la Próstata/radioterapia , Traumatismos por Radiación/patología , Recto/irrigación sanguínea , Índice de Severidad de la Enfermedad , Telangiectasia/etiología , Neoplasias del Cuello Uterino/radioterapia , Neoplasias Uterinas/radioterapiaRESUMEN
BACKGROUND: Chronic radiation proctitis (CRP), a common complication after radiotherapy for pelvic malignancies, compromises patient quality of life. Vascular damage and aberrant angiogenesis in the mucosal layer are essential histological features, but changes to the submucosal layer are unclear. Thus, we evaluated the histological characteristics and distribution changes of key angiogenic factors in full-layered human CRP samples. METHODS: Thirty paraffin-embedded CRP and twenty-nine non-CRP tissues were used to evaluate histopathological changes. Immunohistochemistry with anti-CD34 antibody was performed to calculate microvascular density (MVD). Frozen tissues from eight CRP patients and five non-CRP controls were collected and analyzed by antibody array, which contained sixty human angiogenesis-related factors. Quality controls with positive and negative controls were performed during antibody array analysis. Two differentially expressed factors were confirmed by ELISA. RESULTS: CRP lesions showed vasculopathy, fibrosis, mucosal ulceration, edema, and inflammatory cell infiltration. Human angiogenesis antibody array and ELISA confirmed the increased angiostatin in CRP lesions. Immunohistochemical staining showed dispersed distribution of angiostatin throughout the mucosal and submucosal layers in CRP lesions, while angiostatin accumulated within the vessel lumens in non-CRP tissues. MVD significantly decreased in the submucosal layer of CRP, suggesting a potential association with increased angiostatin. CONCLUSIONS: Angiostatin increased and had a distinct distribution in CRP lesions. Compensatory telangiectasia in the mucosa, vessel stenosis, and reduced MVD might attenuate blood flow in the submucosa and contribute to CRP progression. Restoration of vascular functionality by promoting angiogenesis in the submucosal layer may help alleviate CRP in clinical practice.
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Angiostatinas , Adulto , Anciano , Inhibidores de la Angiogénesis/farmacología , Femenino , Regulación de la Expresión Génica/efectos de la radiación , Humanos , Masculino , Persona de Mediana Edad , Neovascularización Patológica , Proctitis/etiología , Traumatismos por Radiación , TranscriptomaRESUMEN
Radiation proctitis is radiation-induced rectal mucositis, occurring as a result of radiation therapy for various pelvic malignancies. The management of radiation proctitis is challenging as guidelines are not currently available, and studies of the various treatment modalities are limited. There are various medical, endoscopic, and surgical measures for treating chronic radiation proctitis. Medical options such as anti-inflammatory agents, antioxidants, formalin application, and hyperbaric oxygen may improve bleeding related to chronic radiation proctitis. Endoscopic measures such as argon plasma coagulation are effective and safe. Surgery is considered for refractory or severe cases. A review and discussion of the different treatment modalities is presented.
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Técnicas de Ablación , Coagulación con Plasma de Argón , Procedimientos Quirúrgicos del Sistema Digestivo/métodos , Endoscopía Gastrointestinal/métodos , Fármacos Gastrointestinales/uso terapéutico , Proctitis/terapia , Traumatismos por Radiación/terapia , Técnicas de Ablación/efectos adversos , Coagulación con Plasma de Argón/efectos adversos , Procedimientos Quirúrgicos del Sistema Digestivo/efectos adversos , Endoscopía Gastrointestinal/efectos adversos , Fármacos Gastrointestinales/efectos adversos , Humanos , Proctitis/diagnóstico , Proctitis/etiología , Traumatismos por Radiación/diagnóstico , Traumatismos por Radiación/etiología , Radioterapia/efectos adversos , Factores de Riesgo , Índice de Severidad de la Enfermedad , Resultado del TratamientoRESUMEN
The purpose of this study is to determine the effectiveness of endoscopic diode laser therapy in patients presenting rectal bleeding due to chronic radiation proctitis (CRP). A retrospective analysis of CRP patients who underwent diode laser therapy in a single institution between 2010 and 2016 was carried out. The patients were treated by non-contact fibers without sedation in an outpatient setting. Fourteen patients (median age 77, range 73-87 years) diagnosed with CRP who had undergone high-dose radiotherapy for prostatic cancer and who presented with rectal bleeding were included. Six required blood transfusions. Antiplatelet (three patients) and anticoagulant (two patients) therapy was not suspended during the treatments. The patients underwent a median of two sessions; overall, a mean of 1684 J of laser energy per session was used. Bleeding was resolved in 10/14 (71%) patients, and other two patients showed improvement (93%). Only one patient, who did not complete the treatment, required blood transfusions after laser therapy; no complications were noted during or after the procedures. Study findings demonstrated that endoscopic non-contact diode laser treatment is safe and effective in CRP patients, even in those receiving antiplatelet and/or anticoagulant therapy.
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Endoscopía , Láseres de Semiconductores , Proctitis/cirugía , Traumatismos por Radiación/cirugía , Anciano , Anciano de 80 o más Años , Enfermedad Crónica , Humanos , Terapia por Láser , Láseres de Semiconductores/efectos adversos , Masculino , Traumatismos por Radiación/etiología , Estudios RetrospectivosRESUMEN
INTRODUCTION: Chronic radiation proctitis (CRP) usually develops 90 days or more after radiation. Currently, there is no standard available for the treatment of CRP. In argon plasma coagulation, monopolar diathermy is used to ionise the argon gas which coagulates the telengiectatic vessels in a noncontact fashion. However, there are very few studies which have reported its use in extensive CRP. We report the efficacy and safety of APC in seven patients with recurrent, extensive grade 3 radiation proctitis. MATERIALS AND METHODS: This is a retrospective analysis of patients treated with argon plasma coagulation in our institute from June 2013 to June 2016. After adequate bowel preparation, patients underwent APC at an average power of 50 W with flow rate of 5 L/min. All the visible telangiectasia was ablated which required many sittings. RESULTS: The median RPSAS symptom score for frequency of bleeding at enrolment was 5 (range 3-5). After completion of APC, the median RPSAS symptom score for frequency of bleeding decreased to 1. The median RPSAS symptom score for severity of bleeding was 5 (range 3-5). After completion of APC, the mean RPSAS symptom score for severity of bleeding decreased to 1. Mean haemoglobin level before treatment was 5.43 g/dl (SD 2.37). Mean haemoglobin level after treatment was10.04 g/dl (SD 2.0). Compared with pre-treatment levels after APC, there was a mean increase in haemoglobin of 4.61 + 1.78 [95% CI 2.97-6.25, p = 0.00]. CONCLUSION: Argon plasma coagulation is a safe, well tolerated and effective treatment option in extensive chronic radiation proctitis which is refractory to medical management.
Asunto(s)
Braquiterapia/efectos adversos , Hemorragia Gastrointestinal/cirugía , Proctitis/cirugía , Traumatismos por Radiación/cirugía , Neoplasias del Cuello Uterino/radioterapia , Coagulación con Plasma de Argón/efectos adversos , Enfermedad Crónica , Fraccionamiento de la Dosis de Radiación , Femenino , Hemorragia Gastrointestinal/sangre , Hemorragia Gastrointestinal/diagnóstico , Hemorragia Gastrointestinal/etiología , Hemoglobinas/metabolismo , Humanos , India , Proctitis/sangre , Proctitis/diagnóstico , Proctitis/etiología , Traumatismos por Radiación/sangre , Traumatismos por Radiación/diagnóstico , Traumatismos por Radiación/etiología , Recurrencia , Estudios Retrospectivos , Índice de Severidad de la Enfermedad , Factores de Tiempo , Resultado del TratamientoRESUMEN
PURPOSE: The management of haemorrhagic radiation proctitis is challenging because of the necessity for repeated intervention. The efficacy of argon plasma coagulation has been described before but the optimum treatment strategy remains debatable. This is a review of our experience over a decade treating patients with haemorrhagic radiation proctitis and their follow-up. METHODS: This is a retrospective review of consecutive patients who underwent argon plasma coagulation for haemorrhagic radiation proctitis between January 2003 and December 2013. The patients were followed up using a prospectively maintained database. RESULTS: Ninety-one patients were included with a mean follow-up of 13.1 months. Majoity (n = 85, 93.4 %) of the patients were female. Mean age at the time of treatment was 58.2 (range 23-87) years old. Majority of the patients (n = 73, 80.2 %) received radiotherapy for gynaecological malignancies followed by colorectal (n = 13, 14.3 %) and urological (n = 5, 5.5 %) malignancies. Mean interval between radiation and proctitis was 13.8 (range 3-40) months. Seventy-nine percent of patients were successfully treated after 1-2 sessions. Seventeen (18.7 %) patients experienced self-limiting early complications, and three (3.3 %) had late complications of rectal stenosis which was managed conservatively. Severity of bleeding during the initial presentation is an independent factor that predicts the number of sessions required for successful haemostasis (p = 0.002). CONCLUSIONS: Argon plasma coagulation is a reasonable treatment option in patients with haemorrhagic radiation proctitis with good safety profile. Our study suggests that the number of APC sessions required to arrest bleeding correlates with the severity of bleeding on initial presentation.
Asunto(s)
Coagulación con Plasma de Argón/efectos adversos , Endoscopía/efectos adversos , Hemorragia Gastrointestinal/complicaciones , Hemorragia Gastrointestinal/terapia , Proctitis/complicaciones , Proctitis/terapia , Traumatismos por Radiación/complicaciones , Traumatismos por Radiación/terapia , Adulto , Anciano , Anciano de 80 o más Años , Femenino , Humanos , Masculino , Persona de Mediana Edad , Inducción de Remisión , Adulto JovenRESUMEN
For decades, hyperbaric oxygen therapy has been considered a treatment option in patients with chronic radiation-induced proctitis after pelvic radiation therapy. Refractory cases of chronic radiation-induced proctitis include ulceration, stenosis, and intestinal fistulas with perforation. Appropriate treatment needs to be given. In the present study, we assessed the efficacy of hyperbaric oxygen therapy in five patients with radiation-induced rectal ulcers. Significant improvement and complete ulcer resolution were observed in all treated patients; no side-effects were reported. Hyperbaric oxygen therapy has a low toxicity profile and appears to be highly effective in patients with radiation-induced rectal ulcers. However, hyperbaric oxygen therapy alone failed to improve telangiectasia and easy bleeding in four of the five patients; these patients were further treated with argon plasma coagulation (APC). Although hyperbaric oxygen therapy may be effective in healing patients with ulcers, it seems inadequate in cases with easy bleeding. Altogether, these data suggest that combination therapy with hyperbaric oxygen therapy and APC may be an effective and safe treatment strategy in patients with radiation-induced rectal ulcers.