A Practical Approach to the Management of Radiation-Induced Hemorrhagic Cystitis.

Radiation-induced hemorrhagic cystitis (HC) is a complication of pelvic radiotherapy, mainly for prostate and uterine cancers. In the acute phase, patients feel urinary urgency and bladder pain. This phase is reversible after radiotherapy. In the chronic stage, an irritative syndrome is coupled with hematuria during the 2-10 years following radiotherapy. Cystoscopy shows white and frosted mucosa with telangiectasia. The incidence is estimated at 5 % or less. It is suggested that the radiation oncologist reviews the dosimetry plan to validate that the lesions coincide with significant radiation exposure confirming diagnosis of radiation-induced HC. The treatment for HC is first symptomatic, with bladder lavage, clot evacuation, coagulation via cystoscopy and blood transfusions if necessary. Subsequently, hyaluronic acid bladder instillation can be done with little toxicity. Hyperbaric oxygen therapy delivers pure oxygen to patients in a pressurized cabin, promoting angio-neogenesis and lowering hypoxia to the irradiated tissues. The clinical response rate is estimated to be around 80 %. Nevertheless, this approach is limited by the low availability, and length of treatment. While surgery remains an effective treatment for HC, it is the last option because of the high morbidity and mortality risks. Prospective studies need to be conducted to identify and evaluate new interventions, particularly for HC.

Multicenter, phase III trial comparing selenium supplementation with observation in gynecologic radiation oncology: follow-up analysis of the survival data 6 years after cessation of randomization.

PURPOSE: In 2010, we reported that selenium (Se) supplementation during radiation therapy (RT) is effective for increasing blood Se levels in Se-deficient cervical and uterine cancer patients, and reduced the number of episodes and severity of RT-induced diarrhea. In the current study, we examine whether of Se supplementation during adjuvant RT affects long-term survival of these patients. PATIENTS AND METHODS: Former patients were identified and questioned with respect to their health and well-being. RESULTS: A total of 81 patients were randomized in the initial supplementation study, 39 of whom received Se (selenium group, SeG) and 42 of whom served as controls (control group, CG). When former patients were reidentified after a median follow-up of 70 months (range = 0-136), the actuarial 10-year disease-free survival rate in the SeG was 80.1% compared to 83.2% in the CG (P = .65), and the actuarial 10-year overall survival rate of patients in the SeG was 55.3% compared to 42.7% in the CG (P = .09). CONCLUSIONS: Our extended follow-up analysis demonstrates that Se supplementation had no influence on the effectiveness of the anticancer irradiation therapy and did not negatively affect patients' long-term survival. In view of its positive effects on RT-induced diarrhea, we consider Se supplementation to be a meaningful and beneficial adjuvant treatment in Se-deficient cervical and uterine cancer patients while undergoing pelvic radiation therapy.

Long-term control of refractory hemorrhagic radiation proctitis with ozone therapy.

CONTEXT: Persistent or severe hemorrhagic radiation proctitis (HRP) has limited therapeutic options. OBJECTIVES: To describe our experience with ozone therapy (O3T) in the management of refractory HRP. METHODS: Patients (n=17; median age 69 years [range 42-80 years]) previously irradiated for prostate or uterine cancer and suffering persistent or severe HRP without response to conventional treatment were enrolled to receive an O3/O2 gas mixture via rectal insufflations and topical application of ozonized oil. Most of the patients (83%) had Grade 3 or Grade 4 toxicity. Median follow-up post-O3T was 40 months (range 3-56 months). RESULTS: Endoscopic treatments required were: 43 (median 1; range 0-10) pre-O3T; 17 (median 0; range 0-8; P=0.063) during O3T; and five (median 0; range 0-2; P=0.008) during follow-up. Hemoglobin levels were 10.35g/dL (7-14g/dL) pre-O3T and 13g/dL (9-15g/dL) (P=0.001) post-O3T. Median toxicity grades were 3 (range 2-4) pre-O3T, 1 (range 0-2; P<0.001) at the end of O3T, and 0 (range 0-1; P<0.001) at the last follow-up. CONCLUSION: Persistent advanced HRP was significantly improved with O3T. The addition of O3T can be useful as a complementary treatment in the long-term management of HRP and, as such, merits further evaluation.

Multicenter, phase 3 trial comparing selenium supplementation with observation in gynecologic radiation oncology.

PURPOSE: We assessed whether adjuvant supplementation with selenium improves the selenium status and reduces side effects of patients treated by radiotherapy (RT) for cervical and uterine cancer. METHODS AND MATERIALS: Whole-blood selenium concentrations were measured in patients with cervical cancer (n = 11) and uterine cancer (n = 70) after surgical treatment, during RT, at the end of RT, and 6 weeks after RT. Patients with initial selenium concentrations of less than 84µg/L were randomized before RT either to receive 500 µg of selenium (in the form of sodium selenite [selenase, biosyn Arzneimittel GmbH, Fellbach, Germany]) by mouth on the days of RT and 300 µg of selenium on the days without RT or to receive no supplement during RT. The primary endpoint of this multicenter Phase 3 study was to assess the efficiency of selenium supplementation during RT; the secondary endpoint was to decrease radiation-induced diarrhea and other RT-dependent side effects. RESULTS: A total of 81 patients were randomized. We enrolled 39 in the selenium group (SG) and 42 in the control group (CG). Selenium levels did not differ between the SG and CG upon study initiation but were significantly higher in the SG at the end of RT. The actuarial incidence of diarrhea of Grade 2 or higher according to Common Toxicity Criteria (version 2) in the SG was 20.5% compared with 44.5% in the CG (p = 0.04). Other blood parameters, Eastern Cooperative Oncology Group performance status, and self-reported quality of life were not different between the groups. CONCLUSIONS: Selenium supplementation during RT is effective in improving blood selenium status in selenium-deficient cervical and uterine cancer patients and reduces the number of episodes and severity of RT-induced diarrhea.

Vivências de mulheres submetidas à braquiterapia: compreensão existencial / Experiences of females when brachytherapy treatment has been undertaken: existential understanding

Neste estudo, busquei compreender as vivências de mulheres portadoras de câncer uterino antes de submeterem ao tratamento braquiterápico. Trata-se de uma pesquisa qualitativa embasada na fenomenologia existencial de Martin Heidegger que possibilitou a apreensão dos momentos vividos por esses seres. Para participar dessa pesquisa, procurei por mulheres que haviam iniciado algum tipo de tratamento para câncer uterino. Selecionei aquelas que se submeteram à radioterapia em uma clínica de radioterapia situada no noroeste do Paraná, e, a posteriori, seriam submetidas à braquiterapia no período compreendido entre os meses de abril a maio de 2006. Foram entrevistadas quatro mulheres em um hospital especialista em oncologia no norte do Paraná, antes de iniciarem a braquiterapia. Para buscar os discursos dos sujeitos, utilizei a seguinte questão norteadora: "O que você sente antes de vivenciar a braquiterapia?" Da interpretação emergiram três temáticas: O ser-com-o-outro inautêntico no convívio do hospital; angústia ante o desconhecimento do tratamento; religiosidade: o caminho da esperança. Os resultados obtidos revelam a importância do cuidado holístico ao Ser que vivencia esta facticidade, pois, muitas vezes, a subjetividade do cuidado fica absorvida pela massificação das regras e normas institucionais.

Experiences of females with uterine cancer have been analyzed prior to brachytherapy treatment. The qualitative research has been foregrounded on Martin Heideggerïs existential phenomenology which favors the understanding of instances experienced by the patients. Females who had already initiated some type of treatment for uterine cancer were investigated, although only those undertaken radiotherapy in a specific radiotherapy clinic in the northwestern section of the state of Paraná/Brazil, have been selected. They would later have to undergo brachytherapy treatment which occurred between April and May 2006. Four females were interviewed in an oncology hospital in the north of the state of Paraná, Brazil, prior to brachytherapy treatment. The following question was asked to elicit the subjectsï discourse: "What are your feelings prior to brachytherapy?" Three themes were categorized: the non-authentic being-with-the-other in the hospital; anxiety in the face of the unknown therapy; religiosity or the way to hope. Results show the importance of holistic care to the person experiencing the facts since the subjectivity of care is absorbed by the huge number of rules and institutional norms.

Resumen: En este estudio, busqué comprender las vivencias de mujeres portadoras de cáncer uterino antes de someterse al tratamiento braquiterápico. Se trata de una investigación cualitativa embasada en la fenomenología existencial de Martín Heidegger que posibilitó la aprensión de los momentos vividos por esos seres. Para participar de esa investigación, busqué por mujeres que habían iniciado algún tipo de tratamiento para cáncer uterino. Seleccioné aquellas que se sometieron a la radioterapia en una clínica de radioterapia situada en el noroeste de Paraná, y, después, serían sometidas a braquiterapia en el período comprendido entre los meses de abril y mayo de 2006. Fueron encuestadas cuatro mujeres en un hospital especialista en oncología en el norte del Paraná, antes de iniciar la braquiterapia. Para buscar los discursos de los sujetos, utilicé la pregunta clave: "¿Qué siente usted antes de vivenciar la braquiterapia?" De la interpretación emergieron tres temáticas: El ser-con-el-otro inauténtico en el convivencia del hospital; angustia frente al desconocimiento del tratamiento; religiosidad: el camino de la esperanza. Los resultados obtenidos enseñaron la importancia del cuidado holístico al Ser que vivencia esta fatalidad, pues, muchas veces, la subjetividad del cuidado queda absorbida por la masificación de las reglas y normas institucionales.

[Clinical practice guidelines: 2006 update of recommendations for the radiotherapeutic management of patients with soft tissue sarcoma (sarcoma of the extremity, uterine sarcoma and retroperitoneal sarcoma]. / Recommandations pour la pratique clinique: mise à jour 2006 des standards, options et recommandations pour l'irradiaton des patients adultes atteints de sarcome de tissus mous (sarcomes des membres, sarcomes rétropéritonéaux et sarcomes utérins.

CONTEXT: The National French Federation of Comprehensive Cancer Centres (FNCLCC) initiated the update of clinical practice guideline for the management of patients with soft tissue sarcoma in collaboration with the French Sarcoma Group (GSF-GETO), specialists from French public universities, general hospitals and private clinics and with the French National Cancer Institute. This work is based on the methodology developed in the "Standards, Options and Recommendations" (SOR) project. OBJECTIVES: To update SOR guidelines for the management of patients with soft tissue sarcoma previously validated in 1995. METHODS: The methodology is based on a literature review and critical appraisal by a multidisciplinary group of experts who define the CPGsaccording to the definitions of the Standards, Options and Recommendations project. Once the guidelines have been developed, they are reviewed by independent reviewers. RESULTS: This article presents the updated recommendations for radiotherapeutic management. The main recommendations are: 1) irradiation before or after surgical treatment is the standard for soft tissue sarcoma of the extremity and uterine sarcoma; 2) no systematic irradiation should be done in case of retroperitoneal sarcoma.

The effects of concrete objective information and relaxation on maintaining usual activity during radiation therapy.

PURPOSE/OBJECTIVES: To examine the effects of concrete objective information (COI) and relaxation instruction (RI) on patients undergoing radiation therapy, as well as the contribution of symptom uncertainty and body awareness to the intervention effects. DESIGN: Three-group randomized trial. Assignment was stratified by cancer site. Data collectors were blinded to group assignments. SETTING: University medical center radiation therapy department serving both urban and rural communities in the southeastern United States. SAMPLE: 76 adults having radiation with curative intent for gynecologic, head and neck, or lung cancer. Most were Caucasian and had in situ to stage II disease. Mean age was 55 years. METHODS: COI and RI were delivered by tape recordings. Outcome measures were indicators of usual activities and emotions at treatment week 3 and two and four weeks post-treatment. MAIN RESEARCH VARIABLES: Intervention group; social, household, and recreational activities; anxiety, depression, and anger; body awareness; and symptom uncertainty. FINDINGS: Participants receiving either intervention reported more social activity during treatment. Those given RI who were high in body awareness reported more household activity during treatment. No effects were found regarding emotion. Symptom uncertainty partially explained COI effects. CONCLUSIONS: The findings provide additional support for the effectiveness of COI in helping patients to maintain more of their usual activities during radiation therapy. Instruction in progressive muscle relaxation also may help in maintaining activities. IMPLICATIONS FOR NURSING: COI helps patients to cope with treatment by reducing their uncertainty about symptoms. RI effects may vary by activity type and awareness of usual body sensations.

KTP laser therapy for bleeding from chronic radiation proctopathy.

BACKGROUND: Endoscopic laser photocoagulation is commonly used to treat bleeding from the neovascular lesions of chronic radiation proctopathy. The KTP laser is an Nd/YAG-driven unit that emits light with a wavelength of 532 nm. This wavelength of energy is absorbed by hemoglobin and penetrates tissue to a depth of only 1 to 2 mm. METHODS: Twenty-three patients were treated with KTP laser and followed for a median of 29 months (range 5 to 51 months); 21 had received radiation for prostate cancer and 2 for uterine cancer. The median age was 77 years (range 68 to 87 years). A median of 2 sessions (range 1 to 5 sessions) was performed using 4 to 10 Watts of power and a median energy of 816 Joules per session (range 204 to 2430 Joules). RESULTS: After treatment there was a significant reduction in the frequency (p = 0.0005) of bleeding, increase in hematocrit level (p < 0.0001), improvement in activities of daily life (p = 0.01), and a reduction in use of health care resources (p < 0.0001). There was a trend toward decreased use of iron supplements (11 to 4 patients) and transfusions (4 to 0 patients). Two patients (9%) developed rectal ulcers after treatment. CONCLUSIONS: KTP laser photocoagulation is a safe and effective therapy for bleeding from chronic radiation proctopathy that improves activities of daily living and reduces use of health care resources.

[The use of therapeutic/prophylactic dragee "honey laminolact" in radiotherapy of uterine tumors]. / Opyt primeneniia lechebno-profilakticheskogo drazhe "laminolakt medovyi" pri luchevom lechenii bol'nykh rakom tela matki.

The study deals with the effect of a newly-developed food product--Honey Laminolact, containing live lactic acid bacteria, amino acids, trace elements, fruit pectine and immunomodulators-on the degree of response to radiation in 44 patients who received radiotherapy for uterine tumors. It was shown to lower response of the intestinal tract to radiation when the small pelvis was exposed.

[Chemotherapy with consecutive low-dose CDDP combined with 5-FU for gynecologic malignancies].

CDDP is generally given in a bolus fashion because it has been considered to act in a dose-dependent manner. However, early studies demonstrated anti-tumor activity of CDDP was both dose- and time-dependent. This indicated that the anti-tumor effect of CDDP dependent on the area under the concentration of filterable platinum-time curve (AUC) obtained following an administration of the agent, but not on the maximum concentration (C max) of the agent. To increase the AUC and treatment compliance, we designed a consecutive low-dose CDDP dosing method (10 mg/m2, days 1-7). This method was found to be accompanied by a good treatment compliance and high dose intensity due to significantly reduced toxic effects when CDDP was combined with several other agents. 5-FU alone has been reported to be effective in approximately 20-25% of gynecologic malignancies. Moreover, CDDP can augment the cytotoxic activity of 5-FU through biochemical modulation. Accordingly, combination treatment with consecutive low-dose CDDP with 5-FU could be designed. The present report reviews the efficacy of this combination chemotherapy for cervical carcinoma.

Treatment of carcinoma of the uterine cervix with concomitant cisplatin, 5-fluorouracil and split course hyperfractionated radiotherapy.

To improve local and systemic control of bulky (>4 cm) and/or advanced primary cancer of the uterine cervix, 35 patients were treated with concomitant cisplatin (CDDP), 5-fluorouracil (5-FU) and split course hyperfractionated radiotherapy. Radiation was administered to the pelvis in five-day courses at a dose of 1.5 Gy twice daily every 21 days until a median dose of 45 Gy was reached. 15 Gy more were administered to involved parametrium or central tumor by external radiotherapy or brachytherapy. The irradiated zone was extended to include paraaortic lymph nodes if necessary. CDDP was administered at a dose of 20 mg m(-2) and 5 FU at a dose of 500 mg m(-2) from day one to day five of each course. The median number of combined treatment courses per patient was four (1-6). Local responses were obtained in 19 out of 24 patients in whom evaluation was feasible (i.e. who did not undergo surgery prior to combined therapy). Median survival was not attained with a median follow up of 33 months, three year overall survival was 62% and 52% in patients with local control and in the whole population respectively. Several patients with stage III and IV tumors achieved a very long survival. Acute toxicity was manageable but three patients required surgical repair of late radiation complications. This combined chemotherapy and radiotherapy resulted in good local control and did not rule out surgery.

[Clinical evaluation based on cost-effectiveness].

We carried out two Phase III clinical trials using high dose rate (HDR) remote afterloading brachytherapy unit. We evaluated the clinical results based not only on the medical but also the economical standpoint. The first trial is the Phase III trial for cervical cancer treated with HDR or medium dose rate (MDR) intracavitary radiotherapy. The second one is the Phase III trial for tongue cancer treated with HDR or low dose rate (LDR) interstitial radiation. For cervical cancer, the survival rate of patients treated with HDR brachytherapy is the same as for LDR brachytherapy. The average total cost of treatment for the HDR group was 1.47 million yen, while that for the MDR group was 1.58 million yen. The average total admission days was 63. For tongue cancer, the local control rate of the HDR group is almost the same as that of the LDR groups. The average total cost for the HDR group was 780 thousand yen, and that for the LDR group was 830 thousand yen. The average total admission days was 34. According to the cost-effectiveness, HDR brachytherapy for cervical cancer has the same result as MDR, and HDR brachytherapy for tongue cancer has the same result as LDR. However, HDR can be treated without admission for patients who live near the hospital. HDR can be applied for these patients with less expense. We must be aware of not only the medical results but also the cost-effectiveness.

Effective hyperbaric oxygenation with prostaglandin E1 for radiation cystitis and colitis after pelvic radiotherapy.

Gross haematuria and severe bleeding from the large intestine occurred after pelvic radiotherapy in an 84-year-old woman with cancer of the uterus. Hyperbaric oxygenation treatment at 2 atmospheric absolute pressures for 60 minutes daily over 30 days and infusion of prostaglandin E1 abolished completely haematuria and tarry stool, and reversed the endoscopic findings of radiation cystitis and colitis.

Hyperbaric oxygen therapy in hemorrhagic radiation cystitis: a report of 20 cases.

Radiation cystitis with macroscopic hematuria has been a frustrating clinical problem for urologists. Since 1985 hyperbaric oxygen (HBO) has been used to treat this disease, showing favorable results. Between November 1989 and October 1992, 20 female patients with hemorrhagic radiation cystitis were treated with HBO at a pressure of 2.5 atm abs, breathing 100% O2 for 100 min in our multiplace hyperbaric chamber. After an average of 44 HBO sessions, macroscopic hematuria was completely halted in 16 patients (80%) and markedly decreased in 2 patients (10%). Comparison of the cystoscopic findings before and after HBO showed a significant decrease in hemorrhagic sites and telangiectasis of the bladder mucosa. One patient had urinary frequency and urgency without hematuria during her hospital stay. After 30 sessions of HBO therapy, her symptoms subsided, and the cystoscopic findings were much improved. Only one patient failed to respond to HBO and underwent ileal conduit diversion. The mean follow-up period was 14 mo. (5-41 mo.). From our clinical results and cystoscopic findings, we suggest that HBO is an effective and safe treatment for hemorrhagic radiation cystitis.

Evaluation of CT images, tumour response and prognosis after thermoradiotherapy for deep-seated tumours.

Thermoradiotherapy was applied for the treatment of deep-seated tumours in 41 patients. Low-density area (LDA) on CT images which appeared or expanded within the tumour after treatment was evaluated. Derived conclusions are as follows: (1) of 41 patients, LDA newly appeared or expanded in 24; (2) change of density was related closely with size of a tumour, histological characteristics of the tumour and heating condition; (3) histologically, LDA consisted of coagulation necrosis and tumour cells at the peripheral wall were highly degenerated; (4) a greater extent of LDA indicated the increasing possibility of local control; (5) probability of survival for patients with an increase of LDA was significantly superior to those without changes of LDA; (6) LDA may be a good landmark for judgement of the prognosis of a patient treated by thermoradiotherapy; and (7) new criteria of treatment effectiveness including density changes were proposed.

Successful hyperbaric oxygenation for radiation cystitis due to excessive irradiation to uterus cancer.

Six female patients with radiation cystitis, induced by previous pelvic radiation to uterus cancer, were treated with hyperbaric oxygenation (30-35% of oxygen concentration at 2 atmospheric absolute pressures for 90-120 min daily from 20 to 61 days with the average of 45 +/- 7 days, mean +/- standard error). Except in 1 patient symptoms and cystoscopic findings were improved. No side effects were found. Recurrence of radiation cystitis never occurred during the follow-up period (1.0 +/- 0.1 years). Hyperbaric oxygenation treatment in this pressure environment appears to have a beneficial effect of this disorder.