*Radzisław Trzciński
Proposed treatment algorithm for radiation proctitis considering the Polish realities
Proponowany algorytm leczenia popromiennego zapalenia odbytnicy uwzględniający polskie realia
Jan Kochanowski University in Kielce, Branch in Piotrków Trybunalski,
Collegium Medicum, Piotrków Trybunalski
Streszczenie
Przewlekłe popromienne zapalenie błony śluzowej odbytnicy (PPZO) jest powikłaniem radioterapii przeprowadzanej z powodu nowotworów narządów zlokalizowanych w obrębie miednicy (m.in. gruczoł krokowy, trzon i szyjka macicy). Stopień nasilenia dolegliwości klinicznych ze strony odbytnicy ocenia się według skali chorobowości późnej po napromienianiu zaproponowanej przez RTOG/EORTC (Radiation Therapy Oncology Group/European Organisation for Research and Treatment of Cancer Score for late radiation proctitis). Z kolei, badanie endoskopowe pozwala na ocenę makroskopową zmian popromiennych w obrębie błony śluzowej. Etiologia PPZO nie jest w pełni poznana, dlatego podejmowane leczenie zarówno farmakologiczne, jak i zabiegowe jest jedynie objawowe, a nie przyczynowe. W pracy przedstawiono metody leczenia PPZO i zaproponowano algorytm postępowania terapeutycznego u pacjentów z PPZO.
Summary
Chronic radiation proctitis (CRP) is a complication of radiotherapy for pelvic malignancies (e.g. prostate, endometrial and cervical cancers). The severity of rectal clinical symptoms is graded based on the Radiation Therapy Oncology Group/European Organization for Research and Treatment of Cancer Score for late radiation proctitis (RTOG/EORTC). Endoscopy, on the other hand, allows for macroscopic assessment of radiation-induced mucosal damage. The aetiology of chronic radiation proctitis is not fully understood, therefore symptomatic rather than causal pharmacological and surgical treatment is only used. The paper presents the available treatment options and proposes a therapeutic algorithm for chronic radiation proctitis.
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Introduction
Radiation-induced intestinal damage, which manifested by abdominal pain and diarrhoea, was first described by Walsh in 1897. In 1930, Buie described a pathological syndrome, which he referred to as chronic radiation proctitis. In 1938, Todd described an early complication of acute radiation proctitis after intracavity radium treatment (1-6).
Chronic radiation proctitis (also known as radiation-induced proctitis, radiation proctopathy) is a consequence of radiotherapy for pelvic malignancies, i.e. cervical and endometrial cancer, bladder, prostate, anal and rectal cancer (1, 7-10). Based on the available data, it is estimated that approximately 1-5% of patients undergoing irradiation for pelvic cancer develop CRP, although rates of 20-47% have also been reported (1, 2, 6, 7, 11-14).
There are no clearly defined risk factors for CRP. One of the theories, known as the ‘vascular’ theory, assumes that small blood vessels are damaged as a result of the impact of ionizing radiation on the vascular endothelium, which in turn leads to proliferation and fibrosis of the intima and media. This in turn leads to structural intestinal wall remodelling, accompanied by mucosal atrophy, as well as often ulceration, perforations, fistulae (rectovaginal, vesicovaginal), and faecal incontinence (1, 6, 11, 13, 15-18).
Radiation-induced changes may involve not only the rectum, but also the sigmoid colon (radiation sigmoidopathy) and even the small bowel, with its stricture and symptoms of obstruction (radiation enteropathy, radiation enteritis). Nevertheless, it is emphasised that the rectum and the distal part of the sigmoid colon, due to their location in the abdominal cavity and relatively low mobility, are most exposed to radiation damage as a result of radiotherapy for pelvic tumours (1, 7, 19).
Clinical manifestations of radiation proctitis
Clinical symptoms of CRP vary in severity, with bleeding (the main symptom of the disease) occurring in about 80% of patients. Other conditions with symptoms suggestive of CRP should be excluded (e.g. antibiotic-induced Clostridium difficile infection, NSAID abuse, parasitic diseases, HPV or Neisseria gonorrhoeae infections, immunomodulatory therapy, and cytomegalovirus infection) (7, 8, 10, 17, 20).
It is estimated that 6-78% of patients after radiotherapy develop disturbances in the rhythm of bowel movements, which clearly affects the quality of life, while serious complications, such as bower stricture, intestinal fistulas, as well as massive bleeding requiring blood transfusions, develop in 5-10% of patients (1, 6, 15, 18, 21, 22). About 0 to 26% of patients after pelvic radiotherapy develop various forms of faecal incontinence. The symptoms of CRP most often occur in the first 2-3 years, and even 1-2 years after the end of radiotherapy, when the incidence reaches the plateau phase, but they may also develop a dozen or even several dozen years after irradiation (1, 2, 5, 18, 23).
Rectal clinical symptoms are graded based on the Radiation Therapy Oncology Group/European Organisation for Research and Treatment of Cancer Score for late radiation proctitis (RTOG/EORTC) (tab. 1).
Tab. 1. Clinical assessment of colorectal symptoms according to the RTOG/EORTC scoring system for late bowel toxicity
Grade | Clinical manifestations |
Grade 0 | no symptoms |
Grade 1 | mild diarrhoea and mild abdominal pain; loose bowel movement up to 5 times a day; mild straining or slight bleeding; mild anal pain |
Grade 2 | moderate diarrhoea and colic; loose bowel movement > 5 times daily; excessive rectal mucus or intermittent bleeding |
Grade 3 | persistent pain; obstruction or bleeding requiring surgery |
Grade 4 | necrosis/perforation/fistula |
Grade 5 | fatal toxicity ? sepsis, multiple organ failure |
Endoscopic manifestations of radiation proctitis
Radiation proctitis should be suspected in every patient with a history of pelvic radiotherapy who reports symptoms typical of RP, even if radiation therapy was administered many years before. It is important to perform an endoscopic examination to exclude other causes of proctitis and malignancies. The mucosa is dominated by the presence of telangiectasias (small dilated blood vessels), erosions, and ulcerations; it is fragile and prone to contact bleeding, with no typical vascular pattern; focal necrosis may be present (1, 16, 21, 24-28).
Treatment of chronic radiation proctitis
The aetiology of CRP is not fully understood, therefore symptomatic rather than causal treatment is only used, which significantly limits therapeutic outcomes. Acute treatment is usually used for radiation-induced rectal injury, persistent bleeding in particular (1, 18). The most common treatment approaches for CRP are discussed below.
Sucralphate
Sucralfate stimulates formation of endogenous prostaglandins, which have a cytoprotective effect, as well as promotes healing processes through its beneficial effect on angiogenesis. The drug is administered orally (3.0-4.0 g/day) or in the form of 10% enemas. Sucralfate is currently available in Poland as Ulgastran, a suspension (1 g of sucralfate/5 mL; 10-15 mL of suspension administered through a Foley catheter, i.e. 2.0-3.0 g/day) (1, 3, 7, 13, 21, 29, 30).
5-Aminosalicylic acid (5-ASA)
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Piśmiennictwo
1. Trzciński R: Patologia Kliniczna Przewlekłego Popromiennego Zapalenia Odbytnicy. Uniwersytet Medyczny, Łódź 2016.
2. Trzcinski R, Mik M, Dziki L, Dziki A: Proctological Diseases in Surgical Practice. IntechOpen 2018; http://dx.doi.org/10.5772/intechopen.71454. Chapter 6 ? Radiation Proctitis: 105-117.
3. Bielecki K: Popromienne zapalenie błony śluzowej odbytnicy (PZBSO). Nowa Medycyna 2014; 3: 99-106.