Joint Hospital Grand Round Radiation Proctitis Nancy Ng Colorectal Team Department of Surgery Prince of Wales Hospital The Chinese University of Hong Kong

Why Important ? Increasing no. of patients treated with radiotherapy for pelvic malignancies, mostly with curative intent in UK annually Rectum commonly injured Acute radiation toxicity : up to 80% Self-limiting and resolve after RT

Occur 29-51% of patients Not entirely dose related Depends on physical, patient-related, treatment and genetic factors Dearnaley D et al. Lancet 1999 Widmark A et al. Cancer 1994 Crook J et al. Urology 1996 Impaired QOL in 5% Gami B et al. Aliment Pharmacol Ther 2003 Manifest from months to years after RT  median 8-13 months Chronic radiation rectal bleeding

Histopathologic changes Progressive obliterative endarteritis and submucosal fibrosis Mucosal ischaemia Neo-vascularization Hasleton PS et al. Histopathology 1985 Haboubi NY et al. Am J Gastroenterol 1988

Endoscopic appearance

Severe radiation proctitis

Radiation proctitis with stricture

Diagnosis Usually straightforward from history ? Endoscopy : Yes Older patient and prior pelvic radiation Increased risk of malignancy, esp. rectal tumor Pickles, Phililips, et al. Radiother Oncol 2002 Brenner A, Curtis R, et al. Cancer 2000 Kleinerman R, Boice J, et al. Cancer 1995 Boice J, Day N, et al. Cancer Inst 1985 Other pathologies H R T Williams, P Vlavianos, et al. Ali Phar & Thera 2005

Treatment Medical therapy Oral and rectal steroid 5-aminosalicylates Sucralfate Short chain fatty acid enema Ineffective in severe cases Denton AS et al. Br J Cancer 2002 Hong JJ et al. Aliment Pharmocal Ther 2001 Tagkalidis PP et al. ANZ J Surg 2001

Treatment Endoscopic treatment Local formalin application Surgical treatment Rarely response to colostomy alone High morbidity and mortality Tagkalidis PP et al. ANZ J Surg 2001 Hong JJ et al. Aliment Pharmocal Ther 2001 Indicated for uncertain diagnosis and complications

Surgical specimen

Endoscopic treatment Coagulation can be achieved by heat probe multipolar electrocoagulation laser argon plasma coagulator (APC)

APC monopolar therapy, use argon gas to conduct radiofrequency energy to tissue Instant superficial tissue coagulation over 3-4mm area Non-contact nature minimize tissue sticking and bleeding Require adequate colon cleansing Deep injury include perforation can occur (depends on contact time and total energy delivered

English literature on APC for radiation proctitis

PWH experience From 1/2001 to 12/ (M:4, F:16) with radiation proctitis were treated by endoscopic APC in our hospital Ca prostate : 4 Ca rectum : 1 Gyn malignancy : 15 Age 67.6 (+/-11.5) years

Radiation dosage : 6300 (+/-1197cGy) Onset of PRB : 15 mth Hb before treatment : 10.02g/dl (+/-2) 6 of them need repeated admission for transfusion

Result Mean treatment session : 1.5 (1-4) Bleeding stopped735% Bleeding improved525% Bleeding unchanged630% Bleeding worsened210% Treatment efficacy : 60% Hb after treatment : 10.05g/dl (+/-2) No documented complications

Conclusions APC is a safe treatment modality for radiation proctitis Good result from literature not reproduced

Topical Formalin Formaldehyde mixed with methanol Treatment for radiation cystitis since 1976 First described by Rubinstein et al in 1986 Mechanism Chemical cauterization by protein cross-linking, cell necrosis and vessel sealing. Effect of 4% formalin was transient and confine to the mucosa  Myers et al. Dis Colon Rectum 1998

English literature on formalin dab for radiation proctitis

PWH experience From 1/2001 to 12/ ( M:2, F:9) patient with refractory radiation proctitis failed to medical (11) and /or argon plasma coagulation (7) were included Age 62.8 (+/-14.8) Radiation dosage (+/-980cGy) Ca prostate : 2 Gyn. malignancy : 8 Buttock sarcoma : 1

Onset of PRB after RT : 10.9mth(+/-3.8) Hb before treatment : 7.3g/dl(+/-2.4) 8 need repeated admission for transfusion Treatment was done in minor operating theater without anaesthesia or sedation

4% formalin solution was prepared by mixing 40ml of 10% buffered formalin

Patient in left lateral position. Contact for 1 to 3min, till mucosa appears whitish and bleeding stops.

Before treatment Immediately after treatment 4 days later 11 days later5 weeks later 4 months later

Result Overall efficacy 90.9%

Result Hb after treatment : 10.4g/dl (+/-2.2) P = No major complications documented Conclusion Formalin dab is an effective, safe and inexpensive treatment modality for refractory radiation proctitis.

Summary Radiation proctitis is one of the common cause of PRB Colonoscopy is suggested before making this diagnosis APC is safe but may not be effective for severe bleeding Formalin dab is effective, save and inexpensive for refractory bleeding and can be considered as the first line treatment

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