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

2. Why Important ? Increasing no. of patients treated with radiotherapy for pelvic malignancies, mostly with curative intent. 12000 in UK annually Rectum commonly injured Acute radiation toxicity : up to 80% Self-limiting and resolve after RT

3. 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

4. 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

5. Endoscopic appearance

6. Severe radiation proctitis

7. Radiation proctitis with stricture

8. 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

9. 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

10. 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

11. Surgical specimen

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

14. 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

15. English literature on APC for radiation proctitis

16. PWH experience From 1/2001 to 12/2004 20 (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

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

18. 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

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

20. 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

21. English literature on formalin dab for radiation proctitis

22. PWH experience From 1/2001 to 12/2004 11 ( 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 6723.6 (+/-980cGy) Ca prostate : 2 Gyn. malignancy : 8 Buttock sarcoma : 1

23. 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

24. 4% formalin solution was prepared by mixing 40ml of 10% buffered formalin

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

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

28. Result Overall efficacy 90.9%

29. Result Hb after treatment : 10.4g/dl (+/-2.2) P = 0.007 No major complications documented Conclusion Formalin dab is an effective, safe and inexpensive treatment modality for refractory radiation proctitis.

30. 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

31. Thank You!