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JA Thornhill,RM Long,P Neary,O'Connor HJ,B Ryan,I Fraser
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Ir Med J. 2012 Mar;105(3):91-3
JA Thornhill, RM Long, P Neary, HJ O'Connor, B Ryan, I Fraser
Department of Urology, AMNCH, Tallaght, Dublin 24
Abstract
We present a salutary lesson learned from three cases with significant complications that followed anorectal intervention in the presence of radiation proctitis due to prior radiotherapy for adenocarcinoma of the prostate. After apparent routine rubber band ligation for painful haemorrhoids, one patient developed a colo-cutaneous fistula. Following laser coagulation for radiation proctitis, one patient required a pelvic exenteration for a fistula, while another developed a rectal stenosis. Those diagnosing and treating colonic conditions should be mindful of the increased prevalence of patients who have had radiotherapy for prostate cancer and the potential for complications in treating these patients.
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Introduction
We present a salutary lesson learned from three cases with significant complications that followed anorectal intervention in the presence of radiation proctitis due to prior radiotherapy for adenocarcinoma of the prostate. All three cases had previously undergone external beam radiotherapy for localised prostate cancer, seventy-four Gy in 37 fractions. With the recent increase in detection of prostate cancer in Ireland and increased radiotherapy intervention combined with the massive increase in colonoscopy screening, we believe that these cases highlight an important issue relevant to urologists, radiotherapists, general surgeons and gastroenterologists1,2.
Case 1
A 53 year old male twelve months post radiotherapy for localised prostate cancer developed painful haemorrhoids. After apparent routine rubber band ligation there followed a subsequent wound breakdown complicated by colo-cutaneous fistula. This complication was managed by seton stent but the condition did not resolve until two years.
Case 2
A 60 year old with persistent bleeding per rectum post radiotherapy for prostate cancer had radiation proctitis changes at colonoscopy. Biopsy and argon plasma coagulation (APC) was performed. He subsequently presented with urinary infection and pneumaturia due to the complication of a prostato-rectal fistula. Pelvic exenteration (cysto-prostatectomy and anterior rectal resection) was the only treatment option. Histopathology demonstrated irradiation changes, fistula, and no residual prostate cancer.
Case 3
A 68 year old with persistent bleeding per rectum post prostatic radiotherapy was diagnosed with radiation proctitis at colonoscopy. He underwent eight sessions of APC and subsequently developed difficulty with faecal evacuation due to the complication of an anal stenosis.
Discussion
External beam irradiation is a common treatment modality for prostatic adenocarcinoma. Historically this approach was more prevalent in the United Kingdom where, unlike the United States, there was no tradition of training or practice of radical prostatectomy. With older radiotherapy technology the complications of pelvic irradiation included moderate to severe radiation induced proctitis, colitis, cystitis and even dermatitis3. In another sphere and in military terminology, the collateral damage to innocent civilians is a significant complication after nuclear attack. Practising urologists and colorectal surgeons performing pelvic surgery for whatever reason after prostatic radiotherapy are aware of the severe changes seen after pelvic irradiation which can vary from mild bowel inflammation to a totally fixed and fibrotic pelvis4.
Modern developments in external beam irradiation for prostate cancer have aimed to increase the dose of local irradiation in order to maximise efficacy by focusing treatment to the target area and reducing the dosage to surrounding tissues5. A significant advance has been the introduction of three-dimensional conformal external beam radiotherapy, now standard treatment. In considering a patient for radiation the whole gland is included in treatment field. In suspected or proven locally advanced disease the seminal vesicles are also included. It is important to minimise the dose volume to surrounding normal tissue to a minimum, with the organs at risk clearly being the rectum and bladder6-8. The bladder is filled during CT simulation and during subsequent therapy to exclude it from the field of treatment. Likewise, the rectum is maintained empty to reduce the intra-fractional variation in rectal volume. The rectum, bladder and prostate are contoured throughout the CT planned treatment volume. When treatment plan is constructed the dose restraints are monitored and are not negotiable. If the dose limits to surrounding tissues can not be met due to significant prostate size then neo-adjuvant androgen deprivation therapy may be given to reduce prostate volume. During three-dimensional conformal therapy, CT monitoring may be repeated once or more during treatment fractions. Treatment is delivered by three, four or five beams depending on machine technology. Fiducials are radio-opaque micro implants that can be placed in prostate tissue prior to radiotherapy and used to monitor prostate position during treatment.
Intensity modulated radiotherapy (IMRT) involves newer technology that delivers radiotherapy as seven to nine external beams. Using this technology the target dose can be increased to 81 Gy. This may be of therapeutic benefit but protection of organs at risk is at an even higher priority. The treatment exclusion margin is often reduced to 5 mms, bladder must be full, rectum must be empty and fiducials are commonly used. IMRT is both time consuming and expensive but will become more widespread as newer machines are installed. Despite technical advances acute radiation injury still occurs with bladder and rectum most frequently affected. Radiation proctitis is a common occurrence following external beam radiotherapy to the prostate while symptoms usually subside, they may persist at a significant level in 5% to 31% of patients9-11. Brachytherapy, the insertion of radioactive seeds directly into prostate tissue, minimises the dose to surrounding organs at risk but has a smaller dosage field than with external beam and is therefore only applicable to low risk tumours. A study on pre-irradiation endoscopy revealed haemorrhoids in 33%, polyps in 24% and diverticular disease in 13% of patients12. There is no evidence that these findings predict post treatment side-effects but previous pelvic surgery and diabetes may predispose to proctitis bleeding.
These three cases cited highlight the complications that can occur after anorectal intervention in the presence of radiation induced proctitis. These interventions may be either to diagnose or treat radiation colitis (two cases) or haemorrhoids in one case. Only following intervention in the form of biopsy, argon plasma coagulation, or banding of haemorrhoids did the patients develop significant complications. Argon plasma coagulation is a standard treatment modality to control bowel bleeding points and fistula is only rarely reported13. APC may be reserved for the more severe cases of proctitis and bleeding but paradoxically these are the cases with most complications. We would caution against the use of excessive coagulation therapy in the presence of irradiated mucosa. Likewise, mucosal biopsy also likely contributed to complications in one of these cases. Mucosal biopsies are by definition superficial, but in the presence of radiation proctitis, even superficial biopsy may pose a risk. We would question whether biopsy is always required when the diagnosis of radiation proctitis is virtually certain from clinical and endoscopic features.
The anorectal complications seen in these cases were not related to prostate cancer per se. All three had radiotherapy with curative intent, one of whom had temporary adjuvant hormonal therapy in addition. The two cases with fistula and stenosis respectively remain in tumour remission at two years as evidenced by PSA response. The unfortunate case with prostato-rectal fistula requiring pelvic exenteration was also in complete remission confirmed by ongoing PSA response and pathology out-ruling residual prostate cancer. With widespread PSA testing and increased awareness of prostate cancer there has been a dramatic increase in prostate cancer detection and treatment with radiotherapy14,15. In addition, the new emphasis on colorectal screening by colonoscopy is leading to increased detection of many anorectal conditions. Not infrequently, patients who have previously undergone radiotherapy for prostate cancer may present to rapid access clinics because of bleeding or irritative bowel symptoms. In summary, all those diagnosing and treating colonic conditions should be mindful of the increased prevalence of patients who have had radiotherapy for prostate cancer and the potential for complications in treating these patients.
Correspondence: JA Thornhill
Department of Urology, AMNCH, Tallaght, Dublin 24
Email: [email protected]
References
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11. Ataman F, Zurlo A, Artignan X, van Tienhoven G, Blank L, Warde P, Dubois J, Jeanneret W, Keuppens F, Bernier J, Kuten A, Collette L, Pierat M, Bolla M. Late toxicity following conventional radiotherapy for prostate cancer: analysis of the EORTC trial 22863. Eur J Cancer 2004;40:1674-81.
12. Goldner G, Zimmermann F, Feldmann H, Glocker S, Wachter-Gerstner N, Geinitz H, Becker G, Potzi R, Wambersie A, Bamberg M, Molls M, Wachter S, Potter R. 3-D conformal radiotherapy of localized prostate cancer: a subgroup analysis of rectoscopic findings prior to radiotherapy and acute/late rectal side effects. Radiother Oncol2006;78:36-40.
13. Denton AS, Andreyev HJ, Forbes A, Maher EJ. Systematic review for non-surgical interventions for the management of late radiation proctitis.Br J Cancer 2002;87:134-43.
14. Bray F, Sankila R, Ferlay J, Parkin DM. Estimates of cancer incidence and mortality in Europe in 1995. Eur J Cancer 2002;38:99-166.
15. Boyle P, Ferlay J. Cancer incidence and mortality in Europe, 2004. Ann Oncol 2005;16:481-8.
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Author's Correspondence
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Acknowledgement
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No Acknowledgement
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