Defecation into clothing without forewarning and mean radiation dose to bowel and anal-sphincter among gynecological cancer survivors

Abstract

Mean doses to the bowels and anal-sphincter region are related to the risk of defecation into clothing without forewarning in long-term gynecological cancer survivors treated with pelvic radiotherapy. Further radiobiological modeling may distinguish which organ(s) contribute most to development of the symptom.

A systematic review of dose-volume predictors and constraints for late bowel toxicity following pelvic radiotherapy

“…Recommend V15 < 275 cc, V30 < 190 cc, V40 < 150 cc reduces Gr3 toxicity from 23.6 to 5.6%. 1, 4, 6 (n/a 2,3) 2 Isohashi [ 10 ] Small bowel Bowel loops remaining after exclusion of large bowel loops RTOG/EORTC Gr ≥ 2 16/97 (16.5%) V40 best predictor of late toxicity; Recommend V40 < 340 ml to reduce toxicity from 46.2 to 8.7% 1,4,6,7 (n/a 2,3) 2 Lind [ 12 ] Small bowel All visible small bowel in small pelvic cavity to caudal part of sacroiliac joints Defecation into clothing without warning > 1 in last 6 months 63/519 (12.1%) Mean dose>50Gy to small bowel or sigmoid or anal sphincter region associated with symptom (findings for individual organs not clarified) 1, 7 (n/a 2,3) 1,2,3 Adkison [ 34 ] Small bowel Not clearly defined CTCAE v3.0 Gr1 and Gr2 Gr1 16/53 (30%); Gr2 4/53 (8%) No dose-volume relationship with V30-V60 small bowel 1 (n/a 2–6) None Fokdal [ 14 ] Small bowel Opacified & unopacified small intestine loops (outer contour & contents) from 1st slice to minor pelvis LENT-SOMA G1–4 Symptom specific No dose-volume relationship found 1,7 (n/a 2–6) 1,2,3 Fonteyne [ 17 ] Small bowel Not clearly defined RTOG and “RILIT” Gr1 & Gr2 Gr1 112/241 (46%), Gr2 32/241(13%) No dose-volume relationship found 1, (n/a 2–6) 1,2 Poorvu [ 16 ] Small bowel Opacified & non-opacified small bowel loops CTCAE v4.0 Gr3+ 3/46 (6.5%) No dose-volume relationship found 1,7 (n/a 2–6) 2 Huang [ 15 ] Duodenum Duodenal bulb to ligament of Treitz CTCAE v4.0 Gr ≥ 3 8/46 (17.4%) With a V25 > 45% toxicity rates increase from 8 to 48% …”

“…No specific constraints. 1,7 (n/a 2–6) 1,2 Lind [ 12 ] Sigmoid colon From where rectum deviates from its mid- position to where it turns cranially in left abdomen connecting to colon descendens Defecation into clothing without warning > 1 in last 6 months 63/519 (12.1%) Mean dose>50Gy to small bowel or sigmoid or anal sphincter region associated with symptom (findings for individual organs not clarified) 1, 7 (n/a 2–6) 1,2,3 al-Abany [ 18 ] Anal sphincter region Caudal 3 cm of the rectum from anal verge (including filling) Own questionnaire; Faecal leakage >2X/week 9/65 (13.8%) faecal leakage Increased risk with mean dose of 45-55Gy. Constraints: V35 < 60%, V40 < 40% associated with no risk of faecal leakage.…”

“…; 32/368 (7%) NTCP LKB model of incontinence with anal wall dose. Parameters found were n = 7.48; TD50 = 105; m = 0.46 1,3,4,5,6,7 (n/a: 2) 1,3 Smeenk [ 26 ] Anal sphincter muscles Individual muscles defined (Internal anal sphincter (IAS), external anal sphincter (EAS), puborectalis & levator ani) Frequency, Urgency, Incontinence 21/48 (44%) For complication <5% Dmean<30Gy to IAS; <10Gy to EAS, < 50Gy to puborectalis, <40Gy to levator ani 1, 4,5 (n/a 2) 1,2,3 Smeenk [ 22 ] Anal wall Continuation of rectal wall from anal verge to slice below lowest slice with a rectal balloon Frequency, urgency, incontinence 39% frequency, 31% urgency, 31% incontinence For urgency: Anal wall Dmean<38Gy risk < 15%, >38Gy risk is 62% 1,4,7 (n/a 2,3,5,6) 1,3 Lind [ 12 ] Anal sphincter region Inner muscle layer of the sphincter up to anal verge Defecation into clothing without warning > 1 in last 6 months 63/519 (12.1%) Mean dose>50Gy to small bowel or sigmoid or anal sphincter region associated with this symptom (findings for individual organs not clarified) 1, 7 (n/a 2,3) 1,2,3 Yeoh [ 24 ] Anal wall From anorectal junction (not clearly defined) LENT-SOMA total score 72% Anal wall V40 > 65% associated with chronic toxicity. 1,5 (n/a 2,3) 2,3 Thor [ 29 ] Anal sphincter Anal canal, inner and outer sphincter (not clearly defined) Questionnaire of 19 questions in 4 domains: pain urgency, mucus & incontinence.…”

“…However, the positive parameters were different between the studies, with Isohashi et al [ 10 ] recommending a V40 < 340 cc, and Chopra et al [ 11 ] recommending a V15 < 275 cc. Lind et al [ 12 ] found that a mean small bowel dose >50Gy was of significance, however could not clarify whether toxicity was linked specifically to small bowel, sigmoid or anal sphincter dose, making these results difficult to interpret.…”

Lived experiences and quality of life after gynaecological cancer—An integrative review

“…Symptoms from the pelvic region originated predominantly from the bowels, the urinary tract, the lymphatic system and the genitals Bergmark, Åvall-Lundqvist, Dickman, Henningsohn, & Steineck, 1999Dunberger et al, 2013;Liavaag, Dørum, Fosså, Tropé, & Dahl, 2009;Lind et al, 2011Lind et al, , 2016Lindgren et al, 2017;Mikkelsen, Sørensen, & Dieperink, 2017;Mouritsen et al, 2013;Nesvold & Fosså, 2002;Steineck et al, 2017aSteineck et al, , 2017bVistad, Cvancarova, Fosså, & Kristensen, 2008).…”