Treatment and prognosis of patients with late rectal bleeding after intensity-modulated radiation therapy for prostate cancer

Abstract

BackgroundRadiation proctitis after intensity-modulated radiation therapy (IMRT) differs from that seen after pelvic irradiation in that this adverse event is a result of high-dose radiation to a very small area in the rectum. We evaluated the results of treatment for hemorrhagic proctitis after IMRT for prostate cancer.MethodsBetween November 2004 and February 2010, 403 patients with prostate cancer were treated with IMRT at 2 institutions. Among these patients, 64 patients who developed late rectal bleeding were evaluated. Forty patients had received IMRT using a linear accelerator and 24 by tomotherapy. Their median age was 72 years. Each patient was assessed clinically and/or endoscopically. Depending on the severity, steroid suppositories or enemas were administered up to twice daily and Argon plasma coagulation (APC) was performed up to 3 times. Response to treatment was evaluated using the Rectal Bleeding Score (RBS), which is the sum of Frequency Score (graded from 1 to 3 by frequency of bleeding) and Amount Score (graded from 1 to 3 by amount of bleeding). Stoppage of bleeding over 3 months was scored as RBS 1.ResultsThe median follow-up period for treatment of rectal bleeding was 35 months (range, 12–69 months). Grade of bleeding was 1 in 31 patients, 2 in 26, and 3 in 7. Nineteen of 45 patients (42%) observed without treatment showed improvement and bleeding stopped in 17 (38%), although mean RBS did not change significantly. Eighteen of 29 patients (62%) treated with steroid suppositories or enemas showed improvement (mean RBS, from 4.1 ± 1.0 to 3.0 ± 1.8, p = 0.003) and bleeding stopped in 9 (31%). One patient treated with steroid enema 0.5-2 times a day for 12 months developed septic shock and died of multiple organ failure. All 12 patients treated with APC showed improvement (mean RBS, 4.7 ± 1.2 to 2.3 ± 1.4, p < 0.001) and bleeding stopped in 5 (42%).ConclusionsAfter adequate periods of observation, steroid suppositories/enemas are expected to be effective. However, short duration of administration with appropriate dosage should be appropriate. Even when patients have no response to pharmacotherapy, APC is effective.

Preliminary analysis of risk factors for late rectal toxicity after helical tomotherapy for prostate cancer

“…Takemoto et al evaluated the results of the treatment for hemorrhagic proctitis after IMRT for prostate cancer [17]. Among 403 patients treated with IMRT, 64 developed late rectal bleeding with a median follow-up time of 35 months.…”

Intensity-modulated radiation therapy using static ports of tomotherapy (TomoDirect): comparison with the TomoHelical mode

“…Thus, the prostate and the seminal vesicle were contoured as the clinical target volume (CTV) according to our protocol [19]. The CTV was expanded by 6 to 8 mm for the PTV (7 mm in lateral direction, 8 mm in cranial-caudal and anterior directions and 6 mm in posterior direction).…”

“…The prescribed dose was 74.8 Gy in 34 fractions. Five static ports (angles A: 36, 108, 180, 232 and 304 degrees) were used for the TomoDirect plan according to our protocol [19]. In addition, another TomoDirect plan using different angles (angles B: 0, 75, 135, 225 and 285 degrees) was generated for each patient to evaluate influences of port angles.…”

Application of an interstitial and biodegradable balloon system for prostate-rectum separation during prostate cancer radiotherapy: a prospective multi-center study

“…Despite the implementation of new radiotherapy technologies, such as intensity modulated radiation therapy and image guided radiation therapy, rectal toxicity has remained high, thus limiting dose escalation [4-8]. Increased separation between the rectum and prostate gland is expected to reduce the rectal dose and improve both radiotherapy safety and efficacy [9].…”