MANAGEMENT OF RADIATION PROCTITIS

Radiotherapy is frequently used in the treatment of cancer inc ombination with other treatments.

In men the two most prevalent cancers requiring radiotherapy are cancer of the bladder and cancer of the prostate.

“As after radical surgery where complications may occur, radiotherapy is not without problems,” reports Dr Chapuis.

Rectal bleeding is a known treatment complication of prostate cancer. Three different terms are used to describe this condition. They are:

•Actinic proctitis

•Radiation proctitis

•Chronic radiation-induced rectal bleeding (CRRB).


Rectal bleeding may complicate treatment in 5 to 10 percent of patients. Rectal bleeding is caused by radiation thickening of the walls of small arteries supplying the rectum, and so by narrowing them to restrict the blood flow to the rectal wall.

To compensate for this, new thread-like capillaries grow in profusion very close to the internal surface of the rectum. It is the fragility of these capillaries that causes the bleeding. As this does not involve true inflammation, “proctitis” is an inappropriate term.

Professor Chapuis prefers the third description: chronic radiation-induced rectal bleeding(CRRB). The rectal bleeding may not start until some 12 months to three years after treatment. Because bleeding is a known side effectof radiation therapy for prostate cancer, and rarely may be life-threatening, patients should be informed of this risk and consent to such treatment.

Rectal symptoms can fall into two broad categories which are partly dose-related: acute and chronic.


Acute:

Symptoms include tenesmus (pain on passing stools), diarrhoea, urgency of defaecation and bleeding.

Chronic:

Symptoms include stricture (narrowing or restriction), fistula (abnormal passage), CRRB, varying degrees of incontinence, loss of compliance and storage capacity of the rectum.


Clinical features of CRRB include:

• It is classed as Grade III on a scale of seriousness from I to IV, ie quite serious. Around 50 percent of cases are late onset (ie, starting later than one year after treatment).

• From a situation with the patient not experiencing any problems, it may become chronic with progressively increasing bleeding resulting in iron deficiency anaemia which may require daily dosage of iron tablets.

• Fifteen to 20 years ago it quite often led to transfusion-dependent anaemia, necessitating frequent blood transfusions, but this is now very unusual as a result of much improved radiotherapy techniques. It is important for prostate cancer patients to recognise that some degree of “collateral” damage will inevitably occur to the rectum due to the radiation treatment.

Late development of bleeding will be experienced by a small proportion of these patients, but this is nowhere near as common or severe a problem as in the past. A critical decision is whether the benefit of the radiation treatment of the cancer outweighs the risks of rectal bleeding or other complications as a result of that treatment.


The factors which affect the risk include:

• The total dose of the radiation

• The fractionation of the dose ie, how it is delivered

• The build of patient, as obese people are more susceptible

• Diabetes

• Hypertension

• Previous abdominal or pelvic surgery (adhesions)

• Chronic diverticular disease of the proximal bowel

• Bleeding may be exacerbated if taking drugs such as Asprin,Warfarin or Plavix Possibly because of their genetic make-up, some men are inherently more sensitive to radiation.


Quality of life issues that may influence the decision whether to opt for/out of radiotherapy include:

• The alarm caused by unexpected bleeds

• The late onset (leading to several years of anxiety about whether bleeding will occur)

• The absence of identifiable risk factors in many cases pre-venting prediction of whether any particular patient will be affected

• Whether the patient has other conditions, such as diabetesor hypertension.


Additional issues include:

• The unpredictable nature of the bleeding which is socially inconvenient and can be acutely embarrassing

• The resulting anaemia is debilitating

• Poor response to treatment

• Simple treatments often pre-scribed (like steroid supposito-ries or enemas) are usually of little benefit

• The condition can last a longtime

• There is a (small) possibility of it progressing to Transfusion Dependent Anaemia.


Patients with CRRB should be thoroughly assessed, including their history and a physical examination, a blood test including a full blood count, iron studies and coagulation profile. Then a safe and thorough examination by colonoscopy of the large bowel enables the severity of the condition to be determined and identification of other sources of bleeding.

A cystoscopy and/or special small bowel X-ray are sometimes appropriate. Sometimes anorectal manometry is needed to test the strength of the sphincter muscle prior to treatment.

The patient may be asked to keep a record of bleeds by marking a calendar as treatment progresses. There are several options for treatment, which will be influenced by the location of the source of bleeding and the extent of the condition.


Minimally invasive therapy includes:

• Electrocautery

• Argon Plasma Coagulation Therapy (APC)

• Endoscopic laser

• Formalin (formaldehyde) dressings applied under a general anaesthetic

• Hyperbaric oxygenation with multiple treatment episodes required.


In the case of APC or endoscopic laser, each potential bleeding pointneeds to be separately treated. The procedure may require several visits, spaced a few weeks apart, to allow the lining of the rectum to recover. The procedure may be undertaken under conscious sedation or general anaesthesia.

The use of formalin began in the1960s. It was found that the formalin destroyed the superficial lining (which then separated off) thus causing the bleeding to stop and allowing the new lining to regrow without blood vessels.

However, the appropriate concentration for the formalin was uncertain, and the approach was abandoned until more recently, when a particular low concentration has been found to be both effective and safe.

A blood count is taken before and after treatment. The patient undergoes a general anaesthetic and is prepared by applying plastic skin dressings applied to the skin surrounding the anal passage. A speculum is inserted and dressings containing formalin are packed into the rectum through it and left for five to ten minutes before being removed. This is repeated until bleeding ceases.


Up to 20% of patients treated with the formalin method experience complications, like:

• Mucus incontinence either from treatment or from the initial radiotherapy

• Some patients may need to wear a pad

• Acute prostatitis (very rare)

• Narrowing of the rectum (veryrare)

• Ischaemic ulcer.

This is pre-vented by taking care to cover exterior of anus with a plastic skin during treatment. Use of either the laser or the formalin method, or both together, results in 75 – 80% success.

However, treatment and follow up may be necessary for up to 12 months. For otherwise intractable cases, several surgical options exist.

Our sincere thanks to Dr Chapuis for his carefully structured presentation and clear explanations, and for fielding wide ranging questions. Summarised by Mark Tweed-dale and Pam Sandoe. Edited and approved by Dr Chapuis; 'The Management of Radiation Proctitis'.

Radiation Proctitis

Radiation Proctitis

The following video depicts one method of treatment used for Radiation Proctitis. Though somewhat graphic, these images show the presence of lesions and how APC (Argon Plasma Coagulation) is used to treat them.

Video courtesy of the Dave Project

Conservative therapies for hemorrhagic radiation proctitis: a review

ABSTRACT

Chronic radiation proctitis represents a challenging condition seen with increased frequency due to the common use of radiation for treatment of pelvic cancer. Hemorrhagic radiation proctitis represents the most feared complication of chronic radiation proctitis. There is no consensus for the management of this condition despite the great number of clinical approaches and techniques that have been employed. Rectal resection represents an available option although associated with high morbidity and risk of permanent colostomy. The effectiveness of nonoperative approaches remains far from desirable, and hemorrhagic recurrence represents a major drawback that leads to a need for consecutive therapeutic sessions and combination of techniques. We conducted a critical review of published reports regarding conservative management of hemorrhagic chronic radiation proctitis. Although prospective randomized trials about hemorrhagic radiation proctitis are still lacking, there is enough evidence to conclude that topical formalin therapy and an endoscopic approach delivering an argon plasma coagulation represent available options associated with elevated effectiveness for interruption of rectal bleeding in patients with chronic radiation proctitis.

GENERAL CONSIDERATIONS

Radiation proctitis can be classified as acute or chronic. Acute radiation proctitis (ARP) can begin during or shortly after irradiation but usually resolves in up to 6 months. It is characterized by diarrhea, intermittent bleeding, nausea, abdominal pain, mucous discharge, and constipation or even urinary symptoms. Histological alterations are usually confined to the mucosa5, and in general, has a short duration and improves with conservative measures. However, about 20% of the patients with RP require interruption of the treatment for 1 to 2 weeks in order to improve clinical status. Following this acute episode most of the patients remain asymptomatic, but up to 20% of this contingent will develop chronic radiation proctitis (CRP)6. The development of CRP may take up to 2 years and has no relationship with the occurrence of ARP7.

During the course of radiotherapy, virtually all patients present symptoms related to ARP. However, such symptoms usually subside from 2 to 3 months after the end of RDT8. Nevertheless, 2% to 10% of the patients develop CRP, usually 6 to 24 months after RDT, but clinical symptoms may appear up to 30 years after treatment9,10.

Chronic radiation proctitis has several forms of clinical presentation, including mucous rectal discharge, diarrhea, urgency, pain, and bleeding. Recto-vaginal fistula, enteric fistula, cutaneous fistula, perforation, and rectal stenosis can rarely occur. Histological alterations are mainly of a vascular nature, such as subintimal fibrosis and platelet thrombi in the arterioles of the submucosa with fibrosis of connective tissue5.

The development of RP is directly related to the dose of radiation, the irradiated volume, type of radiation exposure, dose fraction regimens, and the interval between sessions. Smith et al. reported a 20% incidence of RP with a radiation dose up to 7.500 Cgy and a 60% incidence of RP with doses greater than 7.500 Cgy11.

Other factors predispose to RP, including previous abdomino-pelvic surgery, obesity, diabetes mellitus, hypertension, atherosclerosis, and simultaneous chemotherapy. In 1997, Bertuccelli et al. studied the effect of the combination of chemotherapy with RDT in the treatment of rectal cancer and observed an increase in incidence of severe diarrhea in the group that received RDT plus chemotherapy when compared to the group that underwent RDT alone (20% versus 10%)12.

Endoscopic findings of RP are also variable. Since 1923, when the first endoscopic findings were reported, there have been many attempts to establish a standardized endoscopic approach to its diagnosis13. Paleness, erythema, vascular abnormalities, and ulcerations are easily recognized alterations. However, in order to correlate the clinical picture to endoscopic findings, Wachter et al. proposed a score for RP based on terminology of the World Organization of Digestive Endoscopy (OMED) and its 5 main alterations, namely telangiectasias, congestion, ulcerations, stenosis, and necrosis14.

The prognosis of RP remains obscure. Gilinsky et al., in 1983, reported on 88 patients with RP followed for more than 8 years. Fifty percent presented slight to moderate symptoms with distinct endoscopic findings that resolved spontaneously in 2 years10. Nevertheless, 17 patients presented refractory symptoms. Cho et al. observed that 19 out of 101 patients developed RP after radiation therapy for prostate cancer15.

Despite the fact that the incidence of RP tends to increase with time, RP still lacks research and attention. It should be noted that no consensus exists about its clinical and endoscopic evaluation and its natural history. Its behavior and prognosis are not completely known.

Rectal bleeding due to RP usually represents a chronic condition, and anemia is a common finding; sometimes bleeding may be severe. Several treatments for this presentation have been used, and as a result of its high recurrence rate, they were rarely utilized in a cyclic manner, which makes their evaluation difficult. We opted to review and analyze the results of conservative treatments of hemorrhagic CRP.

Steroids

In 1976, Goldstein et al. observed clinical improvement of a patient with radiation-induced proctitis who received salicylazosulfapyridine in combination with prednisone16. Subsequently, other studies were developed in an attempt to evaluate the use of steroids as a therapeutic alternative for RP, alone and also in combination with other modalities.

In 1984, Ben Bouali et al. demonstrated clinical and endoscopic improvement in 4 out of 33 patients treated with daily rectal administration of 5 mg of betamethasone in combination with diphenoxylate17. In 1977, Pajares et al. also observed a decrease of rectal bleeding after administration of prednisone18. More recently, Triantafillidis et al. reported 5 patients treated for RP with enemas containing 5 mg of betamethasone without any clinical improvement19.

In a prospective randomized study, Kochhar et al. compared the use of enemas containing prednisolone and 3 g of oral sulfasalazine in 18 patients to the use of enemas containing sucralfate in combination with an oral placebo in 19 patients for 4 weeks20. Clinical improvement was appraised by a score based on the number of bowel movements, bleeding, and tenesmus. Therapy with sucralfate was more efficient, better tolerated, and cheaper.

Another prospective randomized study in mice analyzed administration of 90 mg of hydrocortisone and showed endoscopic improvement and better tolerance when compared with betamethasone enemas21.

Steroids have been used for many years in the treatment of RP despite the absence of larger and well-designed studies22. Moreover, steroids were not able to achieve sustained resolution of symptoms for patients with CRP.

Aminosalicylates

Derivatives of 5-aminosalicylic acids (5ASA), also known as aminosalicylates, have been the object of research in treatment of RP since the studies of Menie et al. in 1975 showed efficiency of the 5-aminosalicylic acid drugs versus placebo in the prevention of diarrhea in patients undergoing pelvic RDT, as well as studies for their previous use in the management of inflammatory proctitis. Aminosalicylates act in reducing the production of prostaglandins in the intestinal mucosa20.

Goldstein et al. demonstrated the effectiveness of oral sulfasalazine in combination with steroid enemas in 1 patient16. Bem Bouali et al. demonstrated that administration of sulfasalazine, in oral or enema form, provided clinical and endoscopic improvement in 60% of patients17. In 1989, Ladas et al. demonstrated that administration of sulfasalazine in combination with sucralfate enemas was effective in controlling rectal bleeding and promoted endoscopic improvement in 1 patient with CRP.23

On the other hand, in 1989, Baum et al. showed that daily administration of enemas containing 5ASA for a period of 2 to 6 months was not able to induce clinical, endoscopic, or histological improvement in 4 patients with CRP24. Another study of 5 patients performed by Triantafillidis et al. demonstrated no improvement over 5ASA enemas.19

We believe that multicenter prospective randomized studies of aminosalicylates are needed to confirm their role in the management of RP, but available evidence suggests that they are not effective.

Sucralfate

Sucralfate is an aluminum salt that adheres to the mucous membrane, promoting the formation of a protective barrier that has been used for many years in the treatment of peptic ulcers. Its possible effectiveness for inflammatory proctitis and for colonic bleeding after endoscopic polypectomy is also under investigation.

The cytoprotective action of sucralfate seems to be derived from the production of prostaglandins and promotion of epithelial cell proliferation. In animal models of colitis in mice, rectal administration of sucralfate induced high E2-prostaglandin levels and increased cellularity of the colonic mucosa25.

The best route for sucralfate administration remains controversial. In 1988, Kochhar et al. used enemas containing 2 g of sucralfate in 4 patients with hemorrhagic RP and demonstrated reduced bleeding26. A previous study by Henriksson et al. in 1987 showed the usefulness of oral sucralfate administered for 2 to 6 weeks after RDT in the reduction of bowel movements, mucous discharge, and rectal bleeding after 1 year27. Another study by Kochhar in 1991 demonstrated the superiority of topical sucralfate over steroid enemas administered in combination with sulfasalazine20.

In 1996, Stockdale and Biswas reported that administration of enemas containing 2 g of sucralfate in a patient with hemorrhagic RP resulted in long-term control of CRP as revealed from 4 years of follow-up28. Again in 1996, Tada et al. demonstrated endoscopic improvement of CRP in 6 out of 7 patients treated with 2 g sucralfate enemas.29

In 1997, O'Brien et al. published the negative effect of a sucralfate suspension for prevention of ARP30. In this multicenter Australian study, 86 patients were randomized into 2 groups: 1 group received 3 g sucralfate enemas and the other group received a placebo. Enemas were administered once daily for a period of 2 weeks after RDT. Sucralfate enemas did not reduce symptoms associated with ARP and therefore should not be recommended in clinical practice.

In 1998, Sasai et al. published 3 cases of patients with hemorrhagic RP who had undergone previous sulfasalazine and steroid treatment without success. They experienced significant improvement of rectal bleeding after daily administration of 4 g of sucralfate during 1 to 2 months31. The authors emphasized the advantages of oral sucralfate, which include good tolerance and few side effects associated with control of the symptoms for a long period.

More recently in 1999, Kochhar et al. demonstrated that topical sucralfate produced sustained resolution of symptoms, in agreement with previous authors32. Stockdale and Biswas 28studied 26 patients with hemorrhagic RP that were treated with 2 g sucralfate enemas twice daily. The patients were examined every 4 weeks in the first 16 weeks of treatment and after that at an interval of 8 to 12 weeks. Twenty patients had a significant reduction of bleeding in the first 4 weeks of treatment, as did another 4 patients after 16 weeks. At a mean of 45 weeks, 7 patients had some kind of symptomatic recurrence. However, bleeding ceased soon after the sucralfate treatment was reintroduced.

Short-Chain Fatty Acids (SCFA)

During the past few years, many studies have been performed on short-chain fatty acids (SCFA) so that knowledge regarding these substances has increased. Short-chain fatty acids are organic acids containing from 1 to 6 carbons that are a product of bacterial metabolism of some carbohydrates in the colon; they are the main source of energy for colonocytes. Butyrate is the most important SCFA and is preferentially metabolized by colonic mucosa when compared to propionate and acetate. The dependence of the colon related to the oxidation of SCFA increases towards the rectum, and 70% of the oxygen consumed by the colonic epithelial cells is used in the oxidation of SCFA33.

The effect of SCFA on rectal and colonic mucosa has been tested in patients with RP in an attempt to obtain healing of mucous lesions33,34. In 1999, Pinto et al. in a double-blind randomized placebo-controlled trial studied 19 patients with CRP35. They demonstrated a beneficial effect from administration of 2 daily enemas with 60 mmol SCFA for 5 weeks in comparison with the administration of an isotonic solution. There was a significant decrease of rectal bleeding with SCFA as well as an endoscopic improvement. In 1995, Mamel et al. also demonstrated the efficacy of enemas containing 60 mL of SCFA twice daily for 4 weeks in the improvement of 6 patients with CRP36. In 1996, Al Sababagh et al. using the same solution described in the previous studies achieved clinical, endoscopic, and histological improvement in 7 patients with hemorrhagic RP37.

These results were not reproduced by Chen et al. in a prospective study, where they evaluated the evolution of 12 patients with hemorrhagic CRP for 2 weeks and did not find any significant difference in clinical, endoscopic, and histological aspects of patients treated with SCFA38.

More recently, Talley et al. compared daily administration of 2 enemas with 60 mL of butyrate in a concentration of 40 mmol to placebo for 2 weeks in a randomized double-blind study of 15 patients with CRP. They found no benefit from SCFA39.

In 1998, Cook and Sellin performed a literature review about SCFA in the management of colitis33. Regarding RP, the authors observed that studies showed early reduction of bleeding episodes, but SCFA had no influence in other symptoms such as chronic pain and tenesmus.

In spite of the great progress in the knowledge of the structure, metabolism, and action of SCFA, there is still need for additional data to confirm its effectiveness. Because of these conflicting data, there are no commercial preparations available for clinical use.

Formalin

The use of formalin in the management of RP emerged from its use in the treatment of bleeding tumors of the bladder and radiation cystitis40,41, 2.

In 1986, Rubinstein et al. successfully used a rectal wash with formalin for the first time in the treatment of RP42. The authors reported a 71-year-old patient irradiated for bladder cancer who developed diffuse hemorrhagic RP. The patient underwent general anesthesia and the rectum was irrigated with two liters of 3.6% formalin for 15 minutes, followed by irrigation with saline. An insufflated vesical probe was used in order to protect the sigmoid colon. The procedure was repeated after 2 weeks and after 3 months. Bleeding episodes immediately ceased and the patient was asymptomatic after 14 months.

After these results, many authors initiated treatments of hemorrhagic CRP with formalin. In 1993, Seow-Choen et al. used formalin in 8 patients with hemorrhagic CRP refractory to steroids and with a constant need for blood transfusions43. In this study, a 4% solution-soaked gauze was applied to the rectum through a rectoscope. Patients underwent regional anesthesia and had their perianal skin protected to avoid direct contact with the formalin. Contact between the gauze and rectal mucosa was maintained until the bleeding stopped (from 2 to 3 minutes). Bleeding ceased in 7 patients after a single session, while another patient needed an additional application.

In 1995, the same authors confirmed the effectiveness of direct application of formalin solution soaked gauze in 29 patients followed for 12 months44. In this study, rectal bleeding ceased right after application in 17 patients. Four patients needed a second application (72% success rate). The 5 remaining patients obtained only partial improvement.

The instillation technique proposed by Rubinstein et al. was modified by 2 groups. One of them used rectal instillation with 4% formalin after placement of a Foley catheter in order to delineate the superior limit of the instillation and protect the normal intestine in 14 patients resistant to steroid and/or sulfasalazine treatment45. Treatment was well tolerated, and 11 patients needed 2 applications while other 3 patients needed 3 sessions. After 6 months, 9 patients were asymptomatic (64%), 3 patients had incomplete resolution of symptoms, and 2 had no improvement. Saclarides et al. reported a study in which aliquots of 50 mL of 4% formalin were instilled into the rectum for 30 seconds each, with a total of 400 to 500 mL per session in 16 patients. They achieved complete symptom control in 81% of after 1 or 2 applications46. Four patients developed fissures in the anal verge and 1 developed tenesmus.

The technique of soaked gauze proposed by Seow-Choen was revised by 5 groups, with a total of 41 patients. Complete success rate ranged from 80% to 100% after 1 to 4 sessions (Table 1)43,47-51.

Recently, in an Australian study, a combination of formalin and Nd:YAG (neodymium yttrium-aluminum-garnet) laser was used in 14 patients52. First, the patients underwent an endoscopic Nd:YAG laser procedure and then were treated with a formalin application as described by Seow-Choen. A single session was enough for 9 patients, 2 sessions were necessary for3 patients, and 3 sessions forthe other 2 patients. After a 3-year follow-up, 10 (71%) patients had no rectal bleeding, and another one had a significant decrease in bleeding episodes. Two patients required an operation to manage their symptoms.

After these first published series with formalin as a therapeutic alternative for hemorrhagic RP, investigators have been trying to determine the best concentration and form of its application as well as its side effects. In low concentrations, formalin is not toxic. However, high concentrations can result in severe toxic effects. Additionally, the nutritional state and smoking can alter blood levels of formalin. The only reported case of intoxication after rectal irrigation occurred due to accidental infusion of 100 mL of 10% formalin. The patient developed chronic colitis that resolved after 2 months53.

Evidence suggests that formalin is very effective in the treatment of hemorrhagic CRP, mainly in cases in which the 2 distal thirds of the rectum are affected. Other advantages of formalin application are low cost, low incidence of side effects, availability, and its easy manipulation.

Endoscopic

Endoscopic management of CRP is based on endoscopic coagulation induced by Nd:YAG laser, electrocoagulation, or argon plasma coagulation (APC).

The first description of Nd:YAG laser use in CRP was published by Leuchter in 1982. The author reported the success of this technique for the control of rectal hemorrhage after 4 applications in 1 patient in which he used 30 shots driven to the endoscopically identified vascular alterations54.

The effectiveness of the Nd:YAG laser was confirmed by other authors in series with a total of 98 patients. One of the most important was published by Viggiono et al. in 1993 reporting on 47 patients. After an average of 2 sessions (7950 joules each), a 79% control rate of rectal bleeding was achieved55.

In 1998, Swaroop et al. described the technique for therapy with a Nd:YAG laser56. Initially, the patient should undergo a complete colonoscopy to determine the extent of the lesion. With an initial energy of 40 W and a maximum pulse duration of half a second, the laser is applied without direct contact to the mucosa, but with its tip less than 1 cm away from it. All visible lesions should be coagulated in the distal direction. A white clot should be obtained as a final effect, avoiding cavities in the intestinal mucosa. Complications of Nd:YAG laser therapy include tenesmus, abdominal pain, rectal stenosis, prostatitis, and recto-vaginal fistula55,57.

Laser therapy for hemorrhagic CRP was supplanted by argon plasma coagulation (APC) because it is more readily available, cheaper, and requires fewer safety precautions, while still yielding excellent results. Argon plasma coagulation is a diathermy method in which there is no direct contact between the electrode and the patient, and high frequency energy is applied to the tissue through the ionized argon. This technique is very suitable for coagulation of large bleeding surfaces and features the advantage of limited penetration (2 to 3 millimeters), minimizing the risks of perforation, stenosis, and fistulization. The char generated with APC promotes an interruption of the current passing through the tissue while Nd:laser continues to penetrate the tissue until it is switched off.

Since the first use of APC with a flexible endoscope described by Grund et al.58 in 1994, it has gained a wide popularity. Silva et al. in a study of 28 patients obtained good results59 and emphasized the possibility of application of the argon plasma in any direction, resulting in excellent access to vascular lesions. Gas flow eliminates oxygen from the coagulation area, avoiding carbonization of the tissue and smoke production. Moreover, light produced by gas ionization promotes good visual control of the procedure. Those authors also propose the use of 50 W of energy and a 1.5 L/min flow for the procedure. Fantin et al. demonstrated the effectiveness of APC in 7 patients after 2 to 4 applications, using as parameters an energy of 60 W and a flow of 3 L/min60.

Other authors have also obtained good results with APC. Taylor et al. used APC in 14 patients with hemorrhagic CRP61. Bleeding episodes ceased in 10 patients (71%), although they needed complementary applications. The summarized series are reported in table 261-63.

Argon plasma coagulation has proven beneficial in almost all available studies. Use of argon plasma technology for other applications especially in surgery increases the usefulness of the equipment.

Endoscopic treatment through electrocoagulation is simple, widely available, and cheap. Bipolar electrocoagulation may be safer than monopolar. Electrocoagulation and heater probes are readily available at most hospitals without significant additional cost. Because of its ready availability, it is one of our first options for hemorrhagic CRP. Distal telangiectasias can be treated conveniently by this method. All visible lesions should be treated in a single session. The most important technical aspect of telangiectasiasablation is to use the smallest possible amount of energy for coagulation, avoiding formation of deep ulcers. After the initial session of coagulation, an interval should be intervene before reexamination, since coagulated areas need time for healing.

Hyperbaric Oxygen Therapy

Hyperbaric oxygen (HBO) has been used in the treatment of the RP after previous experiences with other radiation-induced lesions (cystitis and dermatitis) with satisfactory results.

Its mechanism of action is based on the decrease of tissue hypoxia with consequent acceleration of healing process, restoration of local anti-infectious defenses, and directly toxic effects to bacteria.

Four publications reported excellent results with the use of HBO in 8 patients with hemorrhagic RP64-67. However, 2 recent studies demonstrated more modest results. The first of these obtained a 56% rate of good results for 18 patients68. The other was able to achieve 64% good results in 14 patients69. These studies were retrospective with controversial results. There may be recurrences, and it may take a long period of treatment for symptoms to resolve. In addition to the lack of scientific support, HBO is an expensive technique that is still restricted to specialized centers.

CONCLUSIONS

Many alternative techniques and research with other possible therapeutic agents for the treatment of hemorrhagic CRP, the most frequent chronic complication of radiation injury to the rectum, are currently under investigation71-73.The effectiveness of many therapeutic options has still not been shown with solid scientific evidence from controlled trials, and basic research may open a new perspective. Nowadays, the best alternatives for management of hemorrhagic CRP seem to be topical formalin and APC.

Despite all therapeutic strategies available for the management of CRP, the best one remains its prevention. Use of more advanced radiation techniques in the past few decades and introduction of less toxic regimens are good examples that may contribute to a decrease in incidence of CRP. However, the prevalence of CRP may increase as result of widespread use of radiotherapy for cancer treatment.

REFERENCES

1. BEARD CJ, PROPERT KJ, RIEKER PP et al. - Complications after treatment with external-beam irradiation in early-stage prostate cancer patients: a prospective multiinstitutional outcomes study. J Clin Oncol 1997; 15:223-229. [ Links ]

2. CROOK J, ESCHE B, FUTTER N et al. - Effect of pelvic radiotherapy for prostate cancer on bowel, bladder, and sexual function: the patient's perspective. Urology 1996; 47:387-394. [ Links ]

3. MONTANA GS, FOWLER WC - Carcinoma of the cervix: analysis of bladder and rectal radiation dose and complications. Int J Radiat Oncol Biol Phys 1989; 16:95-100. [ Links ]

4. CUNNINGHAM IG - The management of radiation proctitis. Aust N Z J Surg 1980; 50:172-178. [ Links ]

5. HABOUBI NY, SCHOFIELD PF, ROWLAND PL - The light and electron microscopic features of early and late phase radiation-induced proctitis. Am J Gastroenterol 1988; 83:1140-1144. [ Links ]

6. ROTHENBERGER B, LISEHORA GB – Radiation proctitis. Semin Colon Rectal Surg 1993; 4:240-248. [ Links ]

7. AJLOUNI M - Radiation-induced proctitis. Curr Treat Options Gastroenterol 1999; 2:20-26. [ Links ]

8. COIA LR, MYERSON RJ, TEPPER JE - Late effects of radiation therapy on the gastrointestinal tract. Int J Radiat Oncol Biol Phys 1995; 31:1213-1236. [ Links ]

9. DECOSSE JJ, RHODES RS, WENT WB et al. – The natural history and management of radiation induced injury of the gastrointestinal tract. Ann Surg 1969; 170:369-384. [ Links ]

10. GILINSKY NH, BURNS DG, BARBEZAT GO et al. - The natural history of radiation-induced proctosigmoiditis: an analysis of 88 patients. Q J Med 1983; 52:40-53. [ Links ]

11. SMIT WG, HELLE PA, VAN PUTTEN WL et al. - Late radiation damage in prostate cancer patients treated by high dose external radiotherapy in relation to rectal dose. Int J Radiat Oncol Biol Phys 1990; 18:23-29. [ Links ]

12. BERTUCCELLI M, CARTEI F, FALCONE A et al. - Postoperative adjuvant chemoradiotherapy for rectal cancer: analysis of acute and chronic toxicity. Tumori 1997; 83:599-603. [ Links ]

13. VITAUX J – Rectite radique, un diagnostic endoscopique facile, un traitement parfois difficile. Presse Med 1998; 27:1255. [ Links ]

14. WACHTER S, GERSTNER N, GOLDNER G et al. - Endoscopic scoring of late rectal mucosal damage after conformal radiotherapy for prostatic carcinoma. Radiother Oncol 2000; 54:11-19. [ Links ]

15. CHO KH, LEE CK, LEVITT SH - Proctitis after conventional external radiation therapy for prostate cancer: importance of minimizing posterior rectal dose. Radiology 1995; 195:699-703. [ Links ]

16. GOLDSTEIN F, KHOURY J, THORNTON JJ et al. - Treatment of chronic radiation enteritis and colitis with salicylazosulfapyridine and systemic corticosteroids. A pilot study. Am J Gastroenterol 1976; 65:201-208. [ Links ]

17. BEM BOUALI A, VARLAN E – Intérêt de lássociation salazopiryne comprimé-lavement dans les colites radiques. Med Chir Dig 1984; 13:559-565. [ Links ]

18. PAJARES GARCIA JM, MORENTO-OTERO R, ROLDAN NUNEZ J et al. - Actinic protocolitis. Clinical, endoscopical, histopathological and therapeutical aspects. A study of 20 patients. Rev Clin Esp 1977; 147:481-484. [ Links ]

19. TRIANTAFILLIDIS JK, DADIOTI P, NICOLAKIS D et al. - High doses of 5-aminosalicylic acid enemas in chronic radiation proctitis: comparison with betamethasone enemas. Am J Gastroenterol 1990; 85:1537-1538. [ Links ]

20. KOCHHAR R, PATEL F, DHAR A et al. - Radiation-induced proctosigmoiditis. Prospective, randomized, double-blind controlled trial of oral sulfasalazine plus rectal steroids versus rectal sucralfate. Dig Dis Sci 1991; 36:103-107. [ Links ]

21. ROUGIER PH, ZIMMERMANN P, PIGNON JP et al. – Rectites radiques: efficacité comparée de deux types de corticoids administers localement. Med Chir Dig 1992; 21:91-93. [ Links ]

22. GUL YA, PRASANNAN S, JABAR FM et al. - Pharmacotherapy for chronic hemorrhagic radiation proctitis. World J Surg 2002; 26:1499-1502. [ Links ]

23. LADAS SD, RAPTIS AS - Sucralfate enemas in the treatment of chronic postradiation proctitis. Am J Gastroenterol 1989; 84:1587-1589. [ Links ]

24. BAUM CA, BIDDLE WL, MINER PB JR et al. - Failure of 5-aminosalicylic acid enemas to improve chronic radiation proctitis. Dig Dis Sci 1989; 34:758-760. [ Links ]

25. ZAHAVI I, AVIDOR I, MARCUS H et al. - Effect of sucralfate on experimental colitis in the rat. Dis Colon Rectum 1989; 32:95-98. [ Links ]

26. KOCHHAR R, SHARMA SC, GUPTA BB et al. - Rectal sucralfate in radiation proctitis. Lancet 1988; 2:400. [ Links ]

27. HENRIKSSON R, FRANZEN L, LITTBRAND B - Effects of sucralfate on acute and late bowel discomfort following radiotherapy of pelvic cancer. J Clin Oncol 1992; 10:969-975. [ Links ]

28. STOCKDALE AD, BISWAS A - Long-term control of radiation proctitis following treatment with sucralfate enemas. Br J Surg 1997; 84:379. [ Links ]

29. TADA M – Treatment of radiation proctitis with sucralfate suspension enema. Gut 1996; 39:A31. [ Links ]

30. O'BRIEN PC, FRANKLIN CI, DEAR KB et al. - A phase III double-blind randomised study of rectal sucralfate suspension in the prevention of acute radiation proctitis. Radiother Oncol 1997; 45:117-123. [ Links ]

31. SASAI T, HIRAISHI H, SUZUKI Y et al. - Treatment of chronic post-radiation proctitis with oral administration of sucralfate. Am J Gastroenterol 1998; 93:1593-1595. [ Links ]

32. KOCHHAR R, SRIRAM PV, SHARMA SC et al. - Natural history of late radiation proctosigmoiditis treated with topical sucralfate suspension. Dig Dis Sci 1999; 44:973-978. [ Links ]

33. COOK SI, SELLIN JH - Review article: short chain fatty acids in health and disease. Aliment Pharmacol Ther 1998; 12:499-507. [ Links ]

34. SCHEPPACH W, CHRISTL SU, BARTRAM HP et al. - Effects of short-chain fatty acids on the inflamed colonic mucosa. Scand J Gastroenterol Suppl 1997; 222:53-57. [ Links ]

35. PINTO A, FIDALGO P, CRAVO M et al. - Short chain fatty acids are effective in short-term treatment of chronic radiation proctitis: randomized, double-blind, controlled trial. Dis Colon Rectum 1999; 42:788-795. [ Links ]

36. MAMEL JJ, CHEN M, COMBS W et al. – Short-chain fatty acids (SCFA) enemas are useful for the treatment of chronic radiation proctitis (Abstract). Gastroenterology 1995; 108:A305. [ Links ]

37. AL-SABBAGH R, SINICROPE FA, SELLIN JH et al. - Evaluation of short-chain fatty acid enemas: treatment of radiation proctitis. Am J Gastroenterol 1996; 91:1814-1816. [ Links ]

38. CHEN FC, KING DW, TALLEY N – Short-chain fatty acid enemas for chronic radiation proctitis: a pilot study (abstrct). Dis Colon Rectum 1996; 39:A34. [ Links ]

39. TALLEY NA, CHEN F, KING D et al. - Short-chain fatty acids in the treatment of radiation proctitis: a randomized, double-blind, placebo-controlled, cross-over pilot trial. Dis Colon Rectum 1997; 40:1046-1050. [ Links ]

40. DONAHUE LA, FRANK IN - Intravesical formalin for hemorrhagic cystitis: analysis of therapy. J Urol 1989; 141:809-812. [ Links ]

41. BROWN RB - A method of management of inoperable carcinoma of the bladder. Med J Aust 1969; 1:23-24. [ Links ]

42. RUBINSTEIN E, IBSEN T, RASMUSSEN RB et al. - Formalin treatment of radiation-induced hemorrhagic proctitis. Am J Gastroenterol 1986; 81:44-45. [ Links ]

43. SEOW-CHOEN F, GOH HS, EU KW et al. - A simple and effective treatment for hemorrhagic radiation proctitis using formalin. Dis Colon Rectum 1993; 36:135-138. [ Links ]

44. MATHAI V, SEOW-CHOEN F - Endoluminal formalin therapy for haemorrhagic radiation proctitis. Br J Surg 1995; 82:190. [ Links ]

45. MIDOES CORREA J, PINTO A, DIAS PEREIRA A et al. – Successful treatment of hemorrhagic radiation proctitis with formalin irrigation. Gastroenterology 1994; 106:A254. [ Links ]

46. SACLARIDES TJ, KING DG, FRANKLIN JL et al. - Formalin instillation for refractory radiation-induced hemorrhagic proctitis. Report of 16 patients. Dis Colon Rectum 1996; 39:196-199. [ Links ]

47. BISWAL BM, LAL P, RATH GK et al. - Intrarectal formalin application, an effective treatment for grade III haemorrhagic radiation proctitis. Radiother Oncol 1995; 35:212-215. [ Links ]

48. ISENBERG GA, GOLDSTEIN SD, RESNIK AM - Formalin therapy for radiation proctitis. JAMA 1994; 272:1822. [ Links ]

49. SALVATI EP – Invited commentary. World J Surg 1996; 20:1094-1095. [ Links ]

50. ROCHE B, CHAUTEMS R, MARTI MC - Application of formaldehyde for treatment of hemorrhagic radiation-induced proctitis. World J Surg 1996; 20:1092-1094. [ Links ]

51. FARAGHER I, BAILEY H – Topical Formalin: a simple and effective office treatment of hemorrhagic radiation proctitis. Dis Colon Rectum 1997; 40:A28. [ Links ]

52. CHAPUIS P, DENT O, BOKEY E et al. - The development of a treatment protocol for patients with chronic radiation-induced rectal bleeding. Aust N Z J Surg 1996; 66:680-685. [ Links ]

53. MYERS JA, MALL J, DOOLAS A et al. - Absorption kinetics of rectal formalin instillation. World J Surg 1997; 21:886-889. [ Links ]

54. LEUCHTER RS, PETRILLI ES, DWYER RM et al. - Nd: YAG laser therapy of rectosigmoid bleeding due to radiation injury. Obstet Gynecol 1982; 59(6 Suppl):65S-67S. [ Links ]

55. VIGGIANO TR, ZIGHELBOIM J, AHLQUIST DA et al. - Endoscopic Nd:YAG laser coagulation of bleeding from radiation proctopathy. Gastrointest Endosc 1993; 39:513-517. [ Links ]

56. SWAROOP VS, GOSTOUT CJ - Endoscopic treatment of chronic radiation proctopathy. J Clin Gastroenterol 1998; 27:36-40. [ Links ]

57. ALEXANDER TJ, DWYER RM - Endoscopic Nd:YAG laser treatment of severe radiation injury of the lower gastrointestinal tract: long-term follow-up. Gastrointest Endosc 1988; 34:407-411. [ Links ]

58. GRUND KE, STOREK D, FARIN G - Endoscopic argon plasma coagulation (APC) first clinical experiences in flexible endoscopy. Endosc Surg Allied Technol 1994; 2:42-46. [ Links ]

59. SILVA RA, CORREIA AJ, DIAS LM - Argon plasma coagulation therapy for hemorrhagic radiation proctosigmoiditis. Gastrointest Endosc 1999; 50:221-224. [ Links ]

60. FANTIN AC, BINEK J, SUTER WR - Argon beam coagulation for treatment of symptomatic radiation-induced proctitis. Gastrointest Endosc 1999; 49:515-518. [ Links ]

61. TAYLOR JG, DISARIO JA, BUCHI KN - Argon laser therapy for hemorrhagic radiation proctitis: long-term results. Gastrointest Endosc 1993; 39:641-644. [ Links ]

62. BUCHI KN, DIXON JA - Argon laser treatment of hemorrhagic radiation proctitis. Gastrointest Endosc 1987; 33:27-30. [ Links ]

63. O'CONNOR JJ – Argon laser treatment of radiation proctitis. Arch Surg 1989; 124:749. [ Links ]

64. CHARNEAU J, BOUACHOUR G, PERSON B et al. - Severe hemorrhagic radiation proctitis advancing to gradual cessation with hyperbaric oxygen. Dig Dis Sci 1991; 36:373-375. [ Links ]

65. MONTOYA L, ANTON X – Radiation proctitis: treatment with hyperbaric oxygen. Undersea Hyper Med 1993; 20:82. [ Links ]

66. MOULIN C, LI V, LOIZZO F et al. - Value of hyperbaric oxygen in the hemostatic treatment of chronic radiation-induced recto-sigmoiditis. Gastroenterol Clin Biol 1993; 17:520-521. [ Links ]

67. NAKADA T, KUBOTA Y, SASAGAWA I et al. - Therapeutic experience of hyperbaric oxygenation in radiation colitis. Report of a case. Dis Colon Rectum 1993; 36:962-965. [ Links ]

68. WOO TC, JOSEPH D, OXER H - Hyperbaric oxygen treatment for radiation proctitis. Int J Radiat Oncol Biol Phys 1997; 38:619-622. [ Links ]

69. WARREN DC, FEEHAN P, SLADE JB et al. - Chronic radiation proctitis treated with hyperbaric oxygen. Undersea Hyperb Med 1997; 24:181-184. [ Links ]

70. CARL UM, PEUSCH-DREYER D, FRIELING T et al. - Treatment of radiation proctitis with hyperbaric oxygen: what is the optimal number of HBO treatments? Strahlenther Onkol 1998; 174:482-483. [ Links ]

71. YOUNG-FADOK TM – Successful and sustained treatment of chronic radiation proctitis with antioxidant vitamins E and C. Dis Colon Rectum 2002; 45:150. [ Links ]

72. GRIGSBY PW, PILEPICH MV, PARSONS CL - Preliminary results of a phase I/II study of sodium pentosanpolysulfate in the treatment of chronic radiation-induced proctitis. Am J Clin Oncol 1990; 13:28-31. [ Links ]

73. JADOT G, VAILLE A, MALDONADO J et al. - Clinical pharmacokinetics and delivery of bovine superoxide dismutase. Clin Pharmacokinet 1995; 28:17-25. [ Links ]


May 26, 2003.

Radiation Therapy - Week TEN

DAY TWO

D DAY

I couldn't help but smile broadly as I walked into the hospital for the very last time! Approaching the reception area I reflected absent-mindedly on my very first day ...

It was Friday 20th February 2008; it was raining, cold, and late in the afternoon when we were ushered into the Radiation Oncologists office. We were greeted with not one, but two doctors ... THAT started me thinking!

From the very outset, Dr. T impressed me, as forthright, empathetic and very well versed in his chosen field. What really impressed me, was his willingness to talk about 'any matter at all' and to do so with sensitivity AND complete honesty.

[Too many doctors think they are doing the patient a service by 'gliding the lily' (glossing over certain details) to save them (the patient) any unnecessary concerns. But, I maintain that it is the PATIENT'S right to determine what is or isn't unnecessary in regard to the treatment on offer.]

Dr T and I 'clicked' that day and I knew that I was in the right hands!

So much had taken place since that far off day, 3 months and 1 week distant from the present!


Back to the present...

It seemed that everyone that I encountered that day had the broadest of smiles!

It was as though everyone knew how excited I was, that this day, had finally come. Then again ... my own 'beaming smile' may have been a catalyst for others ... who knows?


The staff attending the Linear Accelerator that day, it seemed to me, were particularly pleased to see me. Each of them in their own way, had been a BIG part off my life for (what seemed like) such a long time now. Many of these individuals had accompanied me through the entire journey.

I must admit to shedding a tear or two at the thought of not seeing these wonderful people again. But fortunately, my excitement soon 'took centre stage once again' and I was 'ready for anything'!


My treatment (as usual) went particularly well and before I knew it ... IT was all over!!

Gathering around me, the RT's that I had come to love and respect all took turns in congratulating me on arriving at a successful outcome!!

The room was so emotion-charged, that it was quite difficult for me to eventually 'break the mood' and move out into the outer room; it was like leaving family behind!!

As I passed by the 'computer station', one of my favourite RT's called out to me: "I saw you break into a great big smile, as soon the the 'beam' was turned off for the last time, congratulations and GOOD luck"!!


As I walked out of the hospital for the last time, my mind was awash with memories.

My emotions meantime threatened to overwhelm me; as the excitement of completing my treatment, the very treatment that I was convinced was going to save my life, finally began to 'sink in'!!

After saying my goodbyes and promising to come back one last time, just before flying out of Australia to our new home in Chile, I set off with a new 'bounce in my step' into the bright sunlight that awaited me, ready for whatever new challenge might come my way!

Radiation Therapy - Week TEN

DAY ONE

All ... BUT!!

Arriving at the hospital, I was struck by the almost overwhelming sense of being so close to my final treatment, that I could barely contain my excitement!

In the back of my mind a familiar tape was playing: "37 down ... 1 to go"!

Greeting me, the receptionist commented: "Second last one ... John"?

To which I responded with a resounding: "YES!"


No time for a cup of tea

On my arrival at the dining room, I was surprised to see; not one, but two; Radiation Technicians waiting for me. Each, looking as excited as I felt!

"Are you ready"? They asked in unison, with more than a hint of collusion!

"Try and stop me"! Were the words that spilled out of my mouth ...

Next, I was whisked off to change (into my 'sexy' ... 'smiley face' ... hospital gown) and then ushered straight into the treatment room.


The Good-byes Start

"Hi Charlie".

I bellowed out as I greeted one of the nicest blokes you would be likely to meet anywhere. Charlie was an real 'old gentleman' with the emphasis on 'gentleman'.

Like many others of his vintage, this 'old digger' would only reluctantly accept being referred to as a gentleman; but he would not take kindly to the 'old bit'!

Although 83 years of age, Charlie was 'young at heart' and great fun to be around!

Charlie and I had bonded weeks before and had enjoyed swapping stories about our past and our hopes for the future.

It turned out, that we had lived for many years, in not one, but 3 different Sydney suburbs at the same time; but had never met ... until now!


"Good day ... mate" Charlie said in return, and then added: "This is your second last day isn't it"?

"Yup ... it sure is old mate"!


About 2 metres into 'the tunnel' that leads to the Linear Accelerator; Charlie and I exchanged 'Hi fives" and an emotional hug, we then reluctantly parted; Charlie to his home of 25 years and me to begin my second last treatment.


The treatment went very well; first the pelvic region (prostate treatment) and then the left breast and finally the right breast.

Immediately after treatment one of the newer young Radiation Technicians entered the room to prepare for the next patient.

"Buenos dias senor". "Buenos dias". I returned and followed by: "Como esta"?

To which she responded: "Muy bien, por favor".

We both laughed heartily ... another Spanish lesson was over, for yet another day.

Radiation Therapy - Week NINE

DAY FOUR

Boob Job

It turns out that the tracings of my boobs were not confined simply to posterity, they were also used to trace an exact replica (of my boobs) onto two large sheets of lead!

These were then 'cut out' (circular saw I suspect) to the shape of my left and right boobs (one for each) and were to be used to screen my chest, except for the areas indicated by the doctor's original sketchings!

I watched as these new 'shields' were snapped into place and then I was instructed to climb onto yet another 'incline gadget' only to be 'trussed up' again.

Then they lowered the 'boom' (actually they lowered one 'arm' of the Linear Accelarator) right onto my boob - alright then - a couple of millimitres clearance; I sure felt uncomfortable close!

The treatment itself lasted only about 8-10 seconds and was then repeated for the other breast.

Regular Radiation Treatment

Then it was time to 're-tool' for the prostate treatment. Before long, it was all over and I was no worse for the wear!

"Now ... back to work, I guess"!

Radiation Therapy - Week NINE

DAY THREE

Well today was the BIG day ... today I underwent a 'planning CT' (CT scan) as a precursor to further radiation treatment, this time on my chest!

It was quite a strange experience to be 'trussed up' on an 'incline board' hands and arms secured above my head - naked from the pelvis up!

But more 'strangeness' was to come!

Next I had a doctor drawing pictures of 'boobs' on my chest!

Stranger still these were then traced onto a sheet of clear plastic - no doubt to be preserved for posterity!!

I was told that I had 'breast buds' growing under my nipples and that this was the reason why my nipples were so sore.

A little weird, but it made sense, given that my testosterone production (assuming it was still happening) was 100% blocked and therefore the eostrogen that we all (male an female) have in our bodies was turning me, quite literally, into a female!!

I don't mind admitting, I was tempted to forego the treatment and be 'on hand' to 'breast feed' my grand daughter in Chile if needed ... imagine the possibilities!!

Well after all the planning was concluded; it was off for treatment number 35 ... leaving just 3 to go!!

No strangeness there, just more of the same that I had become so used to over the past couple of months or so!

Radiation Therapy - Week NINE

DAY TWO

Running Late

Arriving at the Oncology Unit early, there is always the chance that you could be offered treatment ahead of schedule - assuming that the unit is on time.

Of course the opposite is also possible ... they could be running well behind schedule and you have to sit there for hours!

Well today, turned out to be one of the latter!!

Fortunately, I was able to fill in some time chatting with staff; having morning tea; and later on, an early lunch.

By the time my treatment was ready, I was desperate to empty my bladder but (stubbornly) I held on because I wasn't going to go through all that again until my bladder was 'comfortably full'!!

The treatment itself was something of an anti-climax ... all over in 'the blink of an eye' (comparatively speaking) or 10 minutes in real time!!

Radiation Therapy - Week NINE

DAY ONE

Chaplain Come Here!

Some, say it's great to be in demand, to be looked up to and be sought after etc!Well maybe that's so in many cases, but not when you're undergoing Radiation Treatment and Hormone Treatment (becoming a female - literally) and struggling with fatigue; whilst still trying to cope with the pressures of work and preparing to relocate overseas!!

I mean ... I've got a lot on my mind at the moment and I really appreciate (more than ever) my own space.

On top of all that, we are currently living in a caravan in a friend's backyard in order to save a little money on rent etc. This means we are living out of suitcases and our routine has been 'turned on it's head'!

The upshot is, I try to limit my availabilty without causing offence - not an easy balance at times.


"Ahhh ... peace ... time to meditate, to rest, time to contemplate ... who am I kidding"?

"Mr Purcell ... how's our bladder today"?

"Not sure about yours ... but mine is ready for anything"! "Lead the way my young friend"!

Radiation Therapy - Week EIGHT

DAY FIVE

All was going well, I managed to jump the queue again by arriving early and my treatment was going well ... then it happened: The Linear Accelerator decided to break down!

I was not impressed!

I mean, there I was; naked except for my socks (you have to have some concessions) and my 'sexy' hospital gown and it was decidely cold!

We had successfully navigated through the CT Scan without any dramas, but upon resetting the Linear Accelerator for the Radiation Treatment ... well it just decided it needed a break!

Fortunately, with a few defts tweaks here and there the technicians were able to 'breath new life' into the decidely over-worked piece of (incredibly expensive) machinery.

Suffice to say, that we were underway in short order and I was no worse for the wear!

I kept muttering to myself: "32 down ... only 6 to Go"!!

It helped!!

Radiation Therapy - Week EIGHT

DAY FOUR

Hospital Chaplain

Somehow word had spread arouund the Oncology Unit, that I had been a Hospital Chaplain for many, many years. Well, it's amazing how many people have started to seek me out for 'chat'.

Today an elderly doctor's wife 'cornered me' literally. I had only spoken to her briefly the day before and today she had escaped my cursory glance an arrival and waited until I turned in her direction ...

"Hello there, you just come and sit over here ... there's lot's I want to tell you"!

Well, as it happened the treatments were running well behind and I had nearly 45 minutes with my 'new best friend'!

Now don't get me wrong, I love to be able to help others where I can but this felt a little more like I was her personal Chaplain!

Fortunately, my turn for treatment arrived in the 'nick of time' before the conversation became too intense and I was off for treatment number 31 ... yay!

My treatment continues to 'go perfectly' according to the weekly review appraisal I received immediately after treatment.

No complaints here ... except ... where's that Chaplain, I want a word with him ...!!

Radiation Therapy - Week EIGHT

DAY THREE

Too Good to be True

Well the day started off like so many others … but ended quite differently!

My trip to the Hospital went without incident, and with the usually formalities over, I made my way to the kitchen for my regular ‘cup of tea’.

With morning tea over, and the time ‘getting on’ I decided to head off to get changed.

So far, so good!

Now, regular readers will know that I have had nothing but praise for the staff of the Radiation Oncology Department (apart from one minor hiccup over phone details). But that’s now changed!

After changing, I headed to the ‘chairs’ to await my appointment … my presence meant that there were now four of us waiting there.

Then it happened … an ‘over-efficient’, ‘strictly-by-the-book’, ‘do-as-I-tell-you’ type nurse came by and starting quizzing the four of us as to what we were doing there!

Well, it turned out that the new (Acting) NUM had decided that a maximum of two patients could wait there; the rest would have to return to the outer waiting room, where we would be sitting amongst every ‘Tom, Dick and Harry who waltzed into the place – in our rather sexy hospital gowns!!

Well, being in a nice mood, I conceded to the request along with one of the women who had also trespassed!

Now as it happened, a few minutes later a young trainee came and ushered me back to the (inner) waiting area, where I once again took a seat!

Just as the young trainee disappeared from view … there she was again!!

“What are you doing back in here”?

“This time, I was given a special invitation”!

“Well you know you shouldn’t be here …”

“Just a minute where do you think you are going … “apparently another person had attempted to ‘sneak in’ but nurse: “I’m-the-boss”, doesn’t miss a trick!

“Now you just stay right there …”

“Mr. Purcell you can come in now”! ‘Thanks”!

“Now where did that other one go”?

Radiation Therapy - Week EIGHT

DAY TWO

False Start

Ring … ring … ring!

“Hello …”

“Hi this is the Radiation Oncology Department … we are running very late so it’s probably not worth your coming until we ring back”.

“OK …” “Well that was unexpected …”

Ahem ...

Ring … ring … ring!

“Hello …”

“Hi this is the Radiation Oncology Department … we’ve caught up quite a bit so come on in … but don’t rush”.

‘What the heck … I’ll go in at the regular time and … ‘take a punt’’!


On Arrival

“Mr. Purcell”?

“Yes.”

“If your bladder is ready you can come right on in.”

“Thanks … lead the way”!

What was that all about … sheesh!

The rest of the day went pretty much according to plan and I left the hospital chanting:

“29 down 9 to go”!!

Radiation Therapy - Week EIGHT

DAY ONE

Running Behind

Well today was certainly ‘back to normal’ … the queue in front of me, was a sure indication that I was in for a late day.

In order to pass some time, I arranged for my weekly (Doctor’s) review to be brought forward. The good news continues on this front: “All is going perfectly”!

Apparently, I am tolerating the treatment ‘perfectly’; meaning I’m not suffering from any of the multitude of side effects that normally attend 38 Prostate Cancer Radiation treatments.

The weekly CT scans (usually the last treatment day of the week) also show that the treatment is working perfectly!

On another note, my Oncologist has arranged for 3 Radiation Treatments on my chest.

Apparently, the most effective way to deal with ‘man boobs’, is to ‘zap’ them. Guess I should cancel those trainer bras!!

Another milestone passed today also … today was treatment number 28; meaning that I have only 10 treatments to go!

And so today, I started the countdown in earnest!!


10... 9 … 8 … 7 … 6 …5 … 4 … 3 … 2 … 1 … ZERO!!

Radiation Therapy - Week SEVEN

DAY FOUR

Back to NORMAL

I can hear somebody already asking: "But what is normal"?

"I'm glad you asked ... in my case normal goes something like this..."

10:00am drive to hospital ... arrive 10:30am.

Log in (more accurately 'scan in' ... high tech stuff!).

Stir the girls at the reception desk.

Sign for parking permit.

Place parking permit in the van and head off to the kitchen.

Make cup of tea, grab some biscuits and chat to whoever is silly enough to sit near me!

Wait for a technician to come and get me.

Get changed into 'sexy' hospital gown.

enter 'the room' and wait to be 'microwaved'!!

Get changed ... a much better look!

Have some lunch - don't have the energy to rive immediately after
treatment.

Return parking permit.

Stir the girls at the reception desk.

Head off ... back to work!!

PHEW I'm tired just thinking about it!

By the way, my treatment is continuing to go without a hitch - even the word perfectly has been bandied about!

No complaints here!

Radiation Therapy - Week SEVEN

DAY THREE ... DEJAVU ...???


GOOD MORNING

"How's your bladder going"?!

Those were the words of greeting offered by the young staff trainee.

Of course, not to be in any way offensive; I responded ... yes, you guessed it...

"Not bad ... how's yours"?!

Of course, we both had a bit of a chuckle afterwards.

Then came the invitation...

"You can come straight through if you like"?

'If I like?! Hmm, let me see it's 10:30am, I'm not 'due' for another 45 minutes ... my bladder is comfortably full ... but I haven't had my regular cup of tea yet ...'?

"Lead the way.."!


ZOOM ... ZOOM

I was no sooner changed ...

"You can come straight in, Mr Purcell."


IN ...OUT ... and ON my WAY

Just like that it was all over and I was on my way!

IT SEEMS AS THOUGH ONE DAY IS BECOMING A CARBON COPY OF THE PREVIOUS ONE???


One more and I 'm thinking about registering for 'Ground Hog Day' rights!

Radiation Therapy - Week SEVEN

DAY TWO

GOOD MORNING

"How's your bladder going"?!

Those were the words of greeting offered by the young staff trainee.

Of course, not to be in any way offensive; I responded ... yes, you guessed it...

"Not bad ... how's yours"?!

Of course, we both had a bit of a chuckle afterwards.

Then came the invitation...

"You can come straight through if you like"?

'If I like?! Hmm, let me see it's 10:30am, I'm not 'due' for another 45 minutes ... my bladder is comfortably full ... but I haven't had my regular cup of tea yet ...'?

"Lead the way.."!


ZOOM ... ZOOM

I was no sooner changed ...

"You can come straight in, Mr Purcell."


IN ...OUT ... and ON my WAY

Just like that it was all over and I was on my way!

Radiation Therapy - Week SIX

DAY FIVE

Time sure is flying these days! Here it is treatment number 23 with only 15 to go and I wonder where all the time has gone!

Don't get me wrong; I'm more than happy that the time is going quickly, I can't wait to see my daughter and grandchildren again.

On the other hand, it's strange that somehow life is speeding by while I desperately want to saviour every moment of every day ... so much more these days.

Every day for me now is precious!!

Once again my treatment went off without a hitch! The team who supervise my treatment are absolutely marvellous.

I've been wondering, just how I'm going to express my gratitude (adequately) when my treatment is over. I'm actually thinking of writing some prose or perhaps a poem - not sure yet!

Hmm... maybe a short play ...?

Who knows, I'll think of something!

Radiation Therapy - Week SIX

DAY FOUR

It's a little strange, attending for treatment these days; as all of the 'usual crowd' have finished their treatment and scattered in all directions back to their home towns.

Many of these, were being accommodated at a lodge in Sydney; as they live in relatively remote locations. I'm sure there have been many 'welcome home parties in the past week or two - all over the state.

There's certainly ... no place like HOME!

So these days, I'm about making new friends, at least until my treatment is finished on 28th this month! Then, I guess with one chapter over; I'll begin in ernest planning the next!

For those who are regular readers of this blog site, you will be aware that it's full steam ahead for our plans to move to Chile.

Well, my treatment went well again today and I said goodbye to treatment number 22 and looked forward to only 16 more to go!

Radiation Therapy - Week SIX

DAY THREE

Day 21 - 17 still to go!

It's such a great feeling this side of halfway!

Now as I count down the treatments left I also say good-bye to more and more fellow patients. It is a little sad to say goodbye to someone you feel as though you know so well.

Even though in reality it's been somewhere between a few weeks and a couple of months!

You seem to bond very closely when you are in circumstances such as this. Sometimes words are almost superfluous; when just an understaning look, or a wink, or even just ... "I understand" can convey quickly and deeply the sentiment needing to be expressed and received!

There are also so many new faces on the scene now! And with the influx of new people, comes the opportunity to get to know some more wonderful people. Of course, not everyone is outgoing, or even wants to talk; but they usually melt after awhile.

Wow! I'm starting to feel like a veteran!

Treatment

My treatment today went well, as expected. I continue to be grateful that there are no side effects from the Radiation Treatment!!