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Purpose: To study prostate specific membrane antigen - positron emission tomography (Ga 68 PSMA-PETCT) based patterns of relapse at biochemical failure (BCF) after prostate-only radiotherapy (PORT) in high-risk (HR) prostate cancer and its implications on pelvic contouring recommendations., Methods and Materials: Patients with clinico-radiological high-risk node-negative prostate cancer treated with curative PORT and androgen deprivation therapy (ADT), either within the POP-RT randomised trial or off trial, who underwent a Ga 68 PSMA-PETCT upon BCF were included. Patterns of regional and distant recurrence on Ga 68 PSMA-PETCT were studied. Pelvic nodal recurrences were mapped with reference to the superior border of pubic symphysis. Pelvic lymph nodal caudal border (PLN cb ) recommendations in the published contouring guidelines (RTOG cb , GETUG cb , PIVOTAL cb , NRG cb , GFRU cb) were evaluated., Results: Of the total 262 patients screened, 68 eligible patients were included (POP-RT trial 35 patients; off-trial 33 patients). Median follow-up was 91 months (IQR, 72-117) and median time to BCF was 65 months (IQR, 49-83). Regional and distant recurrence was seen in 31 (46%) and 31 (46%) patients, respectively. Of the nodal recurrences, nearly half (46%, 14/31) had no distant metastases and 64% (20/31) had a failure in the common iliac nodal region. The lower-most nodal recurrence was 20 mm cranial to the top of pubic symphysis (RTOG cb , GETUG cb , GFRU cb ) and 10 mm cranial to the PIVOTAL cb . The PLN cb recommended by NRG guideline (NRG cb ) had an inter-patient variability of 32 mm, ranging from 16 mm above to 16 mm below the top of pubic symphysis, and the lower most nodal recurrence ranged from 4 mm to 36 mm cranial to NRG cb ., Conclusion: Pelvic failures accounted for a major proportion of recurrences after prostate-only radiotherapy, with the caudal most nodal recurrence being 20 mm cranial to the top of pubic symphysis. This could have implications in defining the caudal border of contouring recommendations., (Copyright © 2024 The Royal College of Radiologists. Published by Elsevier Ltd. All rights reserved.)

Aims: Pelvic radiotherapy can induce gastrointestinal injury and symptoms, which can affect quality of life. We assessed interventions for managing these symptoms., Materials and Methods: A review of randomised controlled trials published between January 1990 and June 2023 from databases including MEDLINE, EMBASE, CENTRAL, CINAHL, clinicaltrials.gov, ISRCTN and grey literature sources was conducted. Meta-analyses were carried out using the DerSimonian and Laird random effects model to produce overall treatment differences with 95% confidence intervals., Results: Twenty-eight studies (2392 participants) of varying methodological quality were included. 4% formalin was superior to sucralfate for improving gastrointestinal symptom score (standardised mean difference [SMD] -1.07, 95% confidence interval -1.48 to -0.65). Argon plasma coagulation (APC) was inferior to sucralfate (SMD 1.22, 95% confidence interval 0.84 to 1.59). Counselling positively influenced symptom score (SMD -0.53, 95% confidence interval -0.76 to -0.29), whereas hyperbaric oxygen therapy showed conflicting results. Sucralfate combined with APC increased endoscopic markers of moderate-severe bleeding versus APC alone (risk ratio 2.26, 95% confidence interval 1.12 to 4.55). No definite conclusions on pain, incontinence, diarrhoea, tenesmus or quality of life interventions were confirmed., Conclusions: Small study sizes, methodological quality and heterogeneity limit support of any individual intervention. APC and 4% formalin seem to be promising interventions, with further larger randomised controlled trials now warranted., (Copyright © 2024 The Authors. Published by Elsevier Ltd.. All rights reserved.)

External beam radiotherapy is a standard treatment option for localised prostate cancer and hypofractionation has become an alternative to conventionally fractionated radiotherapy. In patients who receive external beam radiotherapy, elective pelvic nodal irradiation is sometimes delivered, especially in patients with unfavourable disease who are at risk of micrometastatic spread of cancer into the regional nodes. One elegant approach to combine prostate hypofractionation with elective pelvic nodal irradiation is with a simultaneous integrated boost technique, where a radical hypofractionated dose is delivered to the prostate while the regional pelvic nodes receive a lower microscopic dose simultaneously in a single radiotherapy plan over the same number of treatment fractions. This article reviews the existing published literature evaluating such an approach., (Copyright © 2019 The Royal College of Radiologists. Published by Elsevier Ltd. All rights reserved.)

Aims: Node-positive bladder cancer (NPBC) carries a poor prognosis and has traditionally been treated palliatively. However, surgical series suggest that a subset of NPBC patients can achieve long-term control after cystectomy and lymph node dissection. There is little published data regarding the use of radiotherapy to treat NPBC patients. This is in part due to concerns regarding the toxicity of whole-pelvis radiotherapy using conventional techniques. We hypothesised that, using intensity-modulated radiotherapy (IMRT), the pelvic nodes and bladder could be treated within a radical treatment volume with acceptable toxicity profiles., Materials and Methods: The Intensity-modulated Pelvic Node and Bladder Radiotherapy (IMPART) trial was a phase II single-centre prospective study designed to assess the feasibility of delivering IMRT to treat the bladder and pelvic nodes in patients with node-positive or high-risk node-negative bladder cancer (NNBC). The primary end point was meeting predetermined dose constraints. Secondary end points included acute and late toxicity, pelvic relapse-free survival and overall survival., Results: In total, 38 patients were recruited and treated between June 2009 and November 2012; 22/38 (58%) had NPBC; 31/38 (81.6%) received neoadjuvant chemotherapy; 18/38 (47%) received concurrent chemotherapy; 37/38 (97%) patients had radiotherapy planned as per protocol. Grade 3 gastrointestinal and genitourinary acute toxicity rates were 5.4 and 20.6%, respectively. At 1 year, the grade 3 late toxicity rate was 5%; 1-, 2- and 5-year pelvic relapse-free survival rates were 55, 37 and 26%, respectively. The median overall survival was 1.9 years (95% confidence interval 1.1-3.8) with 1-, 2- and 5-year overall survival rates of 68, 50 and 34%, respectively., Conclusion: Delivering IMRT to the bladder and pelvic nodes in NPBC and high-risk NNBC is feasible, with low toxicity and low pelvic nodal recurrence rates. Long-term control seems to be achievable in a subset of patients. However, relapse patterns suggest that strategies targeting both local recurrence and the development of distant metastases are required to improve patient outcomes., (Copyright © 2019 The Royal College of Radiologists. Published by Elsevier Ltd. All rights reserved.)

Aims: Women treated with pelvic radiation therapy (PRT) for gynaecological or anorectal cancer report a high number of sexual problems and unmet post-treatment psychosexual information needs. Currently, there is suboptimal adherence to recommended rehabilitation aids, such as vaginal dilators, and a paucity of resources to facilitate post-radiation rehabilitation and reduce distress in this population. This randomised controlled trial aimed to evaluate the effectiveness of a study-developed psychosexual rehabilitation booklet in this setting., Materials and Methods: Eighty-two women scheduled for PRT to treat gynaecological/anorectal cancer were randomised to receive the intervention booklet (n = 44) or standard information materials (n = 38). Self-report questionnaires administered at pre-treatment baseline and at 3, 6 and 12 months post-treatment assessed adherence with rehabilitation aids, booklet knowledge, anxiety, depression and sexual functioning/satisfaction., Results: Dilator adherence and booklet knowledge were significantly higher in the intervention group than in the control group (averaged over time points), with scores significantly increasing over time. Younger age and gynaecological cancer were significant predictors of greater dilator adherence. No significant group differences were found on psychological and sexual measures., Conclusions: The psychosexual rehabilitation booklet was effective in educating women with gynaecological and anorectal cancers about PRT-related psychosexual side-effects and rehabilitation options, as well as promoting uptake of vaginal dilator use. Future research should elucidate the effectiveness of this booklet in women with greater psychological and sexual functioning needs., (Copyright © 2018 The Royal College of Radiologists. All rights reserved.)

Aims: Growing numbers of patients with cancer are surviving after treatment with pelvic radiotherapy. We evaluated the technique of volumetric modulated arc therapy (VMAT), which delivers a decreased dose to the organs at risk. We aimed to determine outcomes of this technique in terms of patient-reported acute toxicity and late effects and correlate the frequency of gastrointestinal symptoms with the volume of bowel receiving radiation dose., Materials and Methods: Patients who were to receive VMAT for gynaecological malignancy completed patient-reported outcomes at baseline, the end of treatment, 8 weeks and 1 year. The rates of patient-reported toxicity were correlated with the volume of bowel irradiated., Results: The frequencies of patient-reported gastrointestinal symptoms increased in the acute toxicity phase and tended to improve at 1 year, with the exception of faecal incontinence and rectal bleeding (P < 0.05). There was not a strong association between the volume of small bowel that was irradiated (P > 0.05 at all dose levels) and reported toxicity, suggesting that other factors are involved in the development of toxicity., Conclusion: Although VMAT decreases the dose delivered to the small bowel, this does not translate into a reduction in patient-reported toxicity., (Copyright © 2017 The Royal College of Radiologists. Published by Elsevier Ltd. All rights reserved.)

Aims: Although pelvic radiotherapy is an effective treatment for various malignancies, around half of patients develop significant gastrointestinal problems. These symptoms often remain undetected, despite the existence of effective treatments. This study developed and refined a simple screening tool to detect common gastrointestinal symptoms in outpatient clinics. These symptoms have a significant effect on quality of life. This tool will increase detection rates and so enable access to specialist gastroenterologists, which will in turn lead to improved symptom control and quality of life after treatment., Materials and Methods: A literature review and expert consensus meeting identified four items for the ALERT-B (Assessment of Late Effects of RadioTherapy - Bowel) screening tool. ALERT-B was face tested for its usability and acceptability using cognitive interviews with 12 patients experiencing late gastrointestinal symptoms after pelvic radiotherapy. Thematic analysis and probe category were used to analyse interview transcripts. Interview data were presented to a group of experts to agree on the final content and format of the tool. ALERT-B was assessed for reliability and tested for validity against the Gastrointestinal Symptom Rating Scale in a clinical study (EAGLE)., Results: Overall, the tool was found to be acceptable in terms of wording, response format and completion time. Participant-reported experiences, including lifestyle modifications and the psychological effect of the symptoms, led to further modifications of the tool. The refined tool includes three questions covering rectal bleeding, incontinence, nocturnal bowel movements and impact on quality of life, including mood, relationships and socialising. ALERT-B was successfully validated against the Gastrointestinal Symptom Rating Scale in the EAGLE study with the tool shown broadly to be internally consistent (Cronbach's α = 0.61 and all item-subscale correlation [Spearman] coefficients are > 0.6)., Conclusion: The ALERT-B screening tool can be used in clinical practice to improve post-treatment supportive care by triggering the clinical assessment of patients suitable for referral to a gastroenterologist., (Copyright © 2016 The Royal College of Radiologists. Published by Elsevier Ltd. All rights reserved.)

Aims: Minimisation of organ position variation during pelvic radiotherapy is vital for accurate treatment. We analysed bladder and rectal filling during radiotherapy to understand variation reduction methods., Materials and Methods: Cone beam computed tomography scans (CBCTs) taken twice weekly during three-dimensional conformal radiotherapy were retrospectively analysed for 10 cervical cancer patients. Bladder and bowel preparation was followed. Two independent clinicians outlined bladder, rectum and the primary clinical target volume (CTV) on each CBCT. Effects of time, chemotherapy and drinking time on bladder and rectal volume were analysed. CTV coverage impact was investigated using fixed effect logistic regression modelling., Results: Ten planning scans and 109 CBCTs were reviewed. The bladder volume was 45-578 cm(3) during radiotherapy and 73-664 cm(3) at planning. The bladder volume increased (4 cm(3)/min) with waiting time, decreased (average 4 cm(3)/day) through treatment and was larger (about 50 cm(3)) after chemotherapy. A bladder volume difference > 130 cm(3) from planning led to the planning target volume (PTV) not covering the CTV. The probability of the PTV covering the CTV for every cm(3) deviation from the planning volume reduced by 1.9%, predominantly affecting the uterus. Planning bladder volumes > 300 cm(3) were not reproducible during treatment. The rectal anterior-posterior diameter correlated with volume. No pattern was displayed through treatment. The probability of the PTV covering the CTV with every mm deviation from the planning anterior-posterior diameter reduced by 5.8%, predominantly affecting the cervix. The risk of the PTV not covering the CTV is higher if the rectum is larger during treatment than planning. As bladder volume decreased rectal anterior-posterior diameter increased., Conclusion: Our data suggest an ideal planning bladder volume of 150-300 cm(3), a shorter waiting time on post-chemotherapy days and adequate hydration throughout treatment. Laxatives at planning and throughout treatment may also be beneficial. Even with these measures, regular imaging is vital when implementing advanced radiotherapy techniques for gynaecological cancers., (Copyright © 2016 The Royal College of Radiologists. Published by Elsevier Ltd. All rights reserved.)

Aims: In locally advanced cervical cancer, the dose delivered results from the sum of external beam radiotherapy and brachytherapy, and is limited by the surrounding organs at risk. The balance between both techniques influences the total dose delivered to the high-risk clinical target volume (HR-CTV). The aim of the present study was to compare the ability of reaching different planning aims after external beam radiotherapy pelvic doses of 45 Gy in 25 fractions or 50.4 Gy in 28 fractions, both considered as standard prescriptions., Materials and Methods: The optimised plans of 120 patients treated with pelvic chemoradiation followed by magnetic resonance image-guided intracavitary brachytherapy were reviewed. The doses per pulse were calculated, and the number of pulses required to reach the planning aims, or a limiting dose constraint to organs at risk, was calculated. All doses were converted to 2-Gy equivalents. Three scenarios were applied consisting of different sets of planning aims: 85 and 60 Gy for the HR-CTV and the intermediate-risk CTV (IR-CTV) D90 (minimal dose received by 90% of the volume) in scenario 1, 90 and 60 Gy, respectively, for scenarios 2 and 3. For organs at risk, dose constraints were 90, 75 and 75 Gy to the bladder, rectum and sigmoid D2cm(3), respectively, in scenarios 1 and 2, and 80, 65 and 70 Gy in scenario 3., Results: A similar HR-CTV D90 could have been reached in scenarios 1 and 2 according to both pelvic doses. In scenario 3, a higher mean HR-CTV could have been reached in the 45 Gy arm (83.5 ± 8.0 versus 82.4 ± 8.0, P < 0.0001). The mean D2cm(3) of organs at risk was systematically and significantly increased after a delivery of 50.4 Gy to the pelvis, from 0.9 to 2.89 Gy. The proportions of plans reaching planning aims were 85.8, 72.5 and 42.5% after 45 Gy and 85.5, 67.5 and 33.3% after 50.4 Gy according to scenarios 1, 2 and 3, respectively. According to scenario 3, 50.4 Gy, the reachable HR-CTV D90 was higher in 30% of the cases, by 2 Gy in two cases. Those cases were unpredictable and due to unfavourable organs at risk topography and poor response to external beam radiotherapy., Conclusion: The delivery of 45 Gy in 25 fractions to the pelvis before brachytherapy warrants a higher probability to reach brachytherapy planning aims, in comparison with 50.4 Gy in 28 fractions., (Copyright © 2015 The Royal College of Radiologists. Published by Elsevier Ltd. All rights reserved.)

Survivors who have received pelvic radiotherapy make up many of the long-term cancer population, with therapies for gynaecological, bowel, bladder and prostate malignancies. Individuals who receive radiotherapy to the pelvis as part of their cancer treatment are at risk of insufficiency fractures. Symptoms of insufficiency fractures include pelvic and back pain and immobility, which can affect substantially quality of life. This constellation of symptoms can occur within 2 months of radiotherapy up to 63 months post-treatment, with a median incidence of 6-20 months. As a condition it is under reported and evidence is poor as to the contributing risk factors, causation and best management to improve the patient's bone health and mobility. As radiotherapy advances, chronic symptoms, such as insufficiency fractures, as a consequence of treatment need to be better understood and reviewed. This overview explores the current evidence for the effect of radiotherapy on bone health and insufficiency fractures and identifies what we know and where gaps in our knowledge lie. The overview concludes with the need to take seriously complaints of pelvic pain from patients after pelvic radiotherapy and to investigate and manage these symptoms more effectively. There is a clear need for definitive research in this field to provide the evidence-based guidance much needed in practice., (Copyright © 2015 The Royal College of Radiologists. Published by Elsevier Ltd. All rights reserved.)

Modern multimodality cancer treatment has led to more than 2 million people living with and beyond cancer in the UK, an impressive survival statistic on which clinicians and services continue to build. However, what is less readily acknowledged by health professionals and patients alike are the 500,000 people whose daily lives are adversely affected by the longer term consequences of cancer treatment. Macmillan Cancer Support estimate as many as 350,000 people in the UK experience sexual consequences of cancer and its treatment, an aspect of survivorship and rehabilitation that receives relatively scant attention in service provision, policy development and research terms. This overview addresses the sexual impact of radical pelvic radiotherapy for the more common (prostate, ano-rectal, cervical and endometrial) adult malignancies. Through discussion of the clinical assessment and management of desire, arousal, orgasmic and sexual pain difficulties that arise after pelvic radiotherapy, this overview offers an integrated biopsychosocial model of practice that incorporates the physical, psychological and relationship elements of these treatment sequelae. It is important that clinicians raise the profile of the sexual consequences of cancer treatment as a legitimate aspect of survivorship and service provision. Only in this way can the identification and management of treatment-induced sexual difficulties, frequently experienced by patients and their partners, be better understood and managed. Increased focus on the sexual consequences of treatment and cancer survivorship more broadly may, in time, lead to greater clinical recognition, service development and, most importantly, increased research devoted to the effective management of what remains a neglected aspect of cancer care., (Copyright © 2015 The Royal College of Radiologists. Published by Elsevier Ltd. All rights reserved.)

Aims: External beam radiotherapy followed by brachytherapy is the standard treatment for patients with carcinoma cervix. However, for patients who come from peripheral hospitals after incomplete surgery, whole pelvic radiotherapy (WPRT) followed by boost with either vaginal vault brachytherapy if suitable or further external beam radiotherapy is recommended. This study was conducted to evaluate if it was possible to give a higher tumour dose using intensity-modulated radiotherapy for that group of patients who were not suitable for high dose rate vaginal vault brachytherapy because of gross disease after WPRT., Materials and Methods: A prospective study was carried out from 2005 to 2010 in which 25 postoperative patients of cervical carcinoma with gross residual disease after WPRT of 46 Gy/23 fractions/4.5 weeks were included. Nine patients were treated with 20 Gy to the planning target volume and 30 Gy to the clinical target volume in 10 fractions; 16 patients were treated with 30 Gy to the planning target volume and 35 Gy to the clinical target volume in 15 fractions. The end points of this study were local control, survival and treatment-related toxicity., Results: The median follow-up was 38 months. The 3 year local control, progression-free survival and overall survival rates were 76, 74 and 67%, respectively. Late grade 2 rectal toxicity was seen in 11 patients. Grade 2 bladder toxicity occurred in two patients and grade 3 bowel toxicity in two patients. No other grade 3 or higher toxicity was seen., Conclusion: Inadequate and inappropriate surgery in invasive cervical cancer with resulting gross residual disease is common in India. It is possible to escalate the tumour dose by intensity-modulated radiotherapy boost after WPRT in postoperative cervical carcinoma patients with gross residual disease with low incidence of severe toxicity and excellent local control., (Copyright © 2012 The Royal College of Radiologists. Published by Elsevier Ltd. All rights reserved.)

Aims: To compare the dose to organs at risk (OAR) between a conventional four-field whole pelvis radiotherapy (4F-WPRT) plan and an initial single intensity-modulated WPRT (IM-WPRT) plan for definitive treatment of cervical cancer. The magnitude of potential dose sparing of OAR is unknown when planning target volumes are defined to include potential organ motion and microscopic disease extent., Materials and Methods: Planning computed tomography scans of 50 consecutive, previously treated patients were re-planned using 4F-WPRT and IM-WPRT. Margins compatible with the literature on organ motion were used to create the planning target volume. Dose-volume histograms for target and OAR were compared for each patient with paired t-tests and waterfall plots., Results: The mean target volume covered by 95% (V47.8) was 99.7% for 4F-WPRT and 98.8% for IM-WPRT (P>0.05, ns). Intensity-modulated radiotherapy (IMRT) was associated with a significant reduction in the dose to OAR at the V50, V45, V40 and V30 level. There was a >20% difference in V50 in most patients: 84% (bladder), 58% (small bowel), 54% (sigmoid) and 84% (rectum)., Conclusions: A single, initial IMRT plan with appropriate margins encompassing initial gross and potential microscopic pelvic disease leads to a reduction in the dose to OAR without compromising target coverage. This offers a potential 'class solution' for definitive treatment of patients with cervical cancer. Clinical outcome data are still needed to verify this planning study., (Copyright © 2011 The Royal College of Radiologists. Published by Elsevier Ltd. All rights reserved.)

Aim: Pelvic irradiation in addition to prostate irradiation may improve outcome in locally advanced prostate cancer, but is associated with dose-limiting bowel toxicity. We report the preliminary results of a dose escalation study using intensity-modulated radiotherapy., Materials and Methods: Eligible patients had high-risk (T3, Gleason > or =8 or prostate-specific antigen > or =20 ng/ml) or lymph node-positive disease. Intensity-modulated radiotherapy was inverse planned giving 70 Gy/35 fractions to the prostate and 50 Gy/55 Gy/60 Gy in sequential cohorts to the pelvis with a 5 Gy boost to positive lymph nodes. Acute and late toxicity were recorded with Radiation Therapy Oncology Group (RTOG) and Late Effects Normal Tissue - Subjective Objective Management LENT-SOM scales. Neoadjuvant androgen suppression was given for 3 years. This report concerns the 50 and 55 Gy cohorts., Results: Seventy-nine men were recruited (25 to 50 Gy/54 to 55 Gy) with a median follow-up of 2 years. Patients were divided into two groups according to the total bowel volume outlined (median 450 cm(3)). Acute RTOG (> or =2) bowel toxicity was 40 and 50% for the 50 and 55 Gy groups and 38 and 51% for bowel volume <450 cm(3) and > or =450 cm(3), respectively, suggesting both volume and dose relationships for acute effects. Late RTOG diarrhoea > or =grade 2 was only seen with bowel volume > or =450 cm(3), but no dose effect was apparent (12%/50 Gy and 10%/55 Gy). LENT-SOM bowel > or =grade 2 toxicity occurred in 22%/50 Gy and 15%/55 Gy. Only one patient had grade 3 toxicity. A dose volume histogram analysis showed increased late RTOG diarrhoea > or =grade 2 with larger bowel volume irradiated, significant for BV40 >124 cm(3) (P=0.04), BV45 >71 cm(3) (P=0.03) and BV60 >2 cm(3) (P=0.01)., Conclusions: Acute and late bowel toxicity was acceptably low using a pelvic dose of up to 55 Gy over 7 weeks. Both relate to total pelvic bowel volume and dose volume constraints have been defined., (Copyright 2010 The Royal College of Radiologists. Published by Elsevier Ltd. All rights reserved.)

Aims: We report the results of hyperbaric oxygen therapy (HBOT) used in the treatment of radiation-induced persistent side-effects after the irradiation of pelvic tumours., Materials and Methods: Between January 2001 and December 2005, 13 women (median age 60.3 years) with radiation combined proctitis/cystitis (n=6), longstanding vaginal ulcers and fistulas (n=5) and longstanding skin injuries (n=2) underwent HBOT in a multiplace chamber for a median of 27 sessions (range 16-40). The treatment schedule was HBOT 100% oxygen, at 2 absolute atmospheres, for 90 min, once a day. For radiation-induced toxicity grading we used the National Cancer Institute Common Toxicity Criteria (CTC) grading system, before and after HBOT., Results: Thirteen patients underwent an adequate number of HBOT sessions. The mean CTC grading score before HBOT was 3.3+/-0.75, whereas the mean CTC grading score after HBOT was 0.3+/-0.63. The scores showed a significant improvement after HBOT (P=0.001; exact Wilcoxon signed-rank test). Rectal bleeding ceased in five of six patients with proctitis and dysuria resolved in six of seven cystitis patients. Macroscopic haematuria stopped in seven of seven patients. Scar complications resolved in two of two patients. None reported HBOT-associated side-effects., Conclusion: HBOT is apparently safe and effective in managing radiation-induced late side-effects, such as soft tissue necrosis (skin and vagina), cystitis, proctitis and fistulas.

Up to 300,000 patients per year undergo pelvic radiotherapy worldwide. Nine out of 10 will develop a permanent change in their bowel habit as a result. Five out of 10 of all patients will say that this change in their bowel habit affects quality of life and two to three out of 10 will say that this effect on quality of life is moderate or severe. Between one in 10 and one in 20 patients will develop very serious complications within the first 10 years after treatment. This number will increase to two out of 10 by 20 years from the end of treatment. Although research carried out into the basic molecular, cytokine and physiological changes underlying radiation-induced bowel symptoms and the optimal treatment that should be provided to symptomatic patients is scant, it does seem probable that a significant proportion of these patients can be cured or improved by specialist gastroenterological intervention. However, most patients never get referred to a specialist gastroenterologist and research into late radiation bowel damage has not been considered a priority. With the advent of more effective cancer therapies leading to greater numbers of affected long-term survivors, much more emphasis is urgently required to provide better information to patients at the start and after treatment, developing techniques that might reduce the frequency of significant bowel toxicity and researching better ways of measuring and treating late-onset side-effects.

Late complications of pelvic radiotherapy occur in 5-20% of patients, particularly chronic radiation proctitis (CRP). Rectal bleeding is the most common symptom. Other symptoms include difficulty in defaecation or tenesmus because of loss of distensibility of the rectum or rectal structuring. Treatment options of CRP include oral therapy (5-aminosalicylates, metronidazole), rectal instillation therapy (hydrocortisone, sucralfate, 5-aminosalicylates, formalin), thermal therapy (argon plasma coagulation, heater probe or laser) and hyperbaric oxygen. It is difficult to recommend evidence-based therapy. There are no adequately powered studies of the treatment of CRP and most data are uncontrolled, non-blinded observation studies from single sites. There are no standard evaluation tools (including endoscopic grading, symptom scores and quality-of-life scores), adequate description of preceding radiotherapy dose or adequate follow-up in most studies. Many studies have poor documentation of complications and few are carried out prospectively. A pragmatic approach is to use sucralfate enemas and oral metronidazole. Thermal methods seem to be effective and safe. Simple heater probe treatment or argon plasma coagulation are the preferred methods due to their better safety profile. Intra-rectal formalin seems to be effective, but possibly has a higher rate of complications. For resistant disease, hyperbaric oxygen may be an option.

Aims: Eosinophils have an important role in the pathogenesis of inflammatory bowel disease, with faecal levels of the eosinophil granule proteins, eosinophil cationic protein (ECP) and eosinophil protein X (EPX) reflecting disease activity. Eosinophil crypt abscesses are a characteristic histological finding in acute gastrointestinal radiation-induced mucosal damage. This pilot study aimed to investigate changes in serum levels of ECP/EPX during pelvic radiotherapy., Materials and Methods: Patients with no history of inflammatory bowel disease, starting a 5-week course of pelvic radiotherapy, had serum ECP/EPX levels measured before radiotherapy and during the fourth week of treatment. Bowel toxicity was graded at week 4 using the Common Toxicity Criteria Scale., Results: Fifteen patients who were to undergo adjuvant radiotherapy for gynaecological cancer were recruited. The mean serum levels of ECP and EPX before treatment were 17.3 microg/l (range 2.0-49.3 microg/l) and 37.3 microg/l (range 12.0-94.0 microg/l), respectively. The mean serum levels during week 4 of radiotherapy for ECP and EPX were 43.0 microg/l (range 2.4-164.0 microg/l) and 38.7 microg/l (range 9.0-79.0 microg/l), respectively. Serum ECP levels increased at week 4 compared with levels before radiotherapy (P = 0.02). Acute bowel toxicity was seen in 12 patients (80%) at week 4: Grade 1 in 25% patients and Grade 2 in 75%. In this small study, no correlation was seen between acute bowel toxicity at week 4 and serum ECP or EPX levels., Conclusions: Serum ECP levels increase in response to pelvic irradiation. This may reflect the known involvement of eosinophils in the acute response to radiotherapy. Further study is required to determine when levels start to rise and their relationship to the degree of acute bowel toxicity.

The case notes and simulator films were reviewed from 70 sequential patients who received pelvic irradiation to induce an early menopause as part of their treatment for breast cancer at the Staffordshire Oncology Centre. These patients underwent ultrasound localization of the ovaries immediately prior to simulation. Altogether, 128 ovaries were plotted on a diagrammatic representation of a gynaecoid pelvis to represent their position in both craniocaudal and lateral dimensions in relation to the true bony pelvis. The craniocaudal ovarian position varied from 2.5 cm above the lower aspect of the sacroiliac joint to 2.0 cm above the symphysis pubis. Three (4.6%) right sided ovaries were within 1 cm medial to the right lateral side wall, with none lying lateral to the wall. Seventeen (26%) left sided ovaries were lying within 1 cm of the left pelvic side wall, with four of these lying outside. The limits of the pelvic fields used were from the top of the sacroiliac joint to the bottom of the symphysis pubis. Sixty-one (88%) upper borders were on or above the lower sacroiliac joint. Twenty-six (38%) and 49 (71%) fields were outside the right and left pelvic side walls respectively. This would suggest that field sizes were larger than standard; however, 87% were smaller than 150 cm(2) (assuming a 10x15-cm field as standard). Only one patient failed to respond to treatment. This was thought to be due to underdosing rather than a geographical miss. This patient was successfully retreated. The authors advocate the use of ultrasound localization prior to planning an irradiation menopause, to ensure that the ovaries are encompassed in the pelvic field, thus preventing a geographical miss and reducing field sizes.

A total of 210 patients receiving pelvic radiotherapy were prescribed trimethoprim 200 mg p.o. daily for the duration of radiotherapy. It was prescribed after two mid-stream urine specimens were obtained. Two patients refused to take trimethoprim. The incidence of urinary tract infection prior to starting radiotherapy and trimethoprim was 24% (50 patients). Of these 50 initial infections, eight (16%) were resistant to trimethoprim, necessitating a change to an antibiotic to which the organism was sensitive. Persistent infection occurred in 21 of these 50 patients; 14 (67%) of these infections were resistant to trimethoprim. Of the 160 patients with no initial infection, 25 subsequently developed a urinary tract infection, in spite of prophylactic trimethoprim. Seven of these 25 infections (28%) were resistant to trimethoprim. Prophylactic trimethoprim is not worthwhile for preventing urinary tract infection during pelvic radiotherapy. Eight patients (4%) developed a rash while on trimethoprim, necessitating stopping the drug. Fastidious or anaerobic organisms were isolated in only 15 patients prior to radiotherapy and in seven patients during radiotherapy. Twenty of these 22 patients were female. The organism most commonly isolated was Streptococcus sp. The bacteriuria occurring with these organisms may have resulted from contamination from the vagina.

Combined modality treatment for cancer of the rectum has been shown to reduce recurrences and improve overall survival. We wished to find out if we could safely give concurrent radiotherapy and 5-fluorouracil (5-FU) modulated by leucovorin (LV) in 3 settings: pre-operatively, adjuvantly and in recurrent disease. A total of 39 patients were treated, 11 preoperatively, 17 adjuvantly and 11 with recurrent disease. There were 26 males and 13 females with a median age of 64 years. The median radiotherapy (RT) dose was 45 Gy/25 fractions/1.8 Gy per fraction (range 25-63 Gy). Chemotherapy consisted of LV 80 mg/m2 i.v. infusion over 1.5 hours followed by 5-FU 400 mg/m2 i.v. bolus, both given once a week. The median number of cycles was 8 (range 3-12). Diarrhoea was the main toxicity, and was encountered in 30 patients (77%): grade 1 in 3 (8%), grade 2 in 12 (30%), grade 3 in 11 (28%), and grade 4 in 4 (10%). This required 18 (46%) patients to have modifications to their RT (20% had breaks and 26% ceased at doses < 45 Gy). Nine patients (23%) had modifications in the chemotherapy (10% had breaks and 13% received < 6 cycles). Encouraging responses were seen in the preoperative setting. Concurrent RT and 5-FU/LV, as given in this schedule, results in an unacceptable incidence of diarrhoea, limiting both the total dose of RT and chemotherapy that can be delivered, particularly in patients who have had previous surgery.

One hundred and thirty-six patients with biopsy-proven carcinoma of cervix were treated with external beam irradiation to the whole pelvis (46 Gy in 23 fractions) and three weekly applications of high-dose-rate (HDR) intracavitary brachytherapy of 7 or 8 Gy per fraction to point A (2 cm above and 2 cm lateral to the cervical os). The actuarial 5-year survival rate was 72% (Stage IB 85%; IIA 64%; IIB 70%; IIIA 25%; IIIB 53%). Patient age above 61 years and Stage III disease were adverse determinants for survival as shown by multivariate analysis. Late complications developed in 47% (65/137) of patients. Grade 3 or above complications occurred in the bladder, small bowel and sigmoid colon/rectum in 5%, 3% and 7% of patients, respectively. The most significant determinant of severe rectal complications was the addition of a lower vaginal tandem (P less than 0.01); the other determinants of rectal complications included a uterine length greater than 5 cm, a total biologically effective dose to the rectum of more than 120 Gy3 and Stage III disease.

Thirty advanced ovarian cancer patients have been treated with sequential multimodality treatment including primary surgery, cisplatin or carboplatin-based polichemotherapy, second-look laparotomy followed by abdominopelvic irradiation (moving strip or open-field technique). Toxicity related to the combined treatment was acceptable: only three patients failed to complete and two patients delayed the prescribed course of radiotherapy because of acute myelosuppression or gastroenteric disturbances. One patient without evidence of disease required laparotomy for bowel obstruction one month after completion of radiotherapy. No other chronic toxicity of clinical significance has been observed. Actuarial three-year survival significantly correlated with residual disease at the start of radiotherapy: no residuum, 100%, microscopic disease, 52%; less than 2 cm macroscopic disease, 27.4% (P less than 0.05), whereas recurrences were less frequent only in the group of pathological complete responders (3/9) compared to patients with limited disease (6/11 with micro and 7/10 with macroscopic residuum). In conclusion radiotherapy following surgery and chemotherapy is not associated to serious morbidity but its value in improving progression-free survival rates has to be tested in randomized trials.

A total of 264 patients were treated between January 1981 and December 1985 for abdominal and/or pelvic tumours with high energy photon beams. Pelvic irradiation encompassed the true pelvis with upper limit located at the L5-S1 junction for 126 patients, at the L4-L5 junction for 107 patients with only 31 patients receiving external irradiation with treatment fields extending up to T12. The dose delivered to the pelvis was in the range 40-50 Gy with 72 (27.27%) patients receiving an extra dose on limited volumes up to 60-65 Gy. Acute intestinal reactions were observed in 38 (14%) patients. Using the Chassagne grading, we observed 14 grade 1,9 grade 2,13 grade 3 and 2 grade 4 late intestinal complications. Incidence of severe late intestinal complications in our series was 5.67% (15/264). Among these 15 patients three died of progression of the disease outside the treated volume, two died because of intestinal complications and/or their treatment and two died of unknown reasons. The remaining eight patients are alive with no evidence of the disease but with marked impairment of their intestinal functions. The analysis of risk factors showed only previous surgery (with laparotomy) to be significant, whereas age, delivered dose and treatment field and marked obesity had no influence on incidence of severe late intestinal complications.