Radiation therapy is an effective method of fighting cancer. When a tumor is localized in the pelvic area, directed irradiation affects pathological cells. Post-radiation cystitis is a complication of neoplastic disease caused by the action of radiation on the bladder.
Causes of radiation cystitis
Radiation has a negative effect on the cells of the organ. More than 20 percent of patients with oncopathology of the pelvic organs develop radiation cystitis after a course of treatment.
A number of reasons lead to the development of the disease.
- Non-compliance with dosage, frequency of procedures.
- Sensitivity to radiation.
- Insufficient protection of the organ during the procedure.
- Sensitivity of tissues to radiation exposure.
Cystitis after radiation therapy is caused by sclerotic changes in the vessels of the urinary bladder, loss of functions of nerve fibers. As a result, the activity of metabolic processes, supply and regulation of tissues are reduced.
Cells lose their ability to regenerate. In places of damage, fibrous growths are formed, which reduce the elasticity of the organ. The inflammation can spread to all layers of the bladder.
Symptoms of radiation cystitis
The patient experiences weakness, dizziness, there is a decrease in performance. With radiation cystitis, more than 95 percent of patients suffer from a bladder infection.
Pathologies caused by radiation exposure are of a different nature:
- Vascular changes (telangiectasia)... The surface of the organ has bleeding areas, hemorrhages.
- Catarrhal type of damage... It is characterized by inflammation of the walls with areas of hemorrhage. The capacity of the bladder decreases, functions deteriorate.
- ulceration. The tissues are swollen, ulcers are formed. There is a vasodilation, a decrease in excretory capacity.
- Inlaid type differs in the deposition of salts, stones in the tissues of the bladder and ureters.
- Pseudorak. It is accompanied by a decrease in the organ, edema of the walls, and a decrease in functions. Tumor masses should be differentiated from cancer.
A common symptom in any type of post-radiation disorder is urinary disturbance.
Symptoms of radiation cystitis are pain, frequent urge to urinate with a decrease in the amount of fluid. The urine loses its transparency, contains blood clots, flakes, salt sediment, small stones.
The effects of radiation therapy can be combined into a complex of symptoms:
- Soreness when urinating, cramps in the lower abdomen.
- Urinary incontinence.
- Exhausting desires during the day.
- Difficulty urinating.
- Unproductive urge, scanty urine.
- Lack of feeling of emptying of the bladder.
- Frequent urging at night.
As the disease progresses, the volume of the cavity decreases, pain intensifies, and the patient's quality of life decreases.
Laboratory tests show the presence of calcium salts, pathogenic microorganisms, erythrocytes and leukocytes in the urine. A common complication is damage to the reproductive organs in women.
Treatment methods for radiation cystitis
Cystitis after radiotherapy is difficult to treat due to gross defects in the walls of the organ. The patient can be cured by combining a long course with an integrated approach.
Treatment of radiation cystitis is predominantly symptomatic.
Therapy includes a number of activities.
- Diet food... Coffee, alcoholic drinks, canned food are strictly prohibited. You should refrain from fried, fatty foods, hot spices. Patients need to eat foods rich in protein and vitamins.
- Antibacterial therapy... Antimicrobial drugs of a wide range of effects are used in the form of injections. After a course of injections, drugs are prescribed in tablets.
- General strengthening measures are to take immunomodulators... Use means to improve liver function, tissue regeneration. Instillation, injection directly into the bladder.
- To achieve a therapeutic effect, oxygen-containing drugs, corticosteroids are injected into the organ cavity... Steroid drugs relieve pain, relieve inflammation, swelling. Medicines containing silver give a good therapeutic result. Intracavitary introduction accelerates and enhances their action.
- Symptomatic therapy is aimed at eliminating pain, symptoms of frequent urination... The attending physician prescribes an anti-inflammatory drug, drugs that reduce the ability of tissues to contract.
- Herbal treatment. At home, it is easy to prepare a herbal decoction or infusion with a diuretic effect. Chronic radiological cystitis is treated with plants such as bearberry, cranberry, and nettle. Folk remedies should be used in consultation with the attending physician. With a weak effect, they are used as an auxiliary diuretic, anti-inflammatory drug.
When diagnosed with radiation cystitis, treatment should be permanent. Its effectiveness is evidenced by the restoration of organ functions, relief of the condition, positive dynamics in laboratory tests.
Surgical treatment of radiation cystitis
Operation on the bladder is prescribed in the absence of a positive effect from conservative techniques for six months.
Indications for surgical treatment can be stones, insufficient bladder volume, impaired blood outflow, organ patency. During the operation, ulcerated areas are excised, stones are removed, and the patency of the ducts is recreated.
After the operation, anti-inflammatory therapy is used, pain relievers and drugs that restore immunity are prescribed.
Possible complications
Do not self-medicate. Only a doctor knows how to treat cystitis after radiotherapy.
The course of the disease can be aggravated by complications.
- Cicatricial degeneration of the organ.
- Fistula formation.
- Deposition of stones.
- Bleeding.
- Infectious complications, sepsis.
- Stagnant urine.
- Rupture of the bladder wall.
- Organ tissue necrotization.
Observation by a doctor after radiation therapy, timely intensive treatment will help to avoid complications.
Prevention of the disease
Regular endoscopy of the bladder in patients undergoing radiological treatment of the pelvic organs is the main preventive measure.
Treatment sessions should be carried out in compliance with the technique of procedures. The organ must be protected by a screen, lead plate. An important measure is the prevention of oncology. Regular medical examinations, proper diet, rejection of bad habits will help to overcome the disease.
The results of radiation therapy for bladder cancer depend on the extent of the lesion, localization and histological structure of the tumor. R. Morrison (1978), based on the analysis of treatment results in 185 patients, established a higher sensitivity compared to anaplastic and squamous.
He used a radiation technique that reduced complications. After irradiation of the primary tumor and the area of \u200b\u200bthe external iliac lymph nodes at a dose of 52.5 Gy, administered over 4 weeks, then the tumor was additionally irradiated at a dose of 10 - 12.5 Gy.
Five-year survival rate for transitional cell carcinoma was 28%, anaplastic - 22%, and squamous cell - 20%.
Depending on the stage of the process, the numbers turned out to be as follows:T1 and T2 - 40.7%; TK - 27.6%; T4 - 6.5%. With an increase in the total focal dose from 42.5 to 62.5 Gy, an increase in tumor resorption was noted from 39 to 80%, respectively.
T. Edsmyr et al. (1978) presented the results of treatment of 602 patients with an average age of 65 years.
Radiation therapy was performed in a static mode from three fields:two front with wedge filters and one open back. The total focal dose for 7 weeks was 64 Gy in usual fractions; The 5-year survival rate at T2 was 32%, and the 10-year survival rate was 22%, with TZ - 22 and 12%, respectively, and at T4 - 10 and 1%.
J. C. Fish and J. V. Fayos (1976) demonstrated the dependence of survival on the volume of radiation. Two groups of patients were identified, comparable in all clinical and morphological criteria, differing only in the method of irradiation. Used a moving method.
In the first group (45 patients), the irradiation area included the bladder with paravesical tissue, in the second group (127 patients), the lymph drainage pathways were also irradiated. The weekly dose in each group was 10 Gy. The total focal dose in the first group was 60 Gy, in the second - 65.5 Gy. Analysis of 5-year survival was carried out in both groups, taking into account the stage, histological structure and size of the tumor.
It turned out that the 5-year survival rate in the first group was 12.6 ± 5.4%, in the second - 25.5 ± 4.0% (the data are statistically reliable). A slightly larger number of complications were noted in the second group, but they were not the cause of death in any patient.
With a significant spread of the process, static irradiation can be combined with rotational. It can be started immediately after a static (total dose of 35 Gy) or after a 3-4 week break, during which the tumor may shrink and the radiation reactions will subside. The dimensions of the irradiation fields depend on the length of the process (approximately 8 X 10 - 8 X 12 cm, swing angle 240 °). Single focal dose - 2 Gy, total for two cycles - 60 - 70 Gy.
Palliative radiation therapy is performed when the tumor has spread to the pelvic wall and rectum. With such irradiation, large fields are used so that the entire pelvic area is included in the irradiation zone. Single focal dose - 2 - 2.5 Gy, total - 30 - 40 Gy, irradiation is carried out 5 times a week.
In case of relapses of bladder cancer after previously performed radiation or combined treatment, it is advisable to apply irradiation through a grating from one suprapubic field daily, a single dose - 4 - 8 Gy, total - 100 - 120 Gy. According to I. A. Pereslegin (1969), in the case of detection of tumor remnants 3-4 months after irradiation, radiation therapy can be repeated with a total dose of 40-60 Gy.
"Bladder cancer", V.I.Shipilov
The mucous membrane of the bladder, which arise from the action of ionizing radiation during radiation therapy of malignant neoplasms. In particular, it is a frequent complication of tumors of the reproductive system.
Radiation cystitis is rarely ignored by specialists, therefore, when conducting an examination after radiation therapy and identifying violations of various organs and systems, supportive therapy is prescribed.
There are no special statistics on the detection of this disease, since it is rather not a separate nosological unit, but an adverse consequence.
The reasons
This disease is complication of radiation therapy, which is prescribed for tumors of the genital organs, cancer of the bladder, rectum, and more. By the time of development they are distinguished early and late radiation damage.
The occurrence of these adverse effects it is considered:
- Exceeding the dose of radiation therapy.
- Violation of the frequency of radiation sessions.
- Hypersensitivity to ionizing radiation.
- Since the radiation used in radiation therapy causes hardening of blood vessels and atrophy of nerve fibers, it leads to malnutrition and regulation of the bladder wall.
- As a result, the mechanism of depletion of cells lining the urinary wall, their autolysis ("self-destruction"), tissue necrosis and replacement of damaged areas with dense fibrous fibers, which do not allow the bladder to change its size when filling, is triggered.
- In the future, there is the possibility of developing pancystitis, when the inflammatory process involves all layers of the urinary wall.
Often, structural changes and inflammation in the walls of the organ are accompanied by bleeding, ulceration and erosion. At this moment, favorable conditions are created for the development of secondary bacterial microflora and accession of infectious cystitis.
Classification
Radiation cystitis is divided according to with severity:
- medium;
- heavy;
- extremely hard.
This classification depends on the clinical manifestations, as well as on the dose of ionizing effects.
Symptoms
Specialists have identified the whole, which is characteristic of any, all of them are combined for convenience into one simtomocomplex - disorders of the act of urination.
Urinary Disorders is a large group of signs of a disease that includes:
- difficulty urinating (dysuria);
- frequent unproductive urges (polakiuria);
- urinary incontinence, urgency;
- nocturia (frequent urge to use the toilet at night);
- pain after urination, cramps in the abdomen.
The acute process is characterized by rapid onset of symptoms violations of urination, and this happens during the first day.
- The earliest are pollakiuria and urgency. The intervals between urination are usually no more than ten minutes (plus or minus five).
- The volume of the bladder decreases with the development of the process, therefore, when it is filled, the painful sensations may increase, the portions of excreted urine are scarce.
- Patients often complain of the urge to urinate, which does not stop day or night and are of an imperative (imperative) nature that cannot be suppressed by volitional effort.
Because of this, patients cannot hold urine, it is also noted false urinary incontinencewhen patients do not have time to reach the toilet.
- But even after the act of urination in patients suffering from radiation cystitis, there is a feeling of incomplete emptying of the bladder.
Diagnostics
- And today it is the gold standard, both in the diagnosis of radiation cystitis, and any other. First of all, attention is paid to the number of leukocytes, which normally does not exceed one or two (according to some sources, three to four) leukocytes in the field of view. This is a sign of an inflammatory process.
- In case of mechanical damage to the bladder wall (rupture with its sclerosis, cracks, ulcers), a rather characteristic diagnostic criterion is hematuria (detection of a small amount of blood in the urine).
- It is also possible to use instrumental research methods, such as cystoscopy, biopsy, X-ray diagnostics, uroflowmetry, etc. This will help to establish the volume of the bladder and morphological changes in the wall.
- To identify a secondary bacterial infection, urine culture, however, it is informative for the bacterial or fungal nature of the disease.
To detect protozoa (chlamydia), mycoplasmas or viruses, sometimes you have to use microscopy urine, biopsy, various serological urine tests, but bacteria are more common.
Treatment
- Basically, therapy for radiation cystitis - that is, it will not be eliminated. Currently, immunomodulators, vitamins, antispasmodics and analgesics are used to relieve the main clinical manifestations.
- To date, it has already become traditional to use a domestic drug for radiation cystitis Gepon, which belongs to the class of immunostimulants. Its action is directed at the mucous membrane of the bladder. Gepon has a pronounced local stimulating immunological effect. Relieves inflammation, enhances regeneration (healing) of wounds, and also has antiviral activity.
- Of antispasmodics, it is recommended to use drotaverine (no-shpa).
- If the damage to the bladder is significant and there is no positive dynamics in the patient's condition, the question is raised about surgical intervention... The scope of surgical intervention is determined by a specialist, based on the individual characteristics of each patient.
The action of herbal medicine and homeopathic remedies for radiation cystitis not proven, therefore, this group of drugs cannot act as an independent treatment regimen.
- Recommendations about the patient should also be clarified with the attending specialist, however, in general, it is usually recommended to abandon alcohol, coffee, canned food, fatty fried or dried foods rich in spices and seasonings. It is necessary to use herbal preparations with a diuretic effect, fruit drinks, alkaline mineral waters (at least two liters per day).
Complications
In general, with a timely and adequate prognosis for radiation cystitis favorable... Yet it is rare when this form of the disease is brought to an extremely severe stage.
- In such cases, both large ulcers and total sclero or necrosis of the bladder wall are possible.
- All this makes the attending specialist go for a radical operation - total cystectomy with an artificial bladder replacement. But this measure does not give one hundred percent guarantees.
Prevention
Since the underlying disease does not always depend on the patient, in addition to standard precautions, the patient is advised to carefully approach the issue of treatment with ionizing radiation. The doctor, in turn, should take into account the degree of risk of developing radiation cystitis and strictly control their prescriptions.
Standard treatments for bladder cancer include surgery, radiation, chemotherapy, immunotherapy, or biological therapy.Surgical and radiation treatment for bladder cancer is a local therapy, that is, the treatment is localized. This means the treatment of cancerous growth in the affected area.
Chemotherapy is a systemic treatment that affects the entire body with drugs (cancer cells anywhere in the body).
Radiation therapy
Radiation therapy kills both cancer cells and normal body cells. Mostly, radiation therapy is prescribed for treating small tumors that invade the muscle layer of the bladder wall (invasive cancer). However, as an independent treatment for bladder cancer, radiation therapy is rarely used, more often radiation therapy is combined with other therapies and is widely used as an alternative approach instead of surgery.Two types of radiation therapy are used: external radiation and internal radiation. However, a combination of radiation therapy and chemotherapy is required for maximum effectiveness.
- External exposure produced by a special device that directs radiation to the body. Targeted irradiation occurs directly to the area where the cancer is located. This type of treatment is usually given 5 days a week for five to seven weeks. Radiation according to this scheme allows you to protect the surrounding healthy tissues and reduce the radiation dose for each subsequent session.
- Internal beam therapy or brachytherapy - performed by introducing small granules (or wire, needles, etc.) with radioactive material directly into the bladder cavity to the area of \u200b\u200bthe cancerous tumor. Most often, this material is injected through the urethra or through a small incision at the bottom of the abdominal wall (abdomen).
Radiation side effects
Unfortunately, radiation affects not only cancer cells, but also healthy organ tissue. Since rapidly dividing and growing cells are the most sensitive to radiation, in addition to cancer cells, epithelial cells, which are part of the mucous membrane of the bladder and rectum, or the skin in the bladder region, also die. In this case, the reaction to radiation from the skin will be similar to a sunburn: the code becomes reddened, dryish, erosion may appear, and in severe cases, ulcers, itching.These manifestations depend both on the method of radiation therapy and on the dose of radiation, the duration of the course of radiation therapy, as well as on the individual sensitivity of the patient. Although the consequences can be severe, they are usually not permanent. Usually, the skin in the irradiated area becomes atrophic and dark. In addition to the skin, internal organs (rectum, vagina, bladder), bones (with damage to the bone marrow) are affected. Internal irradiation has been developed to avoid these side effects.
Irradiation of the ovaries in women can sometimes cause menstrual irregularities. If the mucous membrane of the rectum is damaged, there may be soreness during the act of defecation, the release of blood, mucus. And also as a result of radiation, the development of cystitis (inflammation of the mucous membrane of the bladder) is possible.
In addition, with external irradiation of the bladder area, radiation can also affect the bone marrow, which is located in the pelvic bones. The consequence of this may be anemia and a decrease in leukocytes in the blood, which is manifested by fatigue, dizziness and infectious complications due to a decrease in the body's defenses.
In addition, irradiation of the pelvic organs may cause the following side effects, such as nausea, disturbed stool (diarrhea), urinary and sexual problems - vaginal dryness in women, impotence in men.
Chemotherapy
As an independent method, chemotherapy is ineffective in bladder cancer, and therefore it is used extremely rarely, as monotherapy. Chemotherapy is the use of powerful drugs that affect the growth of cancer cells. Most often, chemotherapy is used in combination with surgery or radiation therapy, which improves the quality of treatment and the outcome of the disease. Chemotherapy is given before or after other treatments, such as surgery for bladder cancer, and chemotherapy (therapy with anticancer drugs) is subsequently given to achieve the best effect.The principle of chemotherapy is based on much the same as that of radiation therapy: it affects rapidly dividing cells, which include cancer cells.
Treatment at stages Ta, T1
In stages Ta, T1 of bladder cancer and in-situ cancer, intravesical chemotherapy is used, that is, the introduction of anticancer drugs directly into the bladder. This method is usually chosen after surgery, namely after transurethral resection (TUR) of bladder cancer. After removal of the tumor, a liquid preparation is injected into the bladder cavity through a urinary catheter. The drug is left in the bladder for several hours, while the patient should not urinate. The drug is then released, usually with urination. This treatment is usually repeated once a week for several weeks.Treatment for stages 2 and 3
In invasive bladder cancers, when the tumor grows into regional lymph nodes, other adjacent organs and tissues, systemic or intravenous chemotherapy is used. In this case, the chemotherapy drug is administered intravenously, that is, it enters the general bloodstream. Thus, the chemotherapy drug enters any part of the body, contributing to the death of cancer cells at a distance. The main goal of systemic chemotherapy is to destroy the remaining cancer cells in other areas and organs.Chemotherapy is characterized by unwanted side effects. The nature of the side effects depends on the type of drug used and its method of administration, and also depends on the individual tolerance of the drug.
As you know, anticancer drugs disrupt the metabolism in a cancer cell, however, they also affect healthy cells, which also have high metabolic activity (for example, epithelial cells of the gastrointestinal tract, cells of hair follicles, bone marrow cells).
Therefore, there may be corresponding complications such as nausea, vomiting, loss of appetite, ulcers in the mouth or gastrointestinal tract, hair loss, feeling tired or lack of strength (as a result of suppression of red bone marrow cells, hence a decrease in red blood cells, the development of anemia), increased susceptibility to infections (as a result of a decrease in the number of leukocytes responsible for immunity), the rapid appearance of hematomas and bleeding (as a result of suppression of platelet growth).
However, all side effects are almost always temporary and regress after chemotherapy is completed.
Intravesical chemotherapy with Mitomycin C
Numerous studies show that intravesical chemotherapy is effective in reducing the recurrence of superficial bladder cancer. Intravesical chemotherapy with Mitomycin C after tumor removal is often administered once. The treatment regimen and the choice of the drug depends on the decision of the surgeon.Of the unwanted effects of intravesical chemotherapy, irritation of the bladder or kidneys is noted.
It should also be noted that intravesical chemotherapy is ineffective in invasive (invasion into the muscle layer of the bladder) and metastatic bladder cancer in regional lymph nodes and other organs and tissues.
Immunotherapy or biological therapy
Immunotherapy targets the body's natural ability to fight cancer cells.The body's immune system releases substances into the blood that help it fight off foreign agents (for example, viruses, bacteria, cancer cells).
Sometimes the immune system is suppressed by aggressive foreign agents. Therefore, immunotherapy or biological therapy has been created that helps to strengthen the immune system in the fight against cancer.
BCG vaccine
Immunotherapy is used not only for the Ta, T1 stages of bladder cancer and in-situ cancer.Intravesical BCG therapy is used as an immunotherapy or biological therapy for bladder cancer. An attenuated BCG vaccine containing altered Mycobacterium tuberculosis is injected through a urinary catheter into the bladder cavity.
Mycobacterium tuberculosis in the vaccine stimulates the immune system by producing substances to fight cancer cells. The vaccine solution is left in the bladder for several hours, then it is usually released when urinating. This procedure is repeated every week for six weeks, repeated at different times over several months. Researchers continue to work on the duration of treatment with BCG vaccine.
Some of the side effects of this treatment were bladder irritation and minor bleeding in the bladder. Bleeding is usually invisible to the eye in urine (microscopic). You may feel the need to urinate more often than usual, a burning sensation, or pain when urinating. Another side effect is flu-like syndrome, which includes chills, fever, and nausea. It is caused by stimulation of the immune system. As with other treatments for bladder cancer, side effects are temporary, while the treatment is applied.
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A prerequisite for starting radiation therapy for bladder cancer is a histological examination to confirm the diagnosis. The method can be applied both independently and in conjunction with others. As an independent method, radiation therapy for bladder cancer is rarely used and can be used in the form of:
- A radical course.
- Palliative course (in patients with advanced stages of the disease).
Treatment is carried out using devices for external and contact radiation therapy. The optimal technique is selected depending on the location and extent of the tumor process. Postoperative therapy is carried out in the case of tumor invasion into the muscle wall, in the presence of metastases in regional lymph nodes.
Indications
The main indications for radiation therapy are:
- The presence of contraindications for radical surgery.
- Refusal of the patient from surgical treatment.
- Stage T4.
Pre-radiation preparation
An important condition for radiation therapy for bladder cancer is pre-radiation preparation, which is carried out using an X-ray stimulator. It includes:
- Determination of the correct position of the patient during irradiation.
- Emptying the bladder and injecting a contrast agent into its cavity.
- Application of research results after CT, MRI.
Irradiation technique
Irradiation of the pelvis is performed from four fields:
- Front.
- Back.
- Two side.
The femoral heads and rectum are protected by blocks. The entire bladder falls into the irradiation zone. If the tumor is visualized well, then the tumor itself and the area within 2 cm beyond its borders are subject to radiation. If the tumor is not clearly defined, add another 2 cm.
The course of radiation therapy is carried out in the dose fractionation mode: the radiation is performed for 6-6.5 weeks, 5 times a week. Single focal dose 2 Gy, total focal dose 60-64 Gy. At the beginning of treatment, the entire pelvis is irradiated to a total focal dose of 40-45 Gy, then the bladder zone is in the same mode. External beam therapy is carried out in the following mode: a single focal dose of less than 2 Gy to a total focal dose of 40 Gy. During this period, chemotherapy with cisplatin drugs is carried out.
When complete or partial tumor regression is achieved, chemoradiotherapy continues. If the tumor continues to grow and there are no contraindications, a cystectomy (removal of the bladder) is performed.
Also, for cancer of the bladder, brachytherapy is performed - interstitial and intracavitary radiation therapy. A single focal dose with intracavitary irradiation is 3-5 Gy, the total focal dose is 45-50 Gy.
Contraindications
- Bladder volume less than 100 ml.
- Previously used pelvic irradiation.
- Residual urine volume\u003e 70 ml.
- Urolithiasis disease.
- The presence of cystostomy drainage.
- Exacerbation of chronic cystitis and pyelonephritis.
The effectiveness of the use of radiation therapy
After completion of treatment after 5-6 months, 40% of patients with invasive cancer do not have a tumor. However, in the future, 50-65% of these patients have a relapse, metastases are found in 15-20%. As a result of radiotherapy according to a radical program, the cure of bladder cancer can be only in 15-30% of cases.
