St. Patrick’s Day I collapsed in pain and was rushed to ER. A CT ABD PE revealed a perforated colon near my rectum, broad internal infection (sepsis) with kidneys and liver shutting down. A life flight, three surgeries later, 3 weeks sedated and immobile in an ICU, and seven weeks in hospital rehabs, learning to deal with an ileostomy, and slowly recovering strength, I have learned 20% of radiation treatment PCA patients suffer radiation damage that can result in a perforated colon and up to 70% of perforated colons are septic and fatal. Looking through my records I find no mention of these side effect statistics for the IGIMRT or for my salvage brachytherapy.
Would the knowledge have inclined me toward surgery? I don’t know. But, I would have made a better informed decision. And, likely tried to anticipate and avoid the perforation with lots of liquids and a diverticulitis diet.
Much gratitude to the teams at (Cleveland’s) University Hospital Main and Suburban Campuses. Outpatient rehab is progressing well. Now I’m able to focus on my recent biochemical recurrence following three years of Casodex.
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kreg001
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May your ordeal prove helpful for other people here. This forum is biased in favour of irradiation. When someone newly diagnosed queries about RP vs RT there are a ton of responses in the spirit: "RT is just a walk in the park". But, to the careful reader there is a common denominator among all of them. They had the RT some months to a few years back. I occasionally warn them that radiation is a slow killer, but I am just the odd one out.
In your suffering, you are doing a great service to others. Thank you for that!
I’m not on a crusade but do wish I’d known more back in 2009. There now are several studies but when I retired from Case Western I lost my library privilege of unlimited downloads. 😢. This synopsis from the Michigan Department of Health and Human Services is concise:
“Radiation therapy for prostate cancer can cause chronic radiation-induced colonic injury in up to 20% of patients, including perforation of the sigmoid colon. This is because the rectum and distal sigmoid colon are close to the prostate and are relatively immobile, making them more susceptible to radiation damage. Radiation treatment can also cause scar tissue to develop in the rectum, which can tear and bleed during bowel movements.
Even with surgery, the mortality rate from perforated bowel disease is 30-50%, and even higher at 70% if the patient had a perforation and diffuse peritonitis …. “. Sep 27, 2023
Im very sorry to hear of your shocking outcome with radiation. I had EBRT over about a six week period and two years of ADT ( LUPRON ) GS 7= 4+3, T3b N1 M0 treatment with curative intent. Last three Blood test show an increasing PSA since stopping treatment June 2022.
When you say
" And, likely tried to anticipate and avoid the perforation with lots of liquids and a diverticulitis diet."
Did they warn you for radiation preparation to have a full bladder and an empty bowel for each radiation dosage?
I drank two liters of water before each dose. Ugh. It was SoA for 2009. The Swedish machine. Image Guided and Intensity Modulated. The seed implants, a few years later, produced some blood but I cleared up in a week or so.
Bottom line is no proof it was the radiation treatments that led to the perforation. The surgeons say no one knows the cause(s) of diverticulitis and perforation. It’s a strong coincidence in locale and the relatively recent statistics however.
I’ve reached out to the pathologist to learn if there were any histological samples made. Haven’t heard back. I suspect their concern was colon viability with the sepsis.
Lot of books on diverticulitis including diets. Just thinking that approach might have been beneficial. Let’s face it, in 2009 I wasn’t confident in reaching 2024. Now we have a 4yo grandson and I look forward to being with him as long as I can.
I'm sorry you went through that, but your stats are all wrong. My data show that fistulas occur in 0.5% of radiation patients and 0.6% to 9% of patients after RP.
That study of just 66 people is not exactly exhaustive is it? 66 people 10% developed radiation proctitis (very far from a walk in the park for those 10%) and 1 got a fistula. Would appreciate a long term study with a large population to actually show the colon damage stats as problems from chronic proctitis tend to snowball over time.
In the Richmond VA study, they looked at all 1,006 radiation-treated patients over a 16-year period, and found only 7 with fistulas. Idk why you imagine there were only 66 people and why you imagine it was short-term. Also I don't know why you imagine with no evidence that "problems from chronic proctitis tend to snowball over time." Re-read it.
Retired Radiologist here who interpreted CTs for 45 years(amongst many other studies and performed IR procedures). There is a big difference between a fistula and diverticulitis. The significant majority of people that present with colonic perforation have a diverticulum which has become inflamed/infected and has led to perforation of such. The infection can be mild and walled off or can be more extensive and result in a diverticular abscess or diffuse peritonitis. There are, of course, other causes for colonic perforation including colon cancer, trauma, radiation injury etc. Chronic infection/trauma etc can led to fistulas. Garden variety diverticulitis is much more common than colonic fistulas (that is, an abnormal communication to another viscera-bladder, small bowel - or skin).
Retireddoc wrote: "There are, of course, other causes for colonic perforation including colon cancer...."
There are two papers that I have come accross of, dealing with second cancers 10, 15 and 20 years post irradiation. Don't recal the exact occurancies figures, but they were in the 10-20% range. One claimed that proton was 1/3 that of photon, only specific to PCa.
Actually, Stanford published a paper in 2022 in which 145,000 men were evaluated and followed for 20 years (retrospective study). The incidence of developing a secondary cancer of the bladder or colon was 0.5% higher in the group that received radiation therapy for prostate cancer vs the group that did not receive radiation. It should be noted that the odds of developing a secondary cancer within 5 years was only 1 in 333. 15-20 years later the risk increased to about 1 in 40. In short, radiation therapy rarely induces a secondary malignancy and is probably not a realistic concern for men in their 80s and maybe 70s.
So, it is important not to take information presented here and definitively apply to one's own situation. There are many factors in play. As I have posted in the past, getting a team of experienced, knowledgeable physicians at a COE that you trust is the best advice on this forum. Randomly quoting studies that are years old or suggesting specific treatments or medications for individuals without knowing their complete medical history (and without having the extensive knowledge that MO/RO/ urologists have gained through years of training and practice) can potentially be detrimental to care. This is not to say that patients shouldn't be knowledgeable and ask questions. Quite the contrary. Just be advised that the laypeople on this forum do not have the expertise that a highly qualified, experienced specialist has.
"This study has limitations. Although we were able to classify patients as receiving vs not receiving radiotherapy, it is plausible that some misclassification occurred because patients who did not receive radiotherapy may have sought treatment outside the VA health care system. However, the VA Cancer Registrars capture initial prostate cancer treatments delivered outside of the VA health care system. In addition, some patients in the nonradiotherapy cohort may have received adjuvant or salvage radiotherapy in the years after their initial diagnosis, which may not have been captured. As with any retrospective cohort study, our data carry a risk of selection bias, and patients treated with radiotherapy may have had more comorbid disease with a higher risk of developing a second primary cancer. " Emphasis added
Also, it isn't clear what they did with the people that died before the 20th year mark. Not adjusting for them brings the already low (as an 1-19 years average of a ramping up function) even lower.
Radiation is a SLOW killer. We know that, don't need any paper to let us know.
At any rate, developing a malignancy as a result of modern radiation therapy is unusual/rare. Water the actual number is 0.5% or 1-2%, the incidence is low. Additionally, it occurs years (15+) after treatment. All therapies carry risks. Radiation Therapy as a primary or adjunct treatment for prostate cancer is one of the better choices.
Thank you for your insight. From the CT ABD PEL with contrast report. I added the emphasis. For reasons unknown a scan of the complete report isn’t available via UH-MyChart:
FINDINGS: Numerous locules of free air identified within the abdomen extending from the level of the hemidiaphragms inferiorly to the umbilicus. There is minimal perihepatic fluid. Small amounts of fluid also identified in the right and left lower pelvis. Miniscule presumed cyst of the lower aspect of the liver axial image 57 too small to reliably categorize by CT. Remaining abdominal visceral organs are normal. Small hiatal hernia. Stomach is normal. Moderate stool burden in the colon. There is pericolonic induration of the sigmoid colon, axial image 127, coronal image 72. Sparse diverticula are present. The possibility of a perforated diverticulum is a consideration. Other causes for free air/Free Fluid particularly around the perihepatic region can not entirely be excluded. A umbilical hernia is present containing fat and free air. Brachytherapy seeds are present within the prostate bed. There is no acute osseous abnormality. No bone lesions are seen.
A perforated diverticulum is a fairly common occurrence. The peroration can be micro or macro. When it is micro (small and confined), the inflammation/infection is generally contained to the immediate pericolic area. When the perforation is larger, gas from the colon escapes into the peritoneal cavity as well as some stool and the patient usual develops multiple peritoneal abscesses and inflammation of the peritoneal cavity (peritonitis). If the assesses are large enough (>about 3 cm) they need to be drained. Percutaneous drainage under CT guidance by the Interventional Radiologist (my primary specialty for 40 years) is the method of choice. If the colonic perforation won't heal then surgery follows. Your doctors probably don't know if you had diverticulitis with macro perforation or perforation secondary to a weakened colonic wall as a result of your remote radiation treatment.
Radiation certainly can weaken the bowel (and bladder) wall by inflammation which has short and long term sequelae. These complications are either short lived or self limiting (don't need intervention) or manifest years later. A small percentage result in significant bleeding, damage to the wall with perforation and a few other usual complications. With modern radiation techniques, the potential damage to adjacent organs is greatly minimized.
My PCP, Urologist, related ER doctor, nurse practitioners, and three surgeons have assured us there is no accepted reason for perforated diverticulitis. I’m an R&D chemist, my wife a Chem E and we just find it hard to accept ‘no accepted reason’.
I hope radiation damage and a coincident perforation is extremely rare. It’s been 15 years since my external beam and 10 years since brachy. Would I have accepted the risks for a guarantee of 15 or 10 years. You bet!
Could I have lived with a colitis or diverticulitis diet in an attempt to head off what has transpired? Maybe. Certainly, with hindsight, worth consideration.
I’ve survived this episode. Maybe I’ll get another 10 or 15 years. That would be something!
I’ll try to get histology to examine the cassettes from pathology. Someone must owe me a favor. “There are more things in heaven and earth, Horatio, than are dreamt of in your philosophy”
In the meantime awareness has been raised and I’m grateful for this discussion. Let me be clear, I’m not trying to be an alarmist.
Of course, I haven't seen the CT scan so I can't make a determination. All I can say is that diverticulitis (by definition it is a perforation but may be micro and heal on its own with just antibiotics) is pretty common, especially among the elderly. Perforation caused by prior radiation is rare.
I’m not crusading against RT. I posted in hopes there are others in this group who have experienced perforation of the distal sigmoid colon decades after their RT and might share.
There are 18 pathology cassettes at UH from the three surgeries and I’m not certain any of them actually have the perforation in section so, as of today, I don’t have evidence the perforation is coincidental with some sort of radiation damage.
20% colonic injury and 70% fatality means 86% chance of survival I think. Pretty good odds and close to the five year survival rate IFIMRT was supposed to achieve back in 2008. The Michigan statements don’t have references that I found, may be a Google AI summary, but this German paper (Rektumperforation - love the title) has several links and/or citations: pubmed.ncbi.nlm.nih.gov/281...
Without my library privileges not sure how much poking around I’ll be doing at $39/copy.
Wow! Thanks for sharing. I am glad you are on the mend. When I had brachytherapy and radiation, I don’t recall that side effect ever mentioned. As it is said, sometimes the cure is worse than the disease!
Adding to the story is the electronic record of a colonoscopy from March 2020. I paid little attention to the report since there was only one polyp and it was benign. Reviewing the report now I see the Doc observed radiation proctitis in the distal sigmoid region and ‘obliterated’ some veins near the surface of the radiation damaged region using an argon plasma laser. Unfortunately my earlier colonoscopy was in 2008 in the Carolinas and I don’t have electronic access to the report.
I think maybe it would be better to move on.....I think you acknowledge it is unlikely you would be able to prove that the RT directly caused this horrible situation. Are you saying that 20% of men who receive PCA radiation develop perforated colon? I just don't think that is true.....if it is, then most ROs are subject to malpractice in not warning prospective patients of that fact. TA's numbers are more like what I have seen..... I doubt there would be many takers for PCa RT if the 20% was near the actual occurrence rate!!!
I have seen few, if any, other posts here complaining of this outcome!!!
Perforation or fistula are rare. But radiation damage of some sort may not be. Here is a 2021 ASCO paper on Management of Long-Term Toxicity From Pelvic Radiation Therapy
I had radiation to my prostatebed in 2009 after prostatectomy in 2007. I did not experience very much side effects, but I have been frequently bothered with diverticulitis, which started before the radiation. In February 2024 I started on Docetaxel due to increasing PSA. After 4 treatments I got very sick and they found a 6 cm abscess on my colon which they drained and treated with antibiotics. The plan was to remove drain, but then they found a hole in my colon and had to leave the drain in place. It has now been 2 1/2 month and my last checkup still showed a small hole. There has been talk about surgery, but as there has been improvement they still hope for the hole to heal. I am going for a new abscess X-ray next week, hopefully it will be healed. My worry right now is when to start up the chemo again. Will I risk the abscess returning? I have been on ADT, now Zoladex and Nubeqa since 2008.
Initially the 1st surgeon hoped to avoid a colonectomy. Stitch the perforation and let it repair itself. Exploratory surgery was stopped during the operation when my kidneys began shutting down. Blood tests and other cultures showed infection that was consistent with bowel leakage and sepsis. 48 hours later I was opened up and a short section of my intestine removed. An ostomy was prepared. The idea was that in six months or so the colon and rectum would be rejoined. Fairly common with colon cancers. My infection worsened and pathology suggested the colon was failing from infection. Another 48 hours and a third surgery to remove the entire large intestine, close the ostomy, create an ileostomy, insert three drains, irrigate my abdomen, and hopefully stop the infection. Last hope. After three weeks in ICU where I was sedated, prescribed opioids (fentanyl, oxycodone, etc.) and given IV antibiotics my sedation was stopped and it seemed I was ready to start rehabilitation. Sedation was because I been a bad, delirious, patient trying to remove oxygen face masks and intubation. Their goal was to avoid restraints. There was a setback when I caught pneumonia at the rehab hospital which led to more hospitalization, breathing therapy, and more IV antibiotics. Back to another rehab hospital where I progressed from wheelchair, to walker, to cane with PT and OT. Now living at home with outpatient rehab, rebuilding my strength. The scientist in me and the engineer in my wife are trying to understand what brought on my condition. Radiation damage seems likely. I had two courses. IGIMRT (beam) and years later salvage brachytherapy (seeds). If there’s 20% chance of damage with one course then perhaps there’s a 40% chance with two courses. But, a fistula or perforation would still be rare. I’ve survived and can return to concentrating on keeping PCA at bay.
"...back in 2009... synopsis from the Michigan Department of Health and Human Services...“Radiation therapy for prostate cancer can cause chronic radiation-induced colonic injury in up to 20% of patients, including perforation of the sigmoid colon."
External beam radiation in 2009 did often cause rectal damage. The quoted source does say "can cause" and "up to 20%" and "including", which is more anecdotal than a study. It is not saying that 20% get perforated. The majority of radiation proctitis cases would be milder burns that do not lead to perforation.
Modern external beam radiation like IMRT and SBRT does not often cause proctitis. In 2021 I had 20 sessions of prostate IMRT without rectal spacer, and in 2023 30 sessions of pelvic IMRT, with no after effects from either treatment.
My 2009 machine was SOA - image guided, intensity modulated, and my RO very good. Years later I had salvage brachytherapy. Not as sophisticated but same RO. Perhaps the observed by colonoscopy radiation damage was from the seeds not the beam.
Still uncertain that the perforation was in a radiation damaged region. Working on that.
First and foremost I am glad that you are here and able to tell your story. Second, thanks for sharing the article from 2021. Third your surgeons and all the others involved deserve a huge amount of credit for your survival.
As I read that article I will admit that a portion of it was “Greek” to me but I was able to relate to it because I one year ago had pelvic radiation while undergoing radiation to my prostrate. It consisted of 25 sessions that split the dosage to ~60 GY to the prostrate and ~40 GY to the pelvic region. Reading the article I walked away with the impression that this reduced radiation amount to the pelvic area was to decrease the incidence of this issue in 2024.
If I read correctly there was a long time period since your radiation and seed implant before your recent issues. During that time did you have any symptoms that you ignored and had to had a colonoscopy during this time frame?
Once again thanks for sharing your experience and that article with us. Glad you made it through.
4 years post EBRT (44 sessions), I have been showing small blood on larger bowel movements all along. URO says "Don't chase it"Radiation induced fissure?
Hang in there, kreg001. Sounds like you’ve been through hell. I’m scheduled for 28 hits of IGIMRT in August. My RO wants me to have a Barrigel procedure first, to help protect the rectum. The statistics I recall are that just under 10% of individuals treated with RT experience GI damage. Installing a barrier such as SpaceOr (sp) or Barrigel reduces it to around 4%. I’m assuming you did not have this procedure. Not sure what prompts an RO to recommend this procedure, but that I might reduce the chance for damage by 50% was enough to convince me. Of course it’s the reason my RT has been delayed 3 mos. Best wishes for a continued recovery from your ordeal.
Not available or recommended at the time. Drank lots of water an hour or two before radiation and held it in my bladder. The fact these pre-treatments exist seems to confirm damage from radiation occurred.
good question. I’d say I was symptom free. Photo is after or just before the salvage brachytherapy. Following brachy, when PSA began rising again, I went back to Lupron and became obese. Other than that no health issues until this episode started March 17th.
Photo of me with my daughter and her daughter ~2017.
I had a (dental) patient who had surgery AFTER radiation, and wound up with a situation similar to yours.
When my brother was diagnosed I went with him to a consultation with a RO at MSKCC and told him about my patient, and he claimed they'd gotten so much more precise with RT that that wasn't a large concern. Of course, both my patient and you had your RT quite a while ago, so what the RO said may well be true.
In any case, I've heard literally nothing about RT as posing anything like a high-level risk. Surgery after BR when primary treatment has been RT is another story, and again I have no current information. As to surgery in the head/neck area after RT for cancer, that's another story--we were always terrified about tooth extractions in jaws that had been irradiated. I think the story there has improved too, but there's always a risk.
Whew, sorry that happened to you. It was a risk for me too, but they did some surgery before hand and put in a gel called SPACE-OAR designed to shield the rectum somewhat. Symptoms of photon radiation were limited to increased difficulty in urination, and some diarrhea. I sure hated those early morning enemas.
no protecting the rectum when that’s where the tumor lands. I’ve got bleeding at times since 2019 March. Sorry to hear about your misery but you have given me something to tell my doctor when I get my next colonoscopy in September.
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