|Year : 2013 | Volume
| Issue : 2 | Page : 118-121
A prospective randomized controlled trial to study the role of sulfasalazine in prevention of acute gastrointestinal toxicity associated with concurrent chemoradiation in carcinoma cervix
Santanu Pal, Shyam Sundar Adhikary, Biswamit Bhattacharya, Joydeep Basu, Tanmoy Ghosh, Niladri Behari Patra
Department of Radiotherapy, Medical College, Kolkata, West Bengal, India
|Date of Web Publication||19-Jun-2013|
Flat 3C, Merlin Niket, 88C Baburam Ghosh Road, Kolkata - 700 040, West Bengal
Source of Support: None, Conflict of Interest: None
Background: The primary aim of the study was to evaluate the effectiveness of sulfasalazine in reducing the incidence of acute radiation-induced enteritis in carcinoma cervix patients receiving pelvic external beam radiotherapy along with concurrent cisplatin-based chemotherapy. Materials and Methods: Between November 2011 and July 2012 a total of 98 patients of locoregionally advanced carcinoma of cervix (49 each in study and control arms) were enrolled in this study. Patients in both the arms were treated with whole pelvis external beam radiotherapy with total dose of 50 Gy in conventional fractionation. Along with this inj. cisplatin was given concurrently at the dose of 40 mg/m 2 of body surface area every week during radiation for 5 weeks. Concurrent chemoradiation was followed by brachytherapy after a gap of 2 weeks. Patients in the study arm also received tablet sulfasalazine 1,000 mg orally twice daily from the day of starting of radiotherapy to 1 week after completion of treatment. Weekly follow-up of all patients to assess acute toxicities was done using common toxicity criteria version 4.0 (CTC v4.0) toxicity scores. Data analysis was carried out by SPSS version 20.0 software. Results: Incidence of grade II or higher grade, lower gastrointestinal toxicity was 19.14% (09/47) in study arm and 41.66% (20/48) in control arm which was statistically significant (P = 0.017). Conclusion: The study shows that sulfasalazine can significantly reduce the acute radiation-induced diarrhea (ARID) in patients undergoing whole pelvis external beam radiotherapy for carcinoma cervix. The drug is safe, cheap, and readily available.
Keywords: Chemoradiation, diarrhoea, sulfasalazine
|How to cite this article:|
Pal S, Adhikary SS, Bhattacharya B, Basu J, Ghosh T, Patra NB. A prospective randomized controlled trial to study the role of sulfasalazine in prevention of acute gastrointestinal toxicity associated with concurrent chemoradiation in carcinoma cervix. Clin Cancer Investig J 2013;2:118-21
|How to cite this URL:|
Pal S, Adhikary SS, Bhattacharya B, Basu J, Ghosh T, Patra NB. A prospective randomized controlled trial to study the role of sulfasalazine in prevention of acute gastrointestinal toxicity associated with concurrent chemoradiation in carcinoma cervix. Clin Cancer Investig J [serial online] 2013 [cited 2019 Nov 18];2:118-21. Available from: http://www.ccij-online.org/text.asp?2013/2/2/118/113633
| Introduction|| |
Radiation therapy is the mainstay of treatment in various common gynecological malignancies like cervical and endometrial carcinoma, gastrointestinal malignancy such as anal and rectal carcinoma, and genitourinary malignancy like carcinoma of urinary bladder and prostate. For these cancers, patients are often subjected to pelvic irradiation in primary or adjuvant setting. Concurrent chemotherapy along with pelvic irradiation is the standard of care in carcinoma cervix stage IIB to IVA. , Pelvic irradiation causes mucosal damage to normal gut tissue;  both small and large intestine which fall within the treatment field; leading to fat malabsorption, leakage of albumin, and hypermotility. Radiation tolerance of small bowel is a dose limiting factor because of early adverse effect. , These patients often present with diarrhea and abdominal cramping termed as acute radiation enteritis (ARE), starting during 2 nd and continuing to 3 rd week of pelvic irradiation.  These side effects occur in about 75-80% of patients receiving pelvic radiotherapy. In patients receiving concurrent chemotherapy, the gastrointestinal toxicity is more severe in grade as anticipated. In some of the patients these side effects are so severe that we have to withhold radiation therapy in the middle of the treatment, leading to prolongation of treatment time, thus reducing the therapeutic benefit. 
This radiation-induced gut toxicity can be reduced by techniques like treating the patients in prone position or treating the patients with full urinary bladder. These techniques help to displace the small gut from the radiation field. , In some studies, it is seen that this radiation-induced diarrhea can be prevented by use of sulfasalazine 1 gm orally twice daily. The rationale for using sulfasalazine is that this radiation-induced diarrhea mainly occurs due to increased synthesis of nuclear regulating proteins that regulate cytokines and have secondary effect on eicosanoids.  Sulfasalazine reduces the synthesis of eicosanoids. So our aim in this present clinical trial is to explore the role of sulfasalazine in concurrent chemoradiation-induced diarrhea. We have also noticed that there is paucity of recent research publications addressing the effectiveness of sulfasalazine in prevention of concurrent chemoradiation-induced diarrhea.
| Materials and Methods|| |
The entire study was conducted in the Department of Radiotherapy, Medical College Hospital, Kolkata between November 2011 and July 2012. Total 98 patients, belonging to the age range 18-70 years and sufficing the following criteria were included in this study: Attending the outpatient department with histologically proven squamous cell carcinoma (SCC) of cervix; Karnofsky performance status (KPS) more than 60; normal hematological, renal, and hepatic function. Informed consent was taken from all the patients. Patients with pregnancy and lactation, history of prior chemotherapy or radiotherapy to the pelvic region, uncontrolled comorbid conditions, and with evidence of distant metastasis were excluded from the study. Patients were randomly allocated to arm A (study arm) and arm B (control arm) who were planned for radical radiation therapy with concurrent chemotherapy; every other patient was recruited in the study arm. Patients on study arm were prescribed sulfasalazine 1,000 mg twice daily as oral medication from the day of starting of radiotherapy and continue till 1 week after completion of treatment while the control population were prescribed placebo.
Patients in both the arms were treated with external beam radiotherapy (EBRT) with conventional 2 Gy/fraction, 5 days a week for 5 weeks with total dose of 50 Gy with standard anteroposterior-posteroanterior (AP-PA) or four-field box technique using Telecobalt unit THERATRON 780C (Theratronics), CT-simulator (Brilliance CT 16-slice configuration, Philips Health Care), and ASHA 3D Planning System (TPS). Cisplatin were given concomitantly at a dose of 40 mg/m 2 of body surface area on every week during radiation for 5 weeks. After EBRT all patients received intracavitary brachytherapy (7-9 Gy per fraction to a total dose of 18-24 Gy) using Gamma Med Plus machine (Varian Medical Systems International India Pvt. Ltd).
Patients were followed-up every week to assess acute toxicities from the start of treatment to 4 weeks after completion of chemoradiation using CTC v4.0 [Table 1]. Level of significance will be calculated by Chi-square test. P values of 0.05 or less is considered to be significant. Data analysis was carried out by SPSS version 20.0 software.
| Results|| |
Total 98 patients were studied and their characteristics are given in [Table 2]. Two patients from the test arm and one patient from control arm discontinued treatment midway due to unknown reasons. One patient in the control arm required hospital admission and parenteral support. Other adverse effects viz. renal, hematological, hepatic and dermatological toxicities were comparable in both arms. Most of the cases of acute radiation-induced diarrhea (ARID) occurred from third week of radiation onwards in both the arms.
[Table 3] and [Figure 1] describe the grades of lower gastrointestinal toxicities in two arms. The incidence of overall (Grade I-IV) lower gastrointestinal toxicity was 44.68% (21/47) in treatment arm and 75% (36/48) in control arm which was statistically significant (P = 0.0025). It is seen that incidence of Grade II or more lower gastrointestinal toxicity was 19.14% (09/47) in treatment arm and 41.66% (20/48) in control arm (P = 0.017). No Grade IV toxicity was found in study arm.
|Table 3: Distribution according to grade of lower gastrointestinal toxicity|
Click here to view
| Discussion|| |
Pelvic radiotherapy is often associated with ARID which mainly starts around 3 rd week of radiation. Radiation causes irritation and inflammation of gastrointestinal tract. There is excess production of prostaglandin, thromboxane, and leukotriene. They also affect water and electrolyte absorption and contractility of the gut. The excess production of prostaglandin as a cause of diarrhea during pelvic radiation was postulated by Mennie et al. 
One study by Resbeut et al.,  showed that mesalazine (5-aminosalicylic acid) is ineffective to reduce the rate of radiation-induced diarrhea. Another study by Martenson et al.,  showed worsening of symptoms after using olsalazine. But two studies, one by Rauch et al.,  and Kilic et al.,  showed decrease in incidence of ARID after use of sulfasalazine. The different results with different formulations of 5-aminosalicylic acid may be due to difference in drug formulation and also due to difference in side effect profile.
Mesalazine contains only 5-aminosalicylic acid. There is no carrier molecule. So it may not be effectively deposited in the terminal part of small intestine or the colon. Olsalazine consists of two molecules of 5-aminosalicylic acid coupled by azo bond. This azo bond is split in the colon. So no separate carrier is needed. But it may aggravate diarrhea by inhibiting water and electrolyte absorption in small intestine and also by decreasing transit time through bowel. However, sulfasalazine is a 5-aminosalicylic acid compound with sulfapyridine linked by an azo bond. This sulfapyridine is only a carrier molecule. The azo bond is broken by colonic bacteria by azoreductase releasing the active molecule, that is, 5-aminosalicylic acid. , It exerts an anti-inflammatory effect by inhibiting lipooxygenase and cyclooxygenase enzymes, and thus reduces production of prostaglandin and leukotriene and other mediators such as cytokines and platelet activation factor. Besides, scavenging of free radicals has also been attributed to 5-aminosalicylic acid as a proposed mechanism of action. 
These unique properties of sulfasalazine and its differences from other 5-aminosalicylic acid congeners prompted us to choose sulfasalazine in our study to prevent ARID. As ARID mainly results from irritation and inflammation of the gut, we have got promising results by using sulfasalazine to reduce the incidence of the same. Grade II or higher grade diarrhea were significantly less in the sulfasalazine arm and the findings were validated statistically. Sulfasalazine is a cheap and effective method to reduce the incidence of ARID. The patients are on routine follow-up to assess any change in disease response and late toxicity profiles as well.
In conclusion, our analysis reveals that administration of sulfasalazine reduces lower gastrointestinal toxicity of pelvic radiation and concurrent chemotherapy. Further clinical trials with greater number of patients will be of value for investigators who want to reduce treatment toxicity as an endpoint in concurrent pelvic chemoradiotherapy.
| References|| |
|1.||Rose PG, Bundy BN, Watkins EB, Thigpen JP, Deppe G, Maiman MA, et al. Concurrent cisplatin-based radiotherapy and chemotherapy for locally advanced cervical cancer. N Engl J Med 1999;340:1144-53. |
|2.||Whitney CW, Sause W, Bundy BN, Malfetano JH, Hannigan EV, Fowler WC Jr, et al. Randomized comparison of fluorouracil plus cisplatin versus hydroxyurea as an adjunct to radiation therapy in stages IIB-IVA carcinoma of cervix with negative para-aortic lymph nodes: A Gynecologic Oncology Group and Southwest Oncology Group study. J Clin Oncol 1999;17:1339-48. |
|3.||Saclarides TJ. Radiation injuries of the gastrointestinal tract. Surg Clin North Am 1997;77:261-8. |
|4.||Crook J, Esche BA. Genital tract, uterine cervix. In: Cox JD, editor. Moss' Radiation Oncology Rationale, Techniques, Results. 7 th ed. St. Louis: Mosby; 1994. p. 655-656. |
|5.||Peters LJ. Radiation therapy tolerance limits. For one or for all?-Janeway Lecture. Cancer 1996;77:2379-85. |
|6.||Resbeut M, Marteau P, Cowen D, Richaud P, Bourdin S, Dubois JB, et al. A randomized double blind placebo controlled multicenter study of mesalazine for the prevention of acute radiation enteritis. Radiother Oncol 1997;44:59-63. |
|7.||Herbert SH, Curran WJ Jr, Solin LJ, Stafford PM, Lanciano RM, Hanks GE. Decreasing gastrointestinal morbidity with the use of small bowel contrast during treatment planning for pelvic irradiation. Int J Radiat Oncol Biol Phys 1991;20:835-42. |
|8.||Adli M, Mayr NA, Kaiser HS, Skwarchuk MW, Meeks SL, Mardirossian G, et al. Does prone positioning reduce small bowel dose in pelvic irradiation with intensity-modulated radiotherapy for gynecologic cancer? Int J Radiat Oncol Biol Phys 2003;57:230-8. |
|9.||Jawetz E. Sulphonamides and trimethoprim. In: Katzung BG, editor. Basic and Clinical Pharmacology. 6 th ed. Norwalk: Appleton and Lange; 1995. p. 716-722. |
|10.||Mennie AT, Dalley VM, Dinneen LC, Collier HO. Treatment of radiation-induced gastrointestinal distress with acetylsalicylate. Lancet 1975;2:942-3. |
|11.||Martenson JA Jr, Hyland G, Moertel CG, Mailliard JA, O'Fallon JR, Collins RT, et al. Olsalazine is contraindicated during pelvic radiation therapy: Results of a double-blind, randomized trial. Int J Radiat Oncol Biol Phys 1996;35:299-303. |
|12.||Rauch K, Weilland H. Therapy of radiogenic colitis with salicylazosulfapyridine (azusulfidine). Strahlentherapie 1972;143:660-3. |
|13.||Kiliç D, Egehan I, Özenirler S, Dursun A. Double-blinded, randomized, placebo-controlled study to evaluate the effectiveness of sulphasalazine in preventing acute gastrointestinal complications due to radiotherapy. Radiotherapy and Oncology 2000;57 (2):p. 125-129. |
|14.||Sandberg-Gertzén H, Järnerot G, Bukhave K, Lauritsen K, Rask-Madsen J. Effect of azodisal sodium and sulphasalazine on ileostomy output of fluid and PGE2 and PGF2 alpha in subjects with a permanent ileostomy. Gut 1986;27:1306-11. |
|15.||Ahnfelt-Rønne I, Nielsen OH, Christensen A, Langholz E, Binder V, Riis P. Clinical evidence supporting the radical scavenger mechanism of 5-aminosalicylic acid. Gastroenterology 1990;98:1162-9. |
[Table 1], [Table 2], [Table 3]
|This article has been cited by|
||Interventions to reduce acute and late adverse gastrointestinal effects of pelvic radiotherapy for primary pelvic cancers
| ||Theresa A Lawrie,John T Green,Mark Beresford,Linda Wedlake,Sorrel Burden,Susan E Davidson,Simon Lal,Caroline C Henson,H. Jervoise N Andreyev |
| ||Cochrane Database of Systematic Reviews. 2018; |
|[Pubmed] | [DOI]|
||Pelvic Radiation and Normal Tissue Toxicity
| ||Sarah Nicholas,Linda Chen,Amanda Choflet,Amanda Fader,Zachary Guss,Sarah Hazell,Daniel Y. Song,Phuoc T. Tran,Akila N. Viswanathan |
| ||Seminars in Radiation Oncology. 2017; 27(4): 358 |
|[Pubmed] | [DOI]|
||N08C9 (Alliance): A Phase 3 Randomized Study of Sulfasalazine Versus Placebo in the Prevention of Acute Diarrhea in Patients Receiving Pelvic Radiation Therapy
| ||Robert C. Miller,Daniel G. Petereit,Jeff A. Sloan,Heshan Liu,James A. Martenson,James D. Bearden,Ronald Sapiente,Grant R. Seeger,Rex B. Mowat,Ben Liem,Matthew J. Iott,Charles L. Loprinzi |
| ||International Journal of Radiation Oncology*Biology*Physics. 2016; 95(4): 1168 |
|[Pubmed] | [DOI]|
||Prevention of pelvic radiation disease
| ||Lorenzo Fuccio |
| ||World Journal of Gastrointestinal Pharmacology and Therapeutics. 2015; 6(1): 1 |
|[Pubmed] | [DOI]|