What is Papillon?

With the introduction and improvements in bowel/colorectal screening in the UK, more patients will be diagnosed with early rectal cancer. The UK has an increasingly elderly population and not all patients diagnosed with early rectal cancer will be suitable for radical surgery. Advances in pre-operational treatment means that in some cases the removal of the rectum, anus and colon might not be the only.

Over the past decade there has been increasing interest in local treatment options for small tumours in the lower third of the rectum as an alternative to Abdomino-Perineal excision of the rectum. This is offered mainly to elderly patients or younger patients with significant medical co-morbidity who are at increased operative risk. In addition, some patients are stoma averse and refuse conventional treatment despite understanding the risk of a lower cure rate.

For T1N0M0 tumours, local treatment with either radical radiotherapy or local surgery is now accepted as a possible alternative to radical surgery. However, for more advanced tumours, this approach is not accepted as a standard treatment in the UK. The key area of discussion is whether the cancer will have spread via the lymph nodes or not, in early rectal cancer (5-10%), and whether that risk is manageable enough for it to be worth removing the primary tumour to preserve sphincter function.

Papillon is a form of treatment which, is known as contact radiotherapy. Papillon was originally developed prior to the Second World War, when there was a shortage of radium in Germany and superficial X-rays were used for intracavitary treatment in cervical carcinoma. This inspired its usage to treat inoperable rectal carcinomas and it was shown that high doses of low energy X-ray could be safely delivered directly to a rectal tumour. Professor Papillon, from Lyon, popularised the technique for clinical use in the mid to late 1940’s, and it is with his name that the treatment remains associated today. Over the last 50 years, thousands of patients have been treated throughout the world and a general overview of the results suggests a long-term local control rate of 80-90%.

In 1992, the Papillon technique was introduced at Clatterbridge Centre for Oncology and who are now, after pioneering this treatment in the UK, training consultants, physicists, radiographers and surgeons from hospitals who are looking to offer Papillon treatment in the UK and mainland Europe. Whilst smaller tumours are now to be considered for this treatment, it is the use of Papillon in conjunction with pre-operative chemo & radiotherapies that is being examined for early T2 tumours larger than 3cm. When combined with these traditional techniques it is possible in some cases to downstage larger or more advanced tumours to allow local treatment such as Papillon and/or micro surgical techniques in order to preserve the organ (anus) and reduce the likelihood of a permanent colostomy bag.

Frequently Asked Questions

What is Bowel Cancer?

When discussing bowel cancer, a lot of people get confused by the differences between bowel, colon and Colorectal cancers, the main reason is to do with the position of the tumour. You may hear these terms used when discussing the bowel and “large bowel”.

The bowel is divided into four sections: ascending; transverse; descending; and sigmoid. Although the bowel itself has no digestive function, it does absorb large amounts of water and electrolytes, which help the maintenance of the body’s systems, known as homeostasis. Waste food is passed on from the small bowel to the large bowel where water is re-absorbed. Cancer occurs when cells in your bowel multiply out of control. These cells can invade surrounding tissue and spread to other parts of the body.

Most bowel cancers develop from polyps, which are usually non-cancerous and, once detected, can be removed easily if caught early enough.

  • Every year, over 40,000 people are diagnosed with the disease: that’s someone every 15 minutes
  • Bowel cancer is the third most common cancer in the UK affecting both men and women
  • Bowel cancer is the second most common cause of cancer death in the UK affecting men and women
  • Every year, over 16,000 people die from the disease: that’s someone every 30 minutes
  • 85% of all diagnoses are in people over the age of 60
  • Bowel cancer is highly treatable when caught in the early stages
  • Most symptoms do not turn out to be caused by bowel cancer

For more information about Bowel Cancer, its symptoms and treatments:



What are the causes of bowel cancer?

There are no definitive reasons as to what are the causes of bowel cancer, but there are four areas that should be taken into account or at the very least be kept in mind when assessing the risk.

For more information:




Bowel cancer affects both men and women equally. It tends to affect people over the age of 60 although the number of younger people that are being diagnosed is increasing quite significantly.

Family history

People with a family history of bowel cancer are often diagnosed before the age of 45 so may need early screening.

Diet and lifestyle

An inactive lifestyle and a low fibre, high-fat diet can increase the risk of bowel cancer. Red and processed meat, insufficient amounts of fruit and vegetables, smoking and excess alcohol are contributory factors.

Inflammatory bowel disease

People with a history of Crohn’s disease in the large bowel, or ulcerative colitis, or who have had previous polyps removed, may also be at an increased risk.

For more information:


What are the symptoms of bowel cancer?

Bowel/Colon cancer can be effectively countered if diagnosed early enough, but with a 50%+ mortality rate it is obvious that people are either not aware or are not taking the symptoms seriously. One of the main problems is that all of these symptoms (below) can be caused by other diseases, apart from cancer. Many of these other conditions are much less serious than bowel cancer, such as piles (haemorrhoids), infections, IBS or inflammatory bowel disease.

The common wisdom is that if you are young and have bleeding from the back passage with itching and soreness, you are much more likely to have piles than bowel cancer. Whilst this is true for the majority of cases it isn’t always, meaning diagnosis may be dictated by the mind set of your GP; so don’t be scared to ask for a second opinion. Another problem is, many people with colorectal cancer don’t have these symptoms. So, if you are worried about any symptoms at all you think may be caused by cancer in the bowel, always question your GP or contact any of the Charities on this site.

For more information:




  • Bleeding from the back passage (rectum) or blood in your stools
  • A lasting change in normal bowel habits towards diarrhoea or looser stools
  • A lump that your doctor can feel in the right side of your abdomen, or in your rectum
  • A straining feeling in the rectum
  • Losing weight
  • Pain in your abdomen or rectum
  • Anemia (low red blood cells)

Because bowel tumours can bleed on and off, cancer of the bowel often causes a shortage of red blood cells. This is called anemia. It can lead to tiredness and sometimes breathlessness. Sometimes cancer of the bowel can cause a blockage also known as a bowel obstruction. The symptoms of this are

  • Griping pains in the abdomen
  • Feeling bloated
  • Constipation
  • Being sick

As mentioned all of the above can and do occur because of other issues that are not cancer related. This should not however stop you from visiting the GP, especially if you are in one of the higher risk categories mentioned. It is always better to check and be wrong than not check and be in potential trouble

What are the treatments for Bowel Cancer?

Traditionally, surgery is the main method of treatment. If you think of the colon as a long pipe, the part of the colon containing the tumour is chopped out and usually a colostomy is performed. In a colostomy, the end of the bowel is diverted to the surface of the abdomen, where the faeces are collected in a plastic bag. This can be a temporary measure, as when the part of the colon that had the cancer has recovered, it can be reconnected to the rest of the bowel. However, if the tumour is in the lower rectum then both the rectum and anus may have to be removed and the colostomy will be permanent. Often patients are given radiotherapy or chemotherapy after the operation as this can kill off any remaining cancer cells.

Alternative treatments to radical surgery are being developed all the time in response to the dangers inherent in undertaking any major surgery – this is of particular concern for the elderly or those with underlying medical conditions.

For futher information:


What is Cancer?

The body is made up of tiny building blocks called cells, which are constantly dying and reproducing themselves. Normal cells divide in an orderly and controlled manner. Sometimes however, this process is disrupted and the cells carry on dividing, developing into a lump which is called a tumour.

A tumours can be either benign or malignant. If the tumour turns out to be malignant it is then classed as a cancerous tumour. In order to determine whether or not the tumour is benign or malignant, a small sample of cells is taken and examined in a procedure called biopsy.

In a benign tumour the cells do not spread to other parts of the body. With a malignant tumour, ie cancer cells that have the ability to spread beyond the original area, if it is left untreated it may spread into and destroy surrounding tissue. Sometimes cells break away from the original (primary) cancer, and may spread to other organs in the body through the bloodstream or the lymphatic system.

There are more than 200 different kinds of cancer, each with its own name and treatment.

For more information on types of cancer go to:



Trans-Endo Microsurgery (TEM)

TEM is a minimally invasive procedure, first reported in 1983, which enables the excision of rectal tumours up to 20 cm from the anal verge. TEM is usually carried out for benign rectal lesions, but can be used for early cancers, and a full-thickness excision is carried out, which can include perirectal tissue. TEM uses a specially designed 40 mm diameter operating rectoscope with a three dimensional optical system of 6_ magnification power. The dissection is precise and the direct magnified vision enables sufficient margins of the surrounding normal healthy tissue to be removed. TEM has a low complication rate and postoperative recovery time is much quicker than it is after conventional surgery.

The basic idea is that through this combined treatment the tumour will be reduced significantly enough to be removed via a local resection, such as the TEM.

What is Chemotherapy?

Chemotherapy is the use of anti-cancer (cytotoxic) drugs to destroy cancer cells (including leukaemia and lymphoma).

The type of chemotherapy you are given will depend on many things, but primarily:

  • the type of cancer you have
  • where the cancer started in your body
  • what the cancer cells look like under the microscope
  • whether the cancer has spread to other parts of your body
  • Chemotherapy may be used as a stand alone treatment for some types of cancer, or used inconjunction with different treatments such radiotherapy, biological & hormonal therapies as well as surgery, or a combination of these

For more information on chemotherapy go to:



Types of Chemo

There are over 50 different chemotherapy drugs. Some are given on their own but often several drugs are given together. This is known as combination chemotherapy.

For more information on specific drugs go to:http://www.macmillan.org.uk/Cancerinformation/Cancertreatment/Treatmenttypes/Chemotherapy/Chemotherapy.aspx

Side effects: Chemotherapy

There are as many different side effects as there are chemotherapy drugs. Everyone will react in a different manner to their own chemotherapy treatment: some people may have very few side effects while others will have a lot. Almost all side effects are only short-term and will gradually disappear once the treatment has stopped.

The main areas of your body that may be affected by chemotherapy are those where normal cells rapidly divide and grow, such as the lining of your mouth, the digestive system, your skin, hair and bone marrow (the spongy material that fills the bones and produces new blood cells).

Side effects may include:

  • Mouth sores and ulcers
  • Diarrhoea
  • Gritty eyes and blurred vision
  • Skin changes such as darkening
  • Temporary reduction in bone marrow function – this comes with a risk of anaemia, bruising or bleeding and infection
  • Nausea and vomiting
  • Hair loss
  • Changes in nails, i.e. changing colour or going brittle, chipped or ridged
  • Sensitivity of the skin to sunlight
  • Rashes
  • Soreness and redness of the palms of the hands and the soles of the feet (sometimes known as Palmar Plantar syndrome.)
  • Increased production of tears

For more information:


What is Radiotherapy?

Radiotherapy is the use of high-energy radiation from X-rays, gamma rays, neutrons, protons and other sources to kill cancer cells and shrink tumours. Radiation may come from a machine outside the body (external-beam radiation therapy), or it may come from radioactive material placed in the body near cancer cells (internal radiation therapy, implant radiation or brachytherapy). Systemic radiation therapy uses a radioactive substance, such as a radio-labeled monoclonal antibody, that circulates throughout the body.

It can be used for the following reasons:

  • For some cancers that are diagnosed early (e.g. coloractal, cancers of the skin, cervix, prostate, lungs, thyroid and brain), when it may be the only treatment needed to cure the cancer. This is known as radical radiotherapy
  • To reduce the size of some cancers before surgery. This is called neo-adjuvant treatment
  • To make sure all the cancer cells are destroyed after surgery, and to treat local spread of the cancer (such as in the treatment of breast cancer). This is called adjuvant treatment
  • In the emergency treatment of a cancer pressing on the spinal cord, to reduce the size of the cancer and prevent damage to the nerves
  • In advanced cancer to slow down the progress of the disease and relieve pain and other symptoms

For more information on radiotherapy:



Side effects: Radiotherapy

Whilst there are several different types of radiotherapy for different cancers, I can only give an overview of some of the general side effects and some that are specific for pelvic radiotherapy. Note – due to the treatment being delivered directly and internally to the tumour via Papillon external and more ranging side effects do not generally occur.

Examples of some of the side effects are:

  • Tiredness
  • Effects on the skin
  • Discomfort when going to the loo
  • Infertility
  • Pain on ejaculation (men only)
  • Early menopause
  • Localised hair loss

For more information of side effects from Radiotherapy:


What to do if you or someone else might have bowel cancer?

If you think that you or somebody close to you might be showing symptoms of bowel cancer, or indeed just having a rather strange toilet time at the moment, contact your GP directly, or one of the charities that is available via this site such as Beating Bowel Cancer or Bowel Cancer UK.

I work on a simple rule – it is better to check and be wrong, than ignore it and be dead.




Key Points

  • Early stage – T1 tumour as stand alone treatment
  • Small tumour less than 3cm
  • Well to moderately differentiated tumour
  • Mobile cancerous polyps
  • No spread into the lymph nodes
  • No spread at distance sights – ie liver, lungs etc
  • Low energy X-rays are directly applied to tumour and kills tumour cells layer by layer with each treatment.
  • With low energy, the depth of penetration is limited and this reduces the collateral damage to normal surrounding tissues.
  • Used mainly for T1 tumour without suspicious lymph node spread.
  • Radiology with current available technology is not wholly reliable.
  • Sometimes it is difficult to differentiate between T1 and early T2 tumour, therefore some early T2 tumours can be treated in the same way.
  • Not suitable for T3 tumours but can be used for patients who are not fit for surgery or potentially in conjunction with external beam radiotherapy and chemotherapy in order to downstage the tumour allowing local treatment options. Results are not as good as early tumours.


For more information both for patients and professionals please follow link to Clatterbridge Center for Oncology:


For more information, click here to download the Papillon Patient Booklet