|Year : 2021 | Volume
| Issue : 3 | Page : 108-110
Aastha Shah, U Suryanarayan
Department of Radiation Oncology, The Gujarat Cancer and Research Institute, Ahmedabad, Gujarat, India
|Date of Submission||11-Aug-2021|
|Date of Decision||12-Aug-2021|
|Date of Acceptance||15-Aug-2021|
|Date of Web Publication||23-Sep-2021|
Dr. Aastha Shah
Department of Radiation Oncology, The Gujarat Cancer and Research Institute, Ahmedabad, Gujarat
Source of Support: None, Conflict of Interest: None
Radiotherapy is one of the widely used modalities of treatment in an oncology setting whether the approach to treat cancer is either curative or palliative. Tumor masses bleeding is not an uncommon emergency in cancer patients and local radiotherapy is very commonly used as a hemostatic therapy. Hemostatic radiotherapy is used in wide variety of cancers such as head-and-neck cancers including oral tongue and base of tongue cancers more commonly, fungating and bleeding neck nodes, bleeding bronchial, and lung tumors presenting as hemoptysis, pelvic malignancies most commonly includes cervical cancers presenting as bleeding per vaginum. teletherapy as well as brachytherapy both can be used for alleviation of symptoms thus avoiding a protracted course and improving the quality of life of patients. The radiotherapy doses of 40 Gray in 15 fractions, 30 Gray in 10 fractions, 20 Gray in 5 fractions, 15 Gray in 5 fractions,8 Gray in single fraction and 4 Gray in single fraction have been used which are equally effective for controlling bleeding but protracted courses should be avoided to prevent treatment dropouts. Long-term side effects are more to be worried of in cases of hypofractionation but such patients have a poor median survival generally so symptom alleviation should be our utmost target. Hypofractionated palliative hemostatic radiotherapy is very effective for the alleviation of symptoms and the purpose of the treatment approach but individualized patient-based decisions should be used for tumor control if to be planned further.
Keywords: Brachytherapy, hemostatic radiation, hypofractionation, palliation
|How to cite this article:|
Shah A, Suryanarayan U. Hemostatic radiotherapy. J Radiat Cancer Res 2021;12:108-10
| Introduction|| |
Radiotherapy is one of the widely used modalities of treatment in an oncology setting whether the approach to treat cancer is either curative or palliative. Tumor masses bleeding is not an uncommon emergency in cancer patients and local radiotherapy is very commonly used hemostatic therapy in these patients. Palliative care that focuses on issues that bring discomfort to the patient needs utmost care and radiation oncology focuses on that. This writing reviews articles that focus on different fractionation regimes used in hemostatic radiotherapy and experiences of different oncology centers in the management of hemostasis of bleeding tumors. Hemostatic radiotherapy is used in wide variety of cancers such as head-and-neck cancers including oral tongue and base of tongue cancers more commonly, fungating and bleeding neck nodes, bleeding bronchial, and lung tumors presenting as hemoptysis, pelvic malignancies most commonly includes cervical cancers presenting as bleeding per vaginum.
| Methods|| |
An intense review of literature was done and different articles showing the employment of different radiotherapy fractionation regimes used in various malignancies for the purpose of hemostasis. The articles and studies cited in the literature have encompassed a variety of tumor sites and used a wide range of dosage schedules. Many advanced tumors usually present with such life-threatening bleeding which requires urgent care. Some have employed teletherapy as well as brachytherapy including intracavitary radiation in gynecological malignancies, endobronchial radiotherapy, and intraluminal radiotherapy in esophageal cancers. The incorporation of brachytherapy has encouraged to deliver a larger biological effective dose (BED) to the tumor to control bleeding. Some studies have also shown that after bleeding control as of priority basis due to tumor shrinkage even further dose escalation for a radical curative intent to treat the tumor can also be done keeping in mind the general condition of the patient, the volume of disease at initial presentation, and post hemostatic radiotherapy.
All the articles that were reviewed are summarized in [Table 1]. All studies were retrospective in nature and one was a case report. Rasool et al. suggested that from its review of 25 patients of advanced as well as recurrent tumors presenting with bleeding that radiotherapy should be considered in controlling bleeding in advanced cancer that is directly related to tumor invasion. Shorter fractionation schedules should be preferred. Reduced fraction regimens appear to be as effective as multiple fractions in controlling bleeding and help in shorter hospital stays of patients. Radiotherapy can control vaginal bleeding in a significant percentage of patients by rapid shrinkage of the tumor and sealing of the oozing vasculature by fibrosis. Both external and intracavitary radiotherapy have been used for hemostatic treatment as seen in Biswal et al. Asakura et al. reviewed the data for all patients with gastric cancer with grade 2 bleeding i.e. requiring blood transfusion treated with radiation. The main purpose of this study was to evaluate the effectiveness of 30 Gy in 10 fractions for bleeding from advanced gastric cancer and concluded that 30 Gy in 10 fractions is as effective as 40 Gy in 16 fractions and 35 Gy in 15 fractions. Aljabab et al. concluded that the duration of hemostasis was relatively modest after irradiation of tumor and average bleeding was controlled but for the majority of the remaining life expectancy in this population with advanced bladder malignancy and a poor prognosis. Sapienza et al. showed that protracted courses of radiotherapy can be safely omitted and shorter courses can be equally effective to prevent dropouts. Helena Sung-In Jang et al. described two cases in which the effect of radiotherapy was lifesaving in hemorrhagic cutaneous skin malignancies. A radical case is described in a neoadjuvant setting for a large malignant fibrous histiocytoma of the scalp skin and a palliative case which used radiation for melanoma metastases of the small bowel. Other studies have shown similar results with radiotherapy as an effective modality for hemostasis of bleeding malignancies.
From these retrospective studies, it can be clearly seen that the median survival of these patients is often short and the approach to whether irradiate the tumor postbleeding control remains individualized. There is no one for all accepted standard radiotherapy dose fractionation to control bleeding. The literature divulges a wide range of radiotherapy dosage schedules ranging from large single fractions to hypofractionated treatments delivered daily or weekly.
| Mechanism of Hemostatic Radiotherapy and Dose Range|| |
Bleeding from tumors can present in many ways depending on their site including hematemesis, hematochezia, melena, hemoptysis, hematuria, epistaxis, vaginal bleeding, or ulcerated skin lesions. Local modalities include topical hemostatic agents, dressings, endoscopy, vessel ligation, tissue resection, cauterization, styptics, transcutaneous arterial embolization, or balloon placement. Systemic treatments include blood products, Vitamin K, vasopressin or desmopressin, somatostatin analogs, and antifibrinolytic agents. Radiotherapy is generally after these resorts. The exact mechanism behind radiation therapy acting as a hemostatic agent is not clear. Despite cancer itself being a prothrombotic state, anticancer treatments also enhance this state. Radiotherapy might cause local thrombus formation through various mechanisms. Cancer treatment results in the release of a series of soluble mediators that can act on the endothelial cells by altering their normal antithrombotic and antiadhesive status. Capillaries are the most radiosensitive part of the vascular system because they contain endothelial cells. Pathological assessment of postirradiated tissue has shown inflammation of the capillary bed, thrombosis, detachment of endothelial cells from the plasma membrane, and loss of large portions of capillary segments.
The BEDs of 40 Gy in 15 fractions is 50.7 Gy, 30 Gy in 10 fractions is 39 Gy, 20 Gy in 5 fractions is 28 Gy, 15 Gy in 5 fractions is 19.5 Gy and 8 Gy in 1 fraction is 14.4 Gy and 4 Gy in 1 fraction is 5.6 Gy as per the Linear-Quadratic Model. Hypofractionated radiation therapy, or the use of a smaller number of fractions but larger dose per fraction (3–8 Gy) of radiation, is ideally suited for palliation of symptoms due to metastatic cancer and keeping in mind the ultimate aim of improving the quality of life of the patients. Long-term side effects are more to be worried of in cases of hypofractionation, but such patients have a poor median survival generally so symptom alleviation should be our utmost target. Radiotherapy has shown excellent results in controlling bleeding, but during this supportive care should be given to the patient strictly including blood transfusions.
| Conclusion|| |
Hypofractionated palliative hemostatic radiotherapy is very effective for the alleviation of symptoms and the purpose of the treatment approach but individualized patient-based decisions should be used for tumor control if to be planned further.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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