|For patients with advanced, incurable or recurrent gynecologic cancer
or other pelvic cancer,
radiation my be useful in shrinking the tumor enough to relive pain, bleeding or blockage.
Often short courses of higher dose radiation (370cGy bid X 4 or 400cGy X 5) will be
quite effective with a 50 - 100% response to symptoms and objective response in 30 - 53%
(i.e. measurable shrinkage in the tumor mass.) Some studies are noted below:
Single-fraction palliative pelvic radiation therapy in gynecologic oncology: 1,000 rads.
Chafe Am J
Obstet Gynecol 1984 Mar 1;148(5):701-5
1000 cGy single dose palliation for advanced carcinoma of the cervix or endometrium.
Halle. Int J Radiat Oncol Biol Phys 1986 Nov;12(11):1947-50
42 patients with symptomatic, incurable gynecologic malignancies were treated at the University of North Carolina with 1000 cGy in a single fraction to the pelvis, repeated once or twice at monthly intervals as necessary. Of patients with adequate follow-up, total cessation of bleeding was seen in 18 of 30 (60%), complete pain relief in 2/9 (22%), and complete tumor eradication in 7/28 (25%). These palliative benefits were permanent in approximately half of the patients. Five serious treatment complications have been documented, four occurred more than 10 months after treatment. We conclude that 1000 cGy single-fraction whole pelvis treatment can be an effective means of palliating advanced gynecologic cancer provided the patient has a life expectancy of less than 1 year. Patients with a longer life expectancy are at risk for both recurrence of symptoms and for treatment related complications.
The experience in using whole pelvic irradiation in management of massive bleeding from carcinoma of the uterine cervix.
Kraiphibul. J Med Assoc Thai 1993 Jan;76 Suppl 1:78-81
there were 35 out of 1,683 new cases of carcinoma of the uterine cervix which presented with massive bleeding per vagina. All were treated via cobalt-60 teletherapy covering the whole pelvic region by 12 x 12 cm2 or 16 x 16 cm2 field sizes. Eighteen cases received a radiation dose of 300 cGy/fraction while 16 cases received 400 cGy and one case received 600 cGy. All had bleeding controlled within 2-6 fractions, twenty-two cases (62.9%) within 3 fractions and 34 cases (97.1%) within 5 fractions. There was no severe acute complication in all patients. In 10 patients who were followed up to the range of 3-70 months, median 16.5 showed no severe late complications.
Palliation of advanced pelvic malignant disease with large fraction pelvic radiation and misonidazole: final report of RTOG phase I/II study.
Spanos. Int J Radiat Oncol Biol Phys 1987 Oct;13(10):1479-82
Pelvic radiation consisted of 1000 cGy in one fraction repeated at 4-week intervals for a total of three treatments. Of the thirty-seven patients completing the three treatments; there were 6 complete responses (14% CR), 10 partial responses (27% PR) 19 minimal or no response (32% NR), and 4 unevaluable. One patient remains NED 5.5 years following radiation. Radiation toxicity was significant for late bowel damage. plot of GI toxicity showed a progressive increase in incidence with time for projected rate of 49% Grade 3, 4 by 12-month. Because of the GI complication rate, this protocol for palliation of advanced pelvic malignancies has been replaced by a protocol that uses 4 fractions over 2 days (b.i.d.) of 370 cGy per fraction repeated at 3-week intervals for a total of 3 courses.
Radiation palliation of cervical cancer.
Spanos. J Natl Cancer Inst Monogr 1996;(21):127-30
The large single-dose schedule consisted of 10-Gy fractions repeated at monthly intervals to a maximum of 30 Gy. This schedule has produced good palliative results with symptomatic improvement in approximately 50% of patients and objective response in 35%-80%. However, severe late toxicity was shown to be as high as 42% (actuarial). The second schedule tested by the Radiation Therapy Oncology Group consisted of 3.7-Gy fractions given twice a day for 2 days (14.8 Gy) repeated after 2-4 weeks for a maximum of 44.4 Gy. The subjective response (50%-100% complete response) and objective response (53%) were similar to those observed with the large single-fraction schedule. The late toxicity was significantly lower (7%-actuarial). For patients who may survive 6 months or longer, this second schedule is preferable.
Late effect of multiple daily fraction palliation schedule for advanced pelvic malignancies (RTOG 8502).
Spanos. Int J Radiat Oncol Biol Phys 1994 Jul 30;29(5):961-7
The dose was 44.40 Gy in 12 fractions (3.7 Gy BID) with a rest after 14.80 Gy and 29.60 Gy. The pilot part of the study allowed for a variable rest interval of 3-6 weeks. The rest interval was then randomized between 2 and 4 weeks to determine effect on tumor control. No difference in tumor control was identified (p = 0.59). The crude late complications rate is 6%. Actuarial analysis using cumulative incidence shows 6.9% by 18 months. This represents a significant decrease in late complications from 49% seen with higher dose per fraction (10 Gy x 3) piloted by Radiation Therapy Oncology Group (7905) for a similar group of patients. Long-term analysis of late complication indicates this schedule can be used in the pelvis with relatively low incidence of complication.
Use of high dose rate gammamed brachytherapy in the palliative treatment of gynaecological cancer.
Tan. Ann Acad Med Singapore 1994 Mar;23(2):231-4
24 patients with advanced and incurable malignancies of the female genital tract were treated at the Department of Therapeutic Radiology, Singapore General Hospital, with high dose rate (HDR) brachytherapy. Results from the evaluation of these patients showed an overall complete palliation of symptoms in 16 of 23 (69.5%) patients. Total cessation of bleeding was observed in 14 of 20 (70%) and pain relief in two of three (66.6%). Of the 16 patients who exhibited full symptomatic response, almost half (43.7%) had clinical complete resolution of their local disease at last follow-up. Acute complications following treatment were minimal and only in one was intervention required to stop radiation haemorrhagic cystitis.
Palliative radiotherapy for ovarian cancer.
Adelson. Int J Radiat Oncol Biol Phys 1987 Jan;13(1):17-21
Large single-fraction irradiation is effective palliation for advanced ovarian cancer. It has an acceptable complication rate and requires only a limited number of visits (i.e., one treatment per 4-week course) to administer. Forty-two patients received single or multiple fractions of (three maximum) 10 Gray (Gy) to the pelvis. Tumor size before and after radiotherapy was evaluable in 34 patients and decreased in 25. Bleeding decreased or stopped in 15 of 21 patients, and pain lessened or ceased in 11 of 20 patients. The safest and most efficient dose may be one or two fractions, since three 10 Gy fractions may not increase palliation.
Recurrent ovarian cancer. Effective radiotherapeutic palliation after chemotherapy failure.
Corn. Cancer 1994 Dec 1;74(11):2979-83
Median RT dose was 35 Gy (range: 7.5-45 Gy). The median fraction size was 2.5 Gy (range, 1-5 Gy). For the entire group, complete palliative response was 51% and overall palliative response was 79%. The median duration of palliation was 4 months, which reflected palliation until death in 90% of cases. The overall response rates by symptoms were: pulmonary symptom relief in 75%, vaginal bleeding control in 90%, rectal bleeding control in 85%, pain relief in 83%, and neurologic symptoms controlled in 50%. Biologically effective doses of at least 44 Gy10 (e.g., 3500 cGy/14 fractions = BED10 of 44) should be sought to maximize the probability of complete response. These results are comparable to the published experience of second-line chemotherapy in the treatment of focally symptomatic ovarian cancer recurrences.
Palliative benefit of external-beam radiation in the management of platinum refractory epithelial ovarian carcinoma.
Gelblum. Gynecol Oncol 1998 Apr;69(1):36-41
Forty-seven patients with platinum-refractory epithelial ovarian carcinoma were referred for palliative radiation and 33 (70%) were evaluable for response. Of the 33 evaluable patients, 23 (69.7%) had a complete resolution of symptoms after radiation, 8 (24%) had a partial resolution, and 2 were unassessable because of unrelated medical complications. The median duration of response was 11 months (range 1-86) and closely approximated their survival. External-beam radiation therapy can provide effective and durable palliation of symptoms in platinum-refractory epithelial ovarian carcinoma patients.
Whole abdominal radiation as salvage therapy for epithelial ovarian cancer.
Hacker Obstet Gynecol 1985 Jan;65(1):60-6
Thirty patients found to have residual epithelial ovarian cancer at second-look laparotomy were treated with whole abdominal radiation as salvage therapy. Dosage fractions were 120 rad per day until 3000 rad were delivered, then the pelvis was boosted to 5000 rad at 180 rad per day. Four of 16 patients (25%) with microscopic residual disease before radiation remain alive and free of disease at 22 to 41 months. Two of six (33%) patients with minimal (less than or equal to 5 mm) residual disease remain alive and free of disease 19 to 40 months after radiation treatment. Patients with residual nodules greater than 5 mm uniformly did poorly. Patients who progressed on primary chemotherapy had a median survival of seven months, compared with more than 38 months for chemotherapy responders. Chronic bowel morbidity was a significant problem, with 30% of patients surviving at least four months from completion of radiation requiring laparotomy for small bowel obstruction.