Rectal Bleeding and Its Management after Irradiation for Cervix Cancer
자궁경부암 환자에서 방사선치료 후에 발생한 직장출혈과 치료
전, 미선; 강, 승희; 길, 훈종; 오, 영택; 손, 정혜; 정, 혜영; 유, 희석; 이, 광재
Radiation oncology journal, 20(4):343-352, 2002
Radiation oncology journal
Purpose: Radiotherapy is the main treatment modality for uterine cervix cancer. Since the rectum is in the radiation target olume, rectal bleeding is a common late side ffect. This study evaluates the risk factors of radiation induced rectal bleeding and discusses its optimal management.
Materials and Methods: A total of 213 patients who completed external beam radiation therapy (EBRT) and intracavitary radiation (ICR) between September 1994 and December 1999 were included in this study. No patient had undergone concurrent
chemo-radiotherapy. Ninety patients received radiotherapy according to a modified hyperfractionated schedule. A midline block was placed at a pelvic dose of between 30.6 ㏉ to 39.6 ㏉. The total parametrial dose from the EBRT was 51 to 59 ㏉ depending
on the extent of their disease. The point A dose from the HDR brachytherapy was 28 ㏉ to 30 ㏉ (4 ㏉×7, or 5 ㏉×6). The rectal point dose was calculated either by the ICRU 38 guideline, or by anterior rectal wall point seen on radiographs, with barium contrast. Rectal bleeding was scored by the LENT/SOMA criteria. For the management of rectal bleeding, we opted for observation, sucralfate enema or coagulation based on the frequency or amount of bleeding. The median follow-up period was 39 months (12~86 months).
Results: The incidence of rectal bleeding was 12.7% (27/213); graded as 1 in 9 patients, grade 2 in 16 and grade 3 in 2. The overall moderate and severe rectal complication rate was 8.5%. Most complications (92.6%) developed within 2 years following completion of radiotherapy (median 16 months). No patient progressed to rectal fistula or obstruction during the follow-up period. In the univariate analysis, three factors correlated with a high incidence of bleeding:an icruCRBED greater than 100 ㏉ (19.7% vs. 4.2%), an EBRT dose to the parametrium over 55 ㏉ (22.1% vs. 5.1%) and higher stages of Ⅲ and Ⅳ (31.8% vs. 10.5%). In the multivariate analysis, the icruCRBED was the only significant factor (p>0.0432). The total parametrial dose from the EBRT had borderline significance (p=0.0546). Grade 1 bleeding was controlled without further management (3 patients), or with sucralfate enema 1 to 2 months after treatment. For grade 2 bleeding, sucralfate enema for 1 to 2 months reduced the frequency or amount of bleeding but for residual bleeding, additional coagulation was performed, where immediate cessation of bleeding was achieved (symptom duration of 3 to 10 months). Grade 3 bleeding lasted for 1 year even with multiple transfusions and coagulations.
Conclusion: Moderate and severe rectal bleeding occurred in 8.5% of patients, which is comparable with other reports. The most significant risk factor for rectal bleeding was the accumulated dose to the rectum (icruCRBED), which corrected with
consideration to biological equivalence. Prompt management of rectal bleeding, with a combination of sucralfate enema and coagulation, reduced the duration of the symptom, and minimized the nxiety/discomfort of patients.
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