High-dose rate brachytherapy for palliative care in rectal cancer: A case with a complete response, followed by a rare complication

Abstract

Purpose: There are no guidelines for palliative care to relieve patients from pain, bleeding and obstruction due to locally advanced rectal tumours. These patients are fragile, with comorbidities, and have been previously treated by external-beam radiotherapy. Brachytherapy with iridium-192 (interstitial or endoluminal) delivers a high dose of radiation to the tumour, while preserving the surrounding tissues. This technique achieves effective palliation in many cancers; it is also used worldwide for recurrent or inoperable rectal tumours. We report a patient diagnosed with inoperable rectal adenocarcinoma. He had received endorectal high-dose rate brachytherapy to reduce rectal bleeding and pelvic pain. Nevertheless, he presented a rare complication after brachytherapy. Method:We selected a patient who had been treated with endorectal high-dose brachytherapy at the Limoges University Hospital Centre. His medical records were analysed retrospectively. The patient had severe cardiovascular comorbidities and had previously received pelvic external-beam radiotherapy. High-dose rate brachytherapy was delivered with an endoluminal vaginal/rectal cylinder applicator connected to an iridium-192 stepping source. A single dose of 5 Gy, weekly, was applied. The aim was to improve his quality of life by relieving him of bleeding and pain.Results: High-dose rate brachytherapy was immediately well tolerated. Moreover, there was no problem of compliance because of the short duration of treatment, which was easily performed. The patient described an overall complete response to his symptoms after 1 month. The bleeding stopped and he was withdrawn from opioids. He regained his quality of life and maintained independence at home. Nevertheless, he died 2 months after the end of the treatment of necrotizing fasciitis of the perineum. Conclusion:Intraluminal high-dose rate brachytherapy is a very effective palliative treatment after external-beam radiotherapy. This technique can be easily performed to reduce bleeding, pain and obstruction with significant improvement in patient quality of life. However, precautions must be taken for patients with severe peripheral arterial disease who have previously received external-beam radiotherapy.