Pitfalls of Ovarian Ablative Magnetic Resonance-guided Radiation Therapy for Refractory Endometriosis

Abstract

In this case presentation, we describe the challenges of performing magnetic resonance-guided radiation therapy (MRgRT) with plan adaptation in a patient with advanced endometriosis, in whom several prior therapeutic attempts were unsuccessful and extensive pelvic irradiation was regarded as being too toxic. Treatment was delivered in two sessions, first for the seemingly only active right ovary, and at a later stage for the left ovary. Some logistical problems were encountered during the preparation of the first treatment, which were subsequently optimized for the second treatment by using transvaginal ultrasound to determine the optimum time point for simulation and delivery. Using breath-hold gated delivery and plan adaptation, radiation dose to the bowel could be minimized, resulting in good tolerance of treatment. Because of the need to simulate and deliver in a brief optimal time span for visibility of the follicles in the ovaries, a single fraction dose of 8 Gy was used in our patient. Hormonal outcome after her second treatment is still pending.In conclusion, MRgRT with plan adaptation is feasible for the occasional patient with refractory endometriosis. Simulation and delivery needs to be synchronized with the menstrual cycle, ensuring that the Graafian follicles allow the ovaries to be visible on magnetic resonance imaging (MRI). Because the ovaries are only visible on T2-weighted MRI for a very brief period of time, we suggest that it is preferable to use single fraction radiotherapy with a brief interval between simulation imaging and delivery.

Radiation treatment for refractory endometriosis: a 38-year-old female presenting with vaginal bleeding

“…This report joins a small number of case reports [7][8][9][10][11][12] that discuss the management of refractory endometriosis with radiation therapy. Most of these case reports describe radiation treatment with the goal of ovarian ablation [9,10] or destruction of symptomatic ovarian remnants [11,12], as opposed to direct delivery to endometriotic tissue as in this report. Bleeding and pelvic pain were successfully controlled in our patient at follow up, suggesting that radiation may be used to control bleeding in cases where there is no detectable, remaining ovarian tissue.…”

“…Literature describing the management of inoperable and medically refractive endometriosis with radiation is limited to a handful of case reports [7][8][9][10][11][12], and fewer still that report radiation targeted specifically at residual endometriotic tissue. These publications report successful pain and bleeding control [7,8].…”

Hemostatic Pelvic Irradiation: A Rarely Reported Approach to Benign Gynecological Bleeding

“…From a practical standpoint, the simulation CT and irradiation should be synchronous with the appearance of the hemorrhagic cyst, and a single fraction of radiation therapy should be given with a short interval between simulation and pelvic irradiation to avoid side effects of radiotherapy and interruptions in the fractionation [1,10].…”

Clinical Applications of Magnetic Resonance-Guided Radiotherapy: A Narrative Review

“…These disease sites and their clinical evidence are summarized below. The indications summarized below by no means represent a comprehensive list, as MRgRT has potential for most disease sites (including head and neck [9], colorectal [10], brain [11], and gynecological cancers [12][13][14]) due to similar rationales to the included indications.…”