Radiotherapy for inoperable and refractory endometriosis presenting with massive hemorrhage: a case report

Abstract

IntroductionMany patients with endometriosis are treated with medication or by surgical approaches. However, a small number of patients do not respond to medication and are inoperable because of comorbidities. This case report shows the effectiveness of radiotherapy for refractory endometriosis and includes a time series of serum estradiol levels.Case presentationA 47-year-old Asian woman presented to our facility with uncontrolled endometriosis refractory to medication. Our patient was considered inoperable because of severe idiopathic thrombocytopenic purpura, and underwent radiotherapy for massive genital bleeding requiring blood transfusions. A radiation dose of 20Gy in 10 fractions was delivered to the pelvis, including the bilateral ovaries, uterus, and myomas. An additional 10Gy in five fractions was delivered to the endometrium to control residual bleeding. Genital bleeding was completely inhibited on day 46 after radiotherapy. Hormonal analysis revealed that radiotherapy induced post-menopausal status. Two years after radiotherapy, atypical genital bleeding had not recurred and has been well controlled without side effects.ConclusionsDisrupted ovarian function is an adverse effect of radiotherapy. However, radiotherapy can be useful for inducing menopause. In cases of medication-refractory or inoperable endometriosis, radiotherapy would be an effective treatment option.

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.…”

“…Our patient was a 39-year-old woman with medically refractive endometriosis who was not a candidate for surgery due to a history of vesicovaginal fistula after a prior surgery. Two other case reports by Kim et al and Nomiya et al describe patients with refractory endometriosis treated with radiation targeted to endometriotic tissue [7,8]. These patients, 47 and 39 years of age, were deemed to be nonviable surgical candidates due to severe idiopathic thrombocytopenic purpura and exhaustion of surgical options, respectively.…”

“…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]. Here, we present a case of a patient with vaginal bleeding secondary to hormone-refractory and inoperable endometrio-sis who was successfully treated with radiation therapy.…”

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

“…For the same reason, we used single fraction radiotherapy, rather than a more prolonged fractionation scheme. Clinical experience of ovarian ablative radiotherapy is mostly derived from older literature in breast cancer patients and has only been reported in case reports for refractory endometriosis [ 2 - 3 ]. While radiotherapy for endometriosis is most commonly delivered in the form of extensive pelvic irradiation in 15-20 Gy in 10 fractions, the literature on hormonal castration in breast cancer patients describes a wider range of fractionation schemes, including the use of single-fraction irradiation.…”

“…Endometriosis is a chronic inflammatory disorder that can significantly impact upon the quality of life with symptoms ranging from dysmenorrhea to pelvic or abdominal bowel symptoms, and in severe cases even obstruction or perforation [ 1 ]. Although pain medication, hormonal therapy, or surgery form the mainstay of treatment for symptomatic patients, radiotherapy, usually in the form of extensive pelvic irradiation, has been applied in exceptional cases with refractory disease [ 2 - 3 ]. In this case presentation, we describe the challenges of performing magnetic resonance-guided radiation therapy (MRgRT) in a patient with advanced endometriosis, in whom several prior therapeutic attempts were unsuccessful and extensive pelvic irradiation was regarded as being too toxic.…”