Palliative radiation treatment used for multiple purposes in a single irradiation field

Abstract

In this case report, radiation therapy was performed for bilateral hydronephrosis developed during multiple bone metastases of breast cancer and ileus due to peritoneal dissemination. The patient’s preirradiation creatinine level was 8.2 mg/dL, which decreased by the fourth day after starting irradiation therapy. Creatinine level ultimately decreased to 0.6 mg/dL. Pain due to lumbar spine metastasis alleviated and ileus was resolved, allowing the patient to live at home for approximately 5 weeks. The effect of radiotherapy for bilateral hydronephrosis and gastrointestinal obstruction was rapid and good. Palliative radiation treatment can be used for multiple purposes, and in the present patient, we were able to prolong the vital prognosis.

Background

Radiation treatment effectively improves local symptoms associated with many cancers. Moreover, it can be used for various purposes, including ‘radical’ treatment to treat several diseases and ‘palliative’ treatment to control symptoms.

Palliative radiation therapy is used for bone metastasis, brain metastasis, pain associated with tumour infiltration into the nerves and soft-tissues, stenosis and obstruction of luminal organs and bleeding from tumours. Here, we discuss the case of a 51-year-old patient with breast cancer who received radiation treatment to resolve hydronephrosis and ileus due to peritoneal dissemination and to relieve pain caused by metastatic lumbar spine cancer.

Case presentation

The patient was a 51-year-old woman who had undergone surgery for breast cancer 4 years earlier. Bone metastasis had been indicated 8 months after surgery, but the patient did not seek treatment. One month earlier, while hospitalised at another hospital, the patient was diagnosed with peritoneal dissemination and left ureteral compression. It was proposed to provide her best supportive care. Subsequently, she developed ileus due to peritoneal dissemination, for which radiation treatment was planned to improve the gastrointestinal obstruction and bone metastasis. Her serum creatinine (Cr) level increased immediately before transfer (figure 1). The increased Cr level was attributed to hydronephrosis and postrenal failure due to bilateral ureteral compression caused by peritoneal dissemination. Figure 2 shows the CT scan obtained before radiation treatment. Although the patient had lower back pain, there were no symptoms of uraemia and the urine volume on the day of transfer was 293 mL.

Figure 1.

Changes in serum creatinine level.

Figure 2.

Pretreatment CT scan. (A) Ileus is identified by a scout view, and a gastric tube has been inserted. (B) Bilateral hydronephrosis is observed with lower back pain sclerosis presentation. (C) Peritoneal dissemination involving the gastrointestinal tract and bilateral ureters, leading to ileus and hydronephrosis.

Treatment

Immediately after transfer, she received 50 Gy/25 fractions of radiation treatment for peritoneal dissemination and lumbar spine metastasis (figure 3).

Figure 3.

Linac graphy. It can be observed that radiation therapy is mainly performed where there is no intestinal gas.

Outcome and follow-up

The patient’s Cr level was 8.2 mg/dL 2 days prior to the start of the radiation treatment, but began to decrease from the fourth day after radiation treatment and ultimately decreased to 0.6 mg/dL. The patient did not present with any side effects due to radiation treatment, and while she had been taking 2 mg/day of Naruvein for pain before the start of radiation treatment, the pain had settled to a self-controllable level after treatment. The gastrointestinal obstruction resolved, the gastric tube could be removed by the end of the radiation treatment, and the patient was capable of oral ingestion. The patient had been receiving 2 mg/day hydromorphone hydrochloride injection for lower back pain prior to radiation treatment, but this was no longer necessary by the third week of radiation treatments. Moreover, by the time of her discharge, she did not require any painkillers, including non-steroidal anti-inflammatory drugs.

She was able to live at home for approximately 5 weeks but died of cancer 12 weeks after the start of radiation treatment.

Discussion

Malignant ureteral obstruction due to infiltration of malignant tumours to the abdomen and pelvis is often recognised as a cause of renal damage and presents with hydronephrosis on images. Normally, unilateral ureteral obstruction does not show any abnormalities in laboratory data; however, bilateral ureteral obstruction tends to cause uraemic symptoms. A study was presented in 2014 in Japan titled ‘Proposal for the shared decision-making process regarding initiation and continuation of maintenance haemodialysis’.¹ Among them, one of the conditions for considering the suspension of haemodialysis is ‘a condition in which an incurable malignant tumour has codeveloped, and death is definitely imminent,’ and haemodialysis is usually not introduced when the prognosis is less than 6 months. Instead, urinary stenting is the first choice of treatment. However, the success rate of urinary stenting is approximately 80%.^2–4 If the urinary stent cannot be inserted due to severe obstruction, it is common to create a renal fistula. At present, the patient had first developed ileus due to peritoneal dissemination, she is an example wherein resolving postrenal failure by stent/renal fistula does not constitute adequate palliative care.

In general, the terminal stage of a malignant tumour is when the attending physician and other physicians determine that ‘there is no further treatment that can be given in addition to what the patient is receiving now, and it is not expected that the patient will recover.’ However, for the present patient, there was a difference of opinion between her attending physician and the radiation oncologist. Radiation oncologists make decisions about treatment by estimating the beneficial effects of providing radiation as a local therapy; while in comparison, a physician makes decisions for therapy primarily based on the general condition of the patient. For the present patient, palliative radiation treatment was planned considering three goals: improvement of postrenal failure, improvement of ileus and relieving the pain of bone metastasis. Jones et al have mentioned ‘multiple progressive symptoms’ as one of the ‘circumstances in which palliative radiotherapy may not be indicated’,⁵ but there can be situations where symptoms can be resolved such as in our patient. Hence, it would not be prudent for a physician who is not a radiation oncologist to unilaterally make a simple judgement on the indication of radiation treatment for a patient. The present patient survived for 12 weeks after the start of radiation treatment, and the fact that there was a dramatic increase in the Cr level immediately before the start of treatment suggested that her vital prognosis had been prolonged by treatment.

Effectiveness of radiation therapy for ureteric obstruction has been well known, similarly to that of superior vena cava obstruction and digestive tract obstruction.⁶ Palliative radiotherapy has traditionally been performed at 30 Gy in 10 fractions. Recent advances in high-precision radiotherapy make it possible to select higher doses and shorter periods of time. However, in this case, renal function is considered to determine the prognosis. However, single large prescription dose is not considered effective early in palliative radiotherapy. Moreover, the larger the amount of one fractional dose, the stronger the oedema of the organs. Therefore, single large radiation dose is not effective for improving obstructions. Furthermore, since the irradiation field was wide in this case, 2 Gy was set as the amount of fraction (figure 3). Therefore, treatment for the present patient was 50 Gy/25 fractions of radiation.

A radiation oncologist performed radical radiation therapy for stage IIIB cervical cancer, knowing that radiation therapy can improve hydronephrosis. The additional presence of hydronephrosis did not significantly worsen the progression-free survival among patients with tumours fixed to the pelvic side wall.⁷ On the other hand, palliative care physicians and urologists may need to be reminded that hydronephrosis can be improved by radiotherapy, because randomised trials are not readily available in the palliative care field. It is, therefore, necessary to educate them about palliative radiotherapy.

Patient’s perspective.

• Patient’s sister’s perspective: What I want to focus on is the fact that my sister’s condition improved remarkably, despite having been told ‘there is no other way’ and ‘she will die’ in other hospitals. For approximately 1 month, she had a tube up her nose and was not able to have meals normally either, but radiation treatment helped her eat normally again. I still remember how surprised I was seeing her ask for and finish an entire steak on the day she was discharged.

• The 1 month of life she spent at home after being discharged was significantly valuable for the family, and she had been able to manage her own affairs herself and have basic meals right up until the point she had to be readmitted. What I learnt is that radiation treatment can reduce symptoms even in patients who have limited time to live.

Learning points.

• Radiation treatment is effective for bilateral hydronephrosis and gastrointestinal obstruction due to peritoneal dissemination.

• Radiation treatment may be indicated even for patients deemed suitable for palliative care, and there may be situations where the vital prognosis can be prolonged.

• The effect of radiotherapy on ureteral compression in peritoneal dissemination was rapid.

Ethics statements

Patient consent for publication

Next of kin consent obtained.