RE-IRRADIATION AFTER PALLIATIVE HEMOSTATIC RADIOTHERAPY IN BREAST, CERVICAL, AND HEAD-AND-NECK CANCERS: A NARRATIVE REVIEW AND PRACTICAL GUIDE
Main Article Content
Keywords
hemostatic radiotherapy, re-irradiation, bleeding, breast cancer, cervical cancer, head and neck cancer, carotid blowout, palliative care
Abstract
Background: Hemostatic radiotherapy (hRT) achieves rapid control of tumor-related bleeding across primary sites using short, hypofractionated schedules (e.g., 8 Gy × 1; 20 Gy × 5; 30 Gy × 10). However, re-bleeding and local progression can necessitate re-irradiation (re-RT), posing cumulative dose and toxicity challenges. PMCAnnals of Palliative Medicine
Objective: To synthesize contemporary evidence on the safety, efficacy, and technique of re-RT following prior h-RT in breast, cervical, and head-and-neck cancers, and to provide pragmatic recommendations for low- and middle-income settings.
Methods: Narrative review of recent reviews, site-specific series, and guideline-adjacent literature on h-RT and re-RT, emphasizing bleeding control, re-bleeding risk, organ-at-risk (OAR) constraints, carotid blowout risk, and technique selection (EBRT, IMRT, SBRT, brachytherapy). AmegroupsBioMed CentralPMC
Results: h-RT provides primary bleeding control in ~80–95% across sites with similar control from 8 Gy × 1, 20 Gy × 5, and 30 Gy × 10; anticoagulation predicts poorer hemostasis. Re-RT can re-establish control in selected patients, with technique tailored to prior dose, interval, target geometry, and proximity to critical vessels/mucosa.
Head-and-neck re-RT carries a small but catastrophic risk of carotid blowout; cervical re-RT (often with image-guided EBRT or brachytherapy) is feasible but fistula risk rises with central pelvic re-irradiation,
Chest-wall/breast re-RT is commonly feasible and may palliate fungation/bleeding.
Conclusions: Re-RT after prior h-RT is reasonable for carefully selected patients with re-bleeding or symptomatic progression, provided cumulative dose accounting, realistic goals of care, and vascular/mucosal risk mitigation. Standardized prospective data are needed; this review offers a practical algorithm for decision-making. Amegroups
References
2. Verschuren P, Slotman BJ, Verkooijen HM, et al. Hemostatic radiotherapy: a narrative review of current evidence. Ann Palliat Med. 2024;13(2):102-112.
3. Meixner E, Bostel T, Nicolay NH, et al. Efficacy of palliative hemostatic radiotherapy for tumor bleeding: a retrospective analysis. Strahlenther Onkol. 2024;200(3):236-245.
4. Kim DH, Suh CO, Cho KH, et al. Short-course palliative radiotherapy for uterine cervical carcinoma. Radiat Oncol J. 2013;31(4):216-221.
5. Shen Z, Liu S, Kang H, et al. Re-irradiation for recurrent cervical cancer: state-of-the-art review. Front Oncol. 2022;12:827465.
6. Kang HJ, Cho Y, Kim YS, et al. Re-irradiation with IMRT in recurrent cervix cancer: feasibility and outcomes. Radiat Oncol J. 2023;41(1):34-42.
7. Pontoriero A, Rizzo D, Iatì G, et al. Recurrent gynecologic tumors in previously irradiated patients treated with stereotactic radiotherapy. BMC Cancer. 2023;23:1189.
8. Fattahi S, Straube W, Horton JK, et al. Reirradiation for locoregional recurrent breast cancer: current evidence and outcomes. Adv Radiat Oncol. 2021;6(2):100614.
9. Wahl AO, Rademaker A, Kiel KD, et al. Multi-institutional review of chest wall re-irradiation for recurrent breast cancer. Int J Radiat Oncol Biol Phys. 2008;70(2):477-484.
10. Zagar TM, Higgins SA, Miles EF, et al. Reirradiation for locoregional recurrent breast cancer: results from a single-institution study. Cancer. 2010;116(12):2620-2626.
11. Gordon K, Sharma A, Lee N. Overview of head and neck tumor re-irradiation: patient selection and modern approaches. Front Oncol. 2023;13:1098273.
12. McDonald MW, Moore MG, Johnstone PA. Risk of carotid blowout after reirradiation of the head and neck: a systematic review. Int J Radiat Oncol Biol Phys. 2012;82(3):1083-1089.
13. Alterio D, Marvaso G, Ferrari A, et al. Carotid blowout syndrome after reirradiation of head and neck tumors: a systematic review. Crit Rev Oncol Hematol. 2020;152:103011.
14. Zhu W, Liang Y, Shen H, et al. Management of post-radiation carotid blowout: outcomes with endovascular techniques. Eur Arch Otorhinolaryngol. 2024;281(4):1673-1682.
15. Rao V, Yadav R, Gogia A, et al. Hemostatic radiotherapy for bleeding gastrointestinal tumors: regimen comparisons. J Gastrointest Cancer. 2024;55(1):53-60.
16. Guhlich M, Habl G, Foerster R, et al. Hemostatic radiotherapy in clinically significant tumor-related bleeding. Radiother Oncol. 2023;185:109709.
17. Eleje GU, Eke AC, Igberase GO, et al. Palliative interventions for controlling vaginal bleeding in advanced cervical cancer. Int J Gynaecol Obstet. 2015;128(3):214-218.
18. Kil WJ, Adams SC, Yu TK, et al. Quad-Shot radiotherapy for palliation of advanced breast cancer. Breast J. 2023;29(1):34-40.
19. Jiang JL, Xu T, Wang Q, et al. Incidence of carotid blowout with contemporary head and neck radiotherapy. Radiat Oncol. 2024;19:87.
20. Dennis K, De Bari B, Slotman BJ, et al. Emergent radiotherapy for pelvic malignancies: a narrative review. Clin Transl Radiat Oncol. 2024;46:101621.
21. Corry J, Peters LJ, Costa ID, et al. The 'QUAD SHOT'—a phase II study of palliative radiotherapy for incurable head and neck cancer. Radiother Oncol. 2005;77(2):137-142.
22. Kouloulias V, Tolia M, Anagnostopoulos G, et al. Hemostatic radiotherapy in bleeding malignancies: a practical approach. Clin Oncol (R Coll Radiol). 2015;27(3):153-160.
23. Wong K, Ma BB, Hui EP, et al. Palliative radiotherapy for advanced head and neck cancer: outcomes and considerations. Oral Oncol. 2019;93:43-50.
24. Nieder C, Langendijk JA, Guckenberger M, et al. Re-irradiation: current practice and future directions. Radiat Oncol. 2018;13:151.
25. Vargo JA, Ferris RL, Clump DA, et al. A modern review of reirradiation in head and neck cancer. Am J Clin Oncol. 2018;41(6):585-592.
26. De Felice F, Musio D, Tombolini V. Re-irradiation for recurrent head and neck cancer: a systematic review. Acta Otorhinolaryngol Ital. 2018;38(1):24-29.
27. Jereczek-Fossa BA, Ronchi S, Orecchia R. Re-irradiation of head and neck cancers: a comprehensive review. Crit Rev Oncol Hematol. 2010;73(3):213-230.
28. Hannoun-Levi JM, Pons E, Gautier M, et al. Re-irradiation for locally recurrent breast cancer: indications and techniques. Cancer Radiother. 2019;23(6-7):703-712.
29. Horton JK, Blitzblau RC, Yoo S, et al. Radiotherapy for locally recurrent breast cancer after prior radiation. Int J Radiat Oncol Biol Phys. 2012;82(4):e837-e844.
30. Wahl AO, Rademaker A, Kiel KD, et al. Chest wall reirradiation for breast cancer: clinical outcomes. Radiother Oncol. 2007;82(3):247-252.
31. Kim YJ, Cho KH, Ahn SJ, et al. Re-irradiation with external beam radiotherapy for cervical cancer recurrence. Gynecol Oncol. 2011;123(3):507-513.
32. Mahantshetty U, Gurram L, Kabra V, et al. Image-guided brachytherapy in recurrent cervical cancer: outcomes and toxicity. Brachytherapy. 2014;13(6):592-599.
33. Chargari C, Deutsch E, Blanchard P, et al. Brachytherapy: an overview for re-irradiation in gynecologic cancers. Cancer Radiother. 2013;17(4):283-290.
34. Chen AM, Farwell DG, Luu Q, et al. Salvage reirradiation for recurrent head and neck cancer using IMRT. Head Neck. 2008;30(6):765-772.
35. Spencer SA, Harris J, Wheeler RH, et al. RTOG 96-10: Palliative radiation for advanced head and neck cancer. Int J Radiat Oncol Biol Phys. 2008;70(2):385-392.
36. Guckenberger M, Andratschke N, Alheit H, et al. Definition and quality assurance in re-irradiation: ESTRO ACROP recommendations. Radiother Oncol. 2020;149:78-86.
37. Hui EP, Ma BBY, Leung SF, et al. Hemostatic radiotherapy for bleeding head and neck tumors: institutional experience. Support Care Cancer. 2013;21(6):1551-1558.
38. Ng M, Tey J, Goh R, et al. Hypofractionated hemostatic radiotherapy for bleeding tumors: outcomes from a multi-site study. Ann Palliat Med. 2021;10(5):5084-5094.
39. Tinkle CL, Weinberg BD, Chen RC, et al. Palliative radiotherapy for bleeding pelvic malignancies: techniques and outcomes. Pract Radiat Oncol. 2019;9(4):e454-e462.
40. Pan HY, Ning MS, Hahn SM, et al. Emerging strategies in palliative radiotherapy: hemostasis and symptom control. Nat Rev Clin Oncol. 2021;18(12):795-814.7
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