Radiotherapy for uncontrolled bleeding from benign pelvic tumors when surgery is high risk

Summary: This case report aims to highlight the increasing role of radiation therapy in the management of benign pelvic tumors, specifically in cases where conventional treatments are ineffective or not viable. Radiation therapy was historically used for benign diseases, until the risk of induced secondary cancers came to light. However, as radiation technology has advanced to create more targeted treatments, the safer use of radiation for non-malignant tumors is increasing. We present the case of a 38-year-old premenopausal female patient diagnosed with myelodysplastic syndrome (MDS), who experienced severe anemia due to bleeding uterine fibroids. Her fibroids were resistant to multiple treatment modalities, including multiple transfusions, uterine artery embolization, and endometrial ablation. Definitive treatment with allogeneic stem cell transplantation was planned to treat her MDS. However, she was unable to undergo transplantation due to anemia from the active fibroid bleeding, and unable to undergo hysterectomy for the large fibroid due to pancytopenia from her MDS. Surgical intervention was not an option, leading to the decision to employ radiation therapy as a palliative measure to control the bleeding and alleviate symptoms. The radiation regimen consisted of 20 Gy delivered in 5 daily fractions. The radiation plan employed a direct expansion from the gross tumor volume (GTV) to the planning target volume (PTV) of 1.5 cm, as benign tumors do not require a clinical target volume (CTV) expansion. After the completion of her radiation, the patient exhibited complete resolution of bleeding, leading to improvement in her anemia and overall quality of life. Her acute symptoms included pelvic pain controlled with oxycodone and increased urinary frequency. This case underscores the potential of radiation therapy as a practical treatment alternative for patients with benign pelvic tumors, especially when conventional treatments fail or are not feasible. As advancements in radiation technology continue to evolve, the ability to create personalized treatment plans with tighter dose constraints becomes increasingly attainable. In planning the radiation, GTV should include the gross tumor causing symptoms, with a palliative margin for set up, for example 1.5 cm. No GTV to CTV expansion is needed for microscopic disease as the treatment is for benign tumors. Supported by minimal published literature on this subject, we recommend a standard palliative dosing and fractionations such as 20 Gy in 5 fractions daily for larger tumors and SBRT in 1-5 fractions for smaller tumors. This case highlights the need for additional research to optimize radiation treatment protocols for larger patient populations facing similar challenges. Spencer Lee, BS (Co-Author) - Brigham Young University - Idaho; Seraphina Choi, MD (Presenting Author) - University of Miami Sylvester Comprehensive Cancer Center, Department of Radiation Oncology; Erin Kaya, MD (Co-Author) - Oregon Health Science University, Department of Radiation Medicine; Cymon Kersch, MD (Co-Author) - Oregon Health Science University, Department of Radiation Medicine; Curtis Lachowiez, MD (Co-Author) - Oregon Health Science University, Department of Medical Oncology; Quincy Seigel, MD (Co-Author) - University of Texas Medical Branch, Department of Internal Medicine; Joe Foy, PhD (Co-Author) - Oregon Health Science University, Department of Radiation Medicine; Ladan Yazdidoust, BS (Co-Author) - Oregon Health Science University, Department of Radiation Medicine; Casey Williamson, MD (Co-Author) - Oregon Health Science University, Department of Radiation Medicine