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Radiotherapy for inoperable and refractory endometriosis presenting with massive hemorrhage: a case report
© Nomiya et al.; licensee BioMed Central Ltd. 2012
Received: 14 February 2012
Accepted: 2 August 2012
Published: 18 September 2012
Many 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.
A 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.
Disrupted 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.
Endometriosis is a gynecological condition characterized by extra-uterine endometrial-like cells, which often proliferate and cause hematomas, menstrual pain, or other symptoms, in conjunction with hormonal changes.
In general, pain relievers and hormonal supplements are prescribed during menopause [1–6]. However, when endometriosis is refractory to medicinal treatments, surgical intervention is required, including endometrial tissue debridement or hysterectomy with/without ovarian excision [7–10].
In this study, we report the case of a patient with refractory and inoperable endometriosis treated with radiotherapy.
A 47-year-old Asian woman presented to the Department of Radiation Oncology, Yamagata University Hospital, with a chief issue of massive atypical genital bleeding.
Our patient was diagnosed as having idiopathic thrombocytopenic purpura (ITP) at three years of age; however, splenectomy, steroid therapy, and γ-globulin therapy failed to improve her condition. She had severe thrombocytopenia (platelet count <10,000 cells/mm3) at the time of radiotherapy. Because of her history of ITP, surgical intervention for endometriosis was ruled out.
Bilateral ovaries (endometriotic cysts) were included as radiotherapy targets to obtain radiation-induced menopause. The uterine myoma and normal endometrium were also included as targets as they may have been the origins of genital bleeding. Radiotherapy of 20Gy in 10 fractions with 10MV photons was delivered to the targets, which was sufficient for inducing menopause. To correct residual genital bleeding as per our patient's wishes, another 10Gy radiation in five fractions was provided to the normal endometrium.
Hormone therapies for endometriosis include medroxyprogesterone, danazol, and gonadotropin-releasing hormone (GnRH), among other drugs [1–3]. These drugs have favorable effects for symptoms of endometriosis, but they occasionally cause side effects such as spotting, weight gain, skin changes, and hypo-estrogenism [4–6].
However, laparoscopic stripping of endometriomas is reported to be as effective as surgical treatments . Laparoscopic excision of the cyst wall of the endometrioma reduces the recurrence rates of endometriomas, dysmenorrhea symptoms, non-menstrual pelvic pain, and requirement for further surgery .
In our patient’s case, surgery could not be considered as an option because our patient had underlying thrombocytopenia (platelet count <10,000 cells/mm3) due to ITP. Our patient seemed to have a very complicated multiple disease scenario, with: (i) endometriosis (bilateral ovaries), (ii) secondary chocolate cysts, (iii) adenomyosis (complicating about 10% of the endometriosis), (iv) thrombocytopenia due to ITP and (v) uterine myoma (subserous myoma). As it was considered that all of the diseases might be a cause of bleeding, a particular state that ‘atypical bleeding gets worse according to female hormone levels’ seemed to be mainly caused by endometriosis. Therefore treatment was performed so as to control the excess of female hormones. Treatment to control the bleeding with interventional radiology procedures was also considered, however, interventional radiology procedures were not indicated because they would not improve the essential cause of disease, there was uncertainty of their effect and there was an inherent risk associated with invasive procedures. Although oral contraceptives and a GnRH analog were administered, both drugs failed to suppress the endometriosis, and only symptomatic treatments such as blood transfusion were performed. Ectopic endometrial-like cell activity is dependent on female hormone levels. Therefore, anti-estrogen, androgen, and GnRH analog therapies were implemented for symptomatic relief of the endometriosis.
In our patient’s case, estrogen secretion was successfully inhibited by bilateral ovarian irradiation. A previous study estimated that the 50% lethal dose (LD50) for human oocytes was 4Gy or less . Several studies reported the ability of radiotherapy for ablating remnant ovarian tissue in recurrent or refractory endometriosis, based on the limited tolerance of human oocytes to radiation damage [12–14]. These studies reported that menopause was induced at a dose of 15 to 30Gy radiation. A previous clinical study reported that menopausal status had been obtained in almost all patients with breast cancer with distant metastases using a radiation dose of 10Gy in four fractions .
Radiotherapy is a less invasive treatment and is widely applicable regardless of a patient’s age or operability. Therefore, radiotherapy should be considered for patients with medication-refractory and/or inoperable endometriosis. However, one limitation of radiotherapy is the irreversible loss of ovarian function; consequently, careful consideration should be given to adolescents and younger women who desire pregnancy. In our patient’s case, radiotherapy was administered because our patient did not desire ovarian preservation and because she was at risk of life-threatening blood loss.
We have demonstrated a case of refractory endometriosis successfully treated with radiotherapy and conclude that radiotherapy is an effective treatment option for patients with medication-refractory or inoperable endometriosis.
Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.
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