Short Communication
Hyperbaric Oxygen in the Treatment of Radiation Proctitis and Cerebral Necrosis
Bora Uysal*, Hakan Gamsız, Ferrat Dıncoglan, Selcuk Demıral, Omer Sager and Murat
Beyzadeoglu
Department of Radiation Oncology, Gulhane Education and Research Hospital, Turkey
*Corresponding author: Bora Uysal, Department of Radiation Oncology, Gulhane Education and Research Hospital, Etlik Kecioren Ankara, Turkey
Published: 06 Dec, 2017
Cite this article as: Uysal B, Gamsız H, Dıncoglan F,
Demıral S, Sager O, Beyzadeoglu M.
Hyperbaric Oxygen in the Treatment
of Radiation Proctitis and Cerebral
Necrosis. Clin Surg. 2017; 2: 1803.
Abstract
Background: Hyperbaric oxygen treatment is a challenging topic for radiation side effects.
Objective: The main goal is to evaulate the results of hyperbaric oxygen to treat proctitis and cerebral
radionecrosis associated with radiotherapy.
Materials and Methods: 25 patients diagnosed with radiation proctitis and cerebral radionecrosis
were treated with hyperbaric oxygen between 2013 January and 2014 December. 15 patients have
radiation proctitis and 10 have cerebral radionecrosis. The symptoms of patients with radiation
proctitis were stool frequency, hematochesia and pain. The presentation of others with cerebral
radiation necrosis were headache, vertigo and dizziness. Hyperbaric oxygen of 2.4 Atmosphere
Absolute was delivered for 5 patients.
Results: Stool frequency and pelvic pain in patients with proctitis was decreased after hyperbaric
oxygen therapy. Symptoms of headache, vertigo and dizziness were better after hyperbaric oxygen.
Also perinecrosal edema was limited and decreased wth hyperbaric oxygen therapy.
Conclusion: Hyperbaric oxygen is an effective and useful therapy for radiation necrosis and
proctitis.
Keywords: Hyperbaric oxygen; Radiation proctitis; Radiation necrosis
Introduction
Hyperbaric Oxygen (HBO2) therapy has been delivered for wide range of diseases in the literature. Firstly in 1950’s, cervical cancer and head and neck tumors were the first usage of HBO in addition to radiotherapy (RT). Tumor hypoxia is a major problem for radiotherapy management. It aggrevates radio resistance and oxyic tumor cells are more radio sensitive compared to hypoxic ones. HBO2 is eminently known agent that increasing tumor oxygenation and it improves radiation results in many tumors. Brain necrosis, proctitis, layngeal radio necrosis, optic neuropathy, soft tissue and bone injuries are the challenging issuesof HBO management in the cancer treatment era. Also HBO was concomitantly used with photodynamic therapy and there was better tumor response at the end of this combination. Claustrophobia, cardiac and lung problems, pancitopenia etc. are the possible contrandications for HBO management [1].
Materials and Methods
This original retrospective article enrolls twenty five patients of radiation necrosis and proctitis treated with HBO between January 2013 and December 2014. 15 of all had a radition proctitis and cerebral necrosis was diagnosed after RT in 10 patients. The patients with proctitis had stool caliber changes, diarrhea, stool frequency, hematochesia and pain. Vertigo, dizziness, headache were the major symptoms of the group of radiation necrosis. 15 patients were diagnosed with rectum adeno carcinoma and they were treated with pelvik IGRT. 45 Gy was given for 14 patients in 1.8 Gy per fraction and 50.4 Gy was delivered just for onepatient in same daily fraction dose. One patient was treated with stereotactic surgery in the dose of 18 Gy. This patient had a radiological diagnosis of arteriovenous malformation. Other last 9 patient had a grade 2 astrocytoma and treated with 54 Gy per 200 cGy fraction after surgery. 2.4 Atmosphere Absolute (ATA) was given with multiplace hyperbaric chamber in 120 minutes for 25 patients.
Results
24 patients of all were man and 1 of them was female. Mean age was 30.6 (22-54). Stool frequency and pelvic pain was decreased and normalized after HBO in the patients with radiation proctitis. Symptoms of headache, vertigo and dizziness were got better in 10 patientsof cerebral necrosis. Perinecrosal edema was decreased and limited after HBO.
Discussion
Radiation complications are categorized in acute, early-delayed
and late-delayed injuries. Late injury enrolls radiation necrosis
and leukoencephalopathy. Cytokines, reactive oxygen species and
vascular endothelial growth factors are leakaged to the cell membrane
by inflammatory activation [2]. Chemoradiotherapy combination
and the increased usage of radiosurgery caused few more cases of
radiation necrosis in brain tumors. It is hard to differentiate necrosis
and recurrence with conventional Magnetic Resonance (MR) but
MR Spectroscopy can be used for it. Bevacizumab is a novel agent
to treat radiation necrosis [3]. Temporal lobe necrosis is unusual
late complicationof RT in nasophayngeal carcinoma but IMRT
and helical therapies decreased its incidence. Steroids, vitamins,
surgery, anticolagulants, hyperbaric oxygen, bevacizumab are the
major treatment methods for radiation necrosis [4]. In an article
of 2012 update by Feldmeier et al. [5], one-third of patients with
delayed radiation injuries get HBO in United States. Supportive
prophylactic usage of HBO in high-risk patients was also discussed
in this article. Gynecologic malignancies are one of the potential
indications for the RT treatment. Late radiation effects and HBO
were reviewed in literature. Radiation proctitis, cystitis and necrosis
should be managed with HBO. The effect of HBO is decreased with
the delaying time [6]. Retrospective series showed that not all but
some patients with radiation necrosis of central nervous system were
lead to improvement in their clinical or radiological findings. This
result is conflictive and inconsistent but it shows that differential
diagnosis should be made accurately and treatment algorithm could
be startedas soon as possible [7]. Preventive usage of HBO in the
management of radiation necrosis is discussed and it is to clear to
start HBO before or after symptoms or clinical findings of necrosis
[8]. In a series of 14 patients with gynecologic malignancy, it was
shown that HBO is effect ie, safe and well-tolerated management
for soft tissue necrosis associated with radiation [9]. So important
issue to be known is complications and side effects of HBO. These
are ocular barotrauma, ear barotrauma, dental complications and
myocardial infarction [10]. Radiation proctitis is a different and
challenging topic. Topical medications and oral steroids should be
recommended but HBO and surgical interventions can be used after
radiation proctitis. Improvements in radiation oncology techniques
like IMRT and proton therapy lead to prevent rectal structures from
radiation treatment. Also rectum spacers and balloons are still be used
by experts in some centers in the World [11]. Necrosis or proctitis
after radiation possibly caused by decreased vascularity, hypoxia
problems and leukocyte disfunction [12]. Treatment indications of
HBO are radiation necrosis, osteoradionecrosis, diabetic foot ulcer,
osteomyelitis, failed flap or skin graft. One single center experience
showed that nearly 82% of patients had better outcomes after HBO
[13].
In a study of 105 patients by Bui et al. [14], HBO response
rate was lower for salivary, neurologic, laryngeal and upper
gastrointestinal symptoms compared to mucous membrane or soft
tissuenecrosis. High-dose steroids have been still used for radiation
induced brain necrosis. HBO treatment decreases steroid usage and
clinical, sympomatic and radiological improvements were shown
after HBO in similar case studies [15,16]. HBO decreases symptoms
of cerebral necrosis, radiation proctitis and also improves life quality.
Therapeutic role of HBO was shown in the literature and randomized
and multicenter studies are needed for future perspective of radiation
complications and side effects.
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