Hyperbaric Oxygen in the Treatment of Radiation Proctitis and Cerebral Necrosis
*Bora Uysal, Hakan Gamsız, Ferhat Dıncoglan, Omer Sager, Selcuk Demıral and Murat Beyzadeoglu
Department of Radiation Oncology, Gulhane Education and Research Hospital, Turkey
Submission: October 24, 2017; Published: November 01, 2017
*Corresponding author: Bora Uysal, Gulhane Education and Research Hospital, Department of Radiation Oncology, Etlik Kecioren 06018 Ankara, Turkey, Tel:+903123044689 ; Fax:+903123044689 ; Email: firstname.lastname@example.org
How to cite this article: Bora U, Hakan G, Ferhat D, Omer S, Selcuk D, Murat B. Hyperbaric Oxygen in the Treatment of Radiation Proctitis and Cerebral Necrosis. Canc Therapy & Oncol Int J. 2017; 7(4): 555720. DOI:10.19080/CTOIJ.2017.07.555720
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 2008 January and 2017 February. 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 25 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.
Hyperbaric oxygen (HBO2) therapy has been deliveredfor wide range of diseases in the literature. Firstly in 1950’s, cervical cancer and head and neck tumors were the first usage of HBO2 in addition to radiotherapy (RT). Tumor hypoxia is a major problem for radiotherapy management. It aggrevates radioresistance. Oxyic tumor cells are more radiosensitive 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 radionecrosis, optic neuropathy, soft tissue and bone injuries are the challenging issuesof HBO2 management in the cancer treatment era. Also HBO2 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 HBO2 management .
This original retrospective article enrolls twenty five patients of radiation necrosis and proctitis treated with HBO2 between January 2008 and February 2017. Fifteen of all had a radition proctitis and ten remaining patients had a cerebral necrosis. The patients with proctitis had stool caliber changes, diarrhea, stool frequency, hematochesia and pain. All fifteen
patients had grade 2 proctitis. Vertigo, dizziness, headache were the major symptoms of the group of radiation necrosis. Ten patients had grade 1 necrosis. Fifteen patients were diagnosed with rectum adenocarcinoma and they were treated with pelvik IGRT. 45 Gy was given for fourteen patients in 1.8 Gy per fraction and 50.4 Gy was delivered just for onepatient in same daily fraction dose. Patients were managed with surgery six weeks after chemoradiotherapy. Adjuvant chemotherapy was delivered after surgery.
One patient with cerebral radionecrosis was treated with stereotactic surgery in the dose of 18 Gy. This patient had a radiological diagnosis of arteriovenous malformation. Other last ninepatient with radionecrosis had a grade 2 astrocytoma and treated with 54 Gy per 200 cGy fraction after surgery. Surgery was total excision.2.4 Atmosphere absolute (ATA) was given with multiplace hyperbaric chamber in 120 minutes for 25 patients. Patients were followed up with magnetic resonance spectroscopy (MR spectroscopy) or pelvic MR.
24 patients (96%) of all were man and 1 (4%) of them was female (Table 1). Mean age was 30.6 (22-54). Stool frequency and pelvic pain was decreased and normalized after HBO2 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
HBO2. Patients were followed up for median 12 months (6-22).
Preraditoherapy verbal numeric scale scores were median 6
(4-10) and postradiotherapy scores were median 3 (0-5) and it
was statistically significant (p<0.05). Median RT dose was 47.6
(18-54). 40% of all patients had grade 1 cerebral radionecrosis
and 60% of all had grade 2 radiation proctitis. 11.1% of cerebral
radionecrosis group had an arteriovenous malformation and
88.9% of remaining had a grade 2 astrocytoma (Table 2).
Radiation complications are categorized in acute, earlydelayed
and late-delayed injuries. Late injury enrolls radiation
necrosis and leukoencephalopathy. Cytokines,reactive
oxygen species and vascular endothelial gorwth factors are
leakaged to the cellmembrane by inflammatory activation .
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
Temporal lobe necrosis is unusual late complicationof
RT in nasopharyngeal carcinoma but IMRT and helical
therapies decreased its incidence. Steroids, vitamins, surgery,
anticolagulants, hyperbaric oxygen, bevacizumab are the major
treatment methodsfor radiation necrosis . In an article of
2012 update by Feldmeier et al. , one-third of patients with
delayed radiation injuries get HBO2 in United States. Supportive
prophylactic usage of HBO2 in high-risk patients wasalso
discussed in this article. Gynecologic malignancies are one of
the potential indications for the RT treatment. Late radiation
effects and HBO2 were reviewed in literature. Radiation proctitis,
cystitis and necrosis should be managed with HBO2. The effect of
HBO2 is decreased with the delaying time .
Retrospective series showed that not all but some patients
with radiation necrosis of central nervous system were
improvedover their clinical or radiological findings after HBO2.
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 . Preventive
usage of HBO2 in the management of radiation necrosis is
discussed and it is not clear to start HBO2 before or after
symptoms or clinical findings of necrosis . In a series of 14
patients with gynecologic malignancy, it was shown that HBO2
is effective, safe and well-tolerated management for soft tissue
necrosis associated with radiation . So important issue to
be known is complications and side effects of HBO2. These are
ocular barotrauma, ear barotrauma, dental complications and
myocardial infarction .
Radiation proctitis is a different and challenging topic. Topical
medications and oral steroids should be recommendedbut HBO2
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 used by
experts in some centers in the World . Necrosis or proctitis
after radiation possibly caused by decreased vascularity, hypoxia problems and leukocyte disfunction . Treatment indications
of HBO2 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 HBO2 .
In a study of 105 patients by Bui et al. , HBO2 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. HBO2 treatment decreases
steroid usage andclinical, sympomatic and radiological
improvements were shownafter HBO2 in similar case studies
[15,16]. One of the largest patient registry in literature was the
study by Niezgoda et al.  2358 patients were analyzed in this
article and the most common injuries were osteoradionecrosis,
dermal soft tissue radionecrosis, radiation cystitis, radiation
proctitis and laryngeal radionecrosis in decreasing order.
Continued therapeutic use of HBO2 was supported and advised
by authors in this large population study.
Radiosensitization of tumors with HBO2 before radiotherapy
was discussed in literature. Mayer et al wrote short overview of
different centers and interval between HBO2 and radiotherapy
was 10-20 minutes . HBO2 decreases symptoms of cerebral
necrosis, radiation proctitis and also improves life quality.
Therapeutic role of HBO2 was shown in the literature and
randomized and multicenter studies are needed for future
perspective of radiation complications and side effects. The
results of our single center retrospective study are consistent
with recent literature.Hyperbaric oxygen is an effective and
useful therapy for radiation necrosis and proctitis.