How can radiotherapy help control bleeding in esophageal cancer?

Radiotherapy for Bleeding Oesophageal Cancer

External beam radiation therapy is the recommended treatment for chronic blood loss from oesophageal cancer, providing effective haemostasis through tumour shrinkage and vascular obliteration. 1

Mechanism of Action

Radiotherapy controls bleeding in oesophageal cancer through:

• Direct tumour cytoreduction, reducing the friable tumour surface that bleeds 1
• Vascular sclerosis and obliteration of abnormal tumour vessels 1
• Reduction of tumour vascularity over the treatment course 1

Clinical Application Based on Bleeding Pattern

Chronic Blood Loss

• External beam radiation therapy is the standard approach for patients with chronic oozing from tumour surfaces 1
• Typical doses range from 40-50 Gy delivered in fractionated schedules 1
• Response develops progressively over 2-4 weeks as tumour shrinks 2

Acute Bleeding

• Exercise extreme caution - acute bleeding may represent a preterminal event from aortoesophageal fistulization 1
• Endoscopic assessment should be undertaken cautiously as intervention may precipitate exsanguination 1
• If bleeding appears primarily from tumour surface rather than fistula, endoscopic electrocoagulation (bipolar or argon plasma coagulation) should be attempted first 1
• Radiotherapy can be considered after acute bleeding is controlled endoscopically 1

Treatment Protocols

External Beam Radiotherapy

• Palliative doses of 30-40 Gy in 10-15 fractions provide effective symptom control with acceptable toxicity 1
• Higher doses (50-60 Gy) may be used if performance status permits and life expectancy exceeds 3-6 months 1
• Hypofractionated regimens (fewer, larger fractions) produce more prompt palliation and are appropriate for bleeding control 3

Brachytherapy Considerations

• May be considered as an alternative to external beam if the lumen can be restored with appropriate applicators 1
• Should only be performed by experienced practitioners 1
• Single-dose brachytherapy provides better long-term dysphagia relief with fewer complications than metal stents in metastatic disease 1

Combined Modality Approaches

Chemoradiation

• Superior to radiotherapy alone for patients with reasonable performance status 1
• Standard regimens include cisplatin/5-FU with concurrent radiation 1
• Provides better local control and may reduce rebleeding risk 1, 4

Adjunctive Measures

• Intratumoral injection of absolute alcohol may control haemorrhage from bleeding tumours in selected cases 1
• Success rate of 80-100% reported for soft exophytic tumours 1

Critical Pitfalls and Caveats

Warning signs requiring immediate assessment:

• Sudden massive haematemesis suggests aortoesophageal fistula - avoid aggressive endoscopy 1
• Tumours adjacent to major vessels require imaging before radiotherapy planning 1
• Mediastinitis and tracheoesophageal fistula can occur in up to 2% with injection therapy 1

Treatment selection factors:

• Performance status and life expectancy guide dose/fractionation choices 1
• Tumour location (proximity to cricopharyngeus or major vessels) affects technique selection 1
• Prior radiation limits retreatment options 2

Expected Outcomes

• Haemostasis achieved in 70-85% of patients with chronic bleeding treated with external beam radiotherapy 2, 3
• Median time to bleeding control is 2-3 weeks from treatment initiation 2
• Duration of bleeding control typically lasts 3-6 months in palliative settings 3
• Serious complications occur in approximately 2% of patients 2