3 | DISCUSSION
Our data indicate that RT of 20 Gy in 5 fractions and 30 Gy in 10 fractions can prevent a rapid decline in the hemoglobin level and reduce the frequency of blood transfusion. From this perspective, palliative RT can contribute to improving the quality of life of patients with advanced gastric cancer with bleeding.
There have been several reports on RT for advanced gastric cancer with bleeding. Lee et al. analyzed hemoglobin and blood transfusion frequency after RT for 57 patients submitted to palliative RT for gastric bleeding (7). The authors reported that the mean hemoglobin levels before, immediately after, and one and two months after RT were significantly higher than before RT. No significant differences in re-bleeding rates were observed according to the total dose (17.5–45 Gy), fractional dose (1.8–5 Gy), or fraction number (4–25 fractions). Tey et al. investigated approximately 50 patients with advanced gastric cancer (8). In that study, the median survival duration was 85 days, and 80% of patients with bleeding responded to RT. Two patients (5%) had grade 3 anorexia and gastritis, but their symptoms resolved after a week. They received 36 Gy in 12 fractions, and the authors concluded that RT was effective and well-tolerated. In Japan, no guideline has yet been established for hemostatic RT for advanced gastric cancer. Taken together, these data indicate that RT at a total of 20–30 Gy is effective in alleviating bleeding from advanced gastric cancer.
The optimal dose for achieving hemostasis in cases of advanced gastric cancer is controversial, as a review by Tey et al. reported wide inter-study variations in dose fractionation (9). Fraction sizes ranged from 1.8 to 8 Gy, and total doses ranged from 8 Gy to 50 Gy, with the most common dose fraction regimen being 30 Gy in 10 fractions. The response to RT for bleeding ranged from 50% to 80.6%. The median duration of response ranged from 1.5 to 11.4 months. This review concluded that there was no marked difference in the response rate of bleeding between regimens with a high biological equivalent dose (BED) of ≥39 Gy versus those with a low BED of <39 Gy. Furthermore, low-BED regimens appear to be adequate for symptom palliation. The BED for 20 Gy in 5 fractions and for 30 Gy in 10 fractions, as was administered to the patients in our study, was 28 and 39 Gy, respectively. Although 30 Gy in 10 fractions is classified as a high BED of ≥39 Gy, no Grade ≥3 complications were observed in our study.
In summary, we report consecutive seven patients with gastric cancer with bleeding treated with palliative RT (20 Gy in 5 fractions or 30 Gy in 10 fractions). The number of blood transfusions decreased significantly post-RT, supporting the hemostatic effect of palliative RT.