Safety and efficacy of 25 Gy in 5 fractions of palliative radiotherapy for symptomatic pelvic tumors

Safety and efficacy of 25 Gy in 5 fractions of palliative radiotherapy for symptomatic pelvic tumors | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Safety and efficacy of 25 Gy in 5 fractions of palliative radiotherapy for symptomatic pelvic tumors Tomomi Aoshika, Takanori Abe, Misaki Iino, Satoshi Saito, Yasuhiro Ryuno, and 6 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-1810085/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background Palliative radiotherapy is one of the effective treatments for pelvic tumor with bleeding or pain. In this study, we evaluated the safety and efficacy of palliative radiotherapy (RT) for symptomatic pelvic tumors when delivered as 25 Gy in 5 fractions. Methods We retrospectively analyzed 34 patients (gynecological cancer: n = 14, rectal cancer: n = 5, metastatic pelvic bone tumor: n = 7, metastatic pelvic lymph node tumor: n = 5, synovial sarcoma of the pelvis: n = 1, prostate cancer: n = 1, and urothelial cancer: n = 1, who were treated between July 2016 and July 2021. Their symptoms were bleeding in 16 patients, pain in 17 patients, and both bleeding and pain in 1 patient. Hemostatic effect of RT was evaluated with pre and post treatment hemoglobin (Hb) values. If the Hb level reached a nadir and increased thereafter, we considered that there is a hemostatic response. Pain was evaluated with a numerical rating scale (NRS) and treatment response was defined as a decrease in NRS. Results Their median follow-up period was 4 months. Hemostatic response was observed in 82% of patients (14 of 17 patients). Pain relief response was observed in 78% of patients (14 of 18 patients). Acute adverse effects (AEs) included grade 1 diarrhea: n = 3, grade 1 dermatitis: n = 1, and grade 1 urinary frequency: n = 1; late AEs were not observed so far. Conclusions We think that 25 Gy of palliative RT in 5 fractions seems to be safe and effective for symptomatic pelvic tumors, similar to conventional palliative RT schedules. Palliative radiotherapy 25Gy/5fr Pelvic tumors Figures Figure 1 Figure 2 Background Radiotherapy (RT) has an established role in palliative care for various cancer [ 1 , 2 ]. It was also applied for advanced pelvic tumors such as rectal cancer, and uterine cervical cancer which often present complicated symptoms including bleeding and pain [ 3 , 4 ]. There are various patterns of dose-fractionation schedule for palliative RT for pelvic tumors from single fraction to 30 fractions [ 3 – 9 ], which could be determined individually considering each patient’s condition, tumor characteristics and resources of each hospital [ 5 ]. A 20 Gy in 5 fractions or 30 Gy in 10 fractions of palliative RT are conventionally used dose-fractionation schedule for various type of tumor and tumor-related symptoms [ 1 , 3 ]. Recently, a 25 Gy in 5 fractions of palliative RT has been proposed from some facilities as slightly modified dose-fractionation schedule of these conventional schedule (eg, 20 Gy in 5 fractions or 30 Gy in 10 fractions) [ 7 , 8 ]. Palliative RT regimen of 25 Gy/5 fractions has greater biologically effective dose (BED) than 8 Gy/1 fraction or 20 Gy/5 fractions; and has almost the same BED as 30 Gy/10 fractions, with a shorter treatment period. Kim et al reported the efficacy of 25 Gy in 5 fractions of palliative RT for symptomatic uterine cervical cancer [ 7 ]. Picardi et al reported that 25 Gy in 5 fractions of palliative RT was effective and tolerable for patients with advanced rectal cancer [ 8 ]. We applied 25 Gy/5 fractions of palliative RT for various tumors at pelvis utilizing its advantage of shorter treatment period than 30 Gy/10 fractions with almost same biological effect. However, increasing acute adverse events are a concern with high-dose (< 5 Gy/fraction) therapy and the efficacy of 25 Gy in 5 fractions of palliative RT for various pelvic conditions and various tumor are also unknown. Therefore, in this study, we assessed the safety and efficacy of 25 Gy/5 fractions of palliative RT for symptomatic pelvic tumors. Methods Patients We retrospectively analyzed patients who were treated with 25 Gy in 5 fractions of palliative RT for symptomatic pelvic tumors between July 2016 and August 2021, under the approval of our institutional review board (reference number: 20–091). Pelvic tumors in this study included as both primary tumors at the pelvis and metastatic tumors at the pelvic bone and lymph node. Radiotherapy Treatment was delivered by a linear accelerator with 3-dimentional conformal RT technique. Gross tumor volume (GTV) was defined on computed tomography images with 2.5-mm thickness. A 5 mm of the clinical target volume (CTV) margin was added to GTV and 5 mm of planning target volume (PTV) margin was added to CTV. Generally, beams from 4–5 directions were used and doses were prescribed at isocenter of beam. Commercially available software (XiO) was used for treatment planning and dose calculation. The dose-calculation algorithm was Superposition. The maximum dose of cauda equina should be less than 25 Gy. Evaluation of treatment response All patients were assessed for pain using the Numerical Rating Scale (NRS) prior to the start of radiation therapy. Also, pain relief was evaluated by a numerical rating scale (NRS) before RT and after RT. Radiotherapy pain relief is considered to require 2–4 weeks after irradiation, so the patients were reevaluated as needed during radiotherapy, and analgesics were readjusted aggressively. Pain relief was evaluated by numerical rating scale (NRS) before RT and after RT. If post-treatment NRS was decreased compared with pre-treatment NRS, we determined that there is a treatment response for pain relief. Hemostatic effect of RT was evaluated with pre and post treatment hemoglobin (Hb) values. If the Hb level reached nadir and increased thereafter, we considered that there is a hemostatic response. Additional endpoints for hemostatic effect were also examined for the presence or absence of blood transfusion within 4 months of radiotherapy. We evaluated adverse events at every patient’s visit to the hospital after palliative RT. Adverse events (AEs) were evaluated using the Common Terminology Criteria for Adverse Events, version 5. Diarrhea or nausea were classified as gastro-intestinal toxicity (GI toxicity) and urinary frequency as classified as genitourinary toxicity (GU toxicity). Statistical analysis The median value of 2 groups were compared with Mann-Whitney's U test and relationships between categorical characteristics and treatment responses were examined using the Chi-square test. Statistical analyses were performed with SPSS, version 26 (IBM: Armonk, NY, USA). P < 0.05 was considered significant and all tests were two sided. Results Patient and tumor characteristics We identified and analyzed 34 patients (gynecological cancer: n = 14, rectal cancer: n = 5, metastatic pelvic bone tumor: n = 7, metastatic pelvic lymph node tumor: n = 5, synovial sarcoma of the pelvis: n = 1, prostate cancer: n = 1, and urothelial cancer: n = 1, who were treated between July 2016 and July 2021. Representative patients were shown in Figs. 1 and 2 . Histological type of the tumor was adenocarcinoma in 19 patients, squamous cell carcinoma in 6 patients, sarcoma in 5 patients, neuroendocrine carcinoma in 2 patients, urothelial carcinoma in 1 patient and undifferentiated carcinoma in 1 patient. Primary tumors of metastatic bone tumors were lung cancer in 3 patients, breast cancer in 2 patients and renal cell carcinoma in 2 patients. Primary tumors of metastatic lymph node tumors were lung cancer in 2 patients, uterine carcinosarcoma in 1 patient, ovarian cancer in 1 patient, and pelvic solitary fibrous tumor in 1 patient. Their symptoms were bleeding in 16 patients, pain in 17 patients and both bleeding and pain in 1 patient. The median PTV volume was 253.3 cc (range; 20.8–1049.0). These characteristics are summarized in Table 1 . Table 1 Patient and tumor characteristics ( n = 34) Characteristic Age, years, median (range) 73 (45–92) Sex, n (%) Male 10 (29) Female 24 (71) Irradiated tumor, n (%) Uterine cervical cancer 7 (20) Rectal cancer 5 (15) Uterine sarcoma 2 (6) Ovarian cancer 2 (6) Vaginal cancer 1 (3) Endometrial cancer 1 (3) Valva cancer 1 (3) Urotherial caner 1 (3) Prostate cancer 1 (3) Synovial sarcoma of pelvis 1 (3) Metastatic bone tumor 7 (20) Metastatic lymph node tumor 5 (15) Histological type, n (%) Adenocarcinoma 19 (56) Squamous cell carcinoma 6 (17) Sarcoma 5 (15) Neuroendocrine carcinoma 2 (6) Urothelial carcinoma 1 (3) Undifferentiated carcinoma 1(3) Performance status, n (%) 0 3 (9) 1 19 (56) 2 10 (29) 3 2 (4) Symptom, n (%) Pain 17 (50) Bleeding 16 (47) Pain and bleeding 1 (3) Volume of planning target volume, (cc) median (range) 253.3 (20.8–1049.0) Treatment response and toxicity The median follow-up period was 4 months. At last follow up, 8 patients were died with a median survival period of 4 months. Among 17 patients with bleeding, the median pre-treatment Hb level was 10.1 g/dL while the post-treatment Hb level was 10.3 g/dL (p = 0.812). A 14 patient of 17 patients (82%) showed hemostatic response. Ten patients had blood transfusions prior to the start of radiotherapy, and only one patient with uterine sarcoma required continued blood transfusions after radiotherapy. All patients were on oral analgesics for pain control prior to initiation of radiotherapy. Of the 18 patients with pain, 11 were on opioid analgesics and 7 on non-opioid analgesics. One patient experienced worsening pain during radiotherapy, which was thought to be a flare phenomenon, and was controllable with increased doses of analgesics. Among 18 patients with pain, the median pre-treatment NRS was 5 while the median post-treatment NRS was 2.5 ( p = 0.001). Among 18 patients with pain, 4 patients (22%) did not show pain relief response after treatment. Histological types of these 4 patients were sarcoma in 3 patients (16%) and renal cell carcinoma in 1 patient (5%). As a result, pain relief response rate was 78% (14 of 18 patients). However, there were no cases in which analgesics could be reduced within 4 months after radiotherapy. Acute adverse effects (AEs) included grade 1 diarrhea: n = 3, grade 1 dermatitis: n = 1, and grade 1 urinary frequency: n = 1; grade 2 or greater acute toxicity were not observed so far. Factors related to treatment response Among 18 patients with pain, 4 patients did not show pain relief response after treatment. Histological type of these 4 patients were sarcoma in 3 patients (16%) and renal cell carcinoma in 1 patient (5%). We found that sarcoma significantly correlated with refractoriness to palliative RT for pain relief response ( p = 0.004). Other factors such as age, performance status, primary tumors or metastatic tumors did not correlate with pain relief response. These results were summarized in Table 2 . Regarding hemostatic response, histological type, age, performance status, primary tumors or metastatic tumors did not correlate with treatment response. Table 2 Factors related with pain relief response ( n = 18) Characteristics pain relief response (+) pain relief response (-) p -value Sex male 7 2 1.000 female 7 2 Age ≥ 72 years 7 3 0.257 < 72 years 7 1 Histological type sarcoma 0 3 0.004 others 14 1 Performance status 0 or 1 8 2 0.8 2 or 3 6 2 Site of tumor Primary tumor 4 1 0.261 metastatic tumor 10 3 Discussion In this study, 14 of 17 patients (82%) of patients showed hemostatic response. Although 3 patients showed no hemostatic response by our definition, decrease of Hb level of these 3 patients became slow and these patients could be discharged from hospital without necessity of blood transfusion. Kim et al reported that 94% of patient (15 of 16 patients) with bleeding showed hemostatic response after 20–25 Gy in 5 fractions of palliative RT for uterine cervical cancer [ 6 ]. Picardi et al reported that 25 Gy in 5 fractions of palliative RT for advanced rectal cancer achieved 100% (9 of 9 patients) of hemostatic response rate [ 7 ]. Our present study similarly showed achieved adequate hemostatic purpose as Kim et al and Picardi et al although our study included various cancer besides uterine cervical cancer or rectal cancer. Although few reports mention hemostasis-dose-response relationships, a meta-analysis suggests that a minimum of 30 Gy EQD2 is necessary for hemostatic radiation therapy for gastric cancer [ 10 ]. A 25 Gy in 5 fractions deserves 31.25 Gy EQD2 , which was higher than this cut-off value. We think that 25 Gy in 5 fractions of palliative radiotherapy has adequate hemostatic effect for pelvic tumors. In this study, pain relief response rate was 78% (14 of 18 patients). Picardi et al reported that pain relief response rate was 87% with 25 Gy in 5 fractions of palliative RT for rectal cancer [ 7 ]. Our study showed same tendency that pain relief response rates were relatively lower compared with hemostatic response rates. However, pain relief response rate was still adequate given the reported pain relief response rate (61–70%) of palliative RT for various cancer [ 11 , 12 ]. In this study, 4 of 18 patients showed no pain relief response. Histological types of these 4 patients were sarcoma in 3 patients and renal cell carcinoma in 1 patient. Histological types of sarcoma significantly correlated with refractoriness to palliative RT for pain relief purpose (p = 0.004) while sex age, PS and primary or metastatic tumor did not show a significant difference. Same tendency was observed in patients with bleeding. Among 17 patients with bleeding, 1 patient with uterine sarcoma could not be free from blood transfusion. Generally, sarcoma showed refractoriness to RT [ 13 , 14 ]. Further study with a larger number of patients is warranted to clarify optimal dose-fractionation schedule of palliative RT for sarcoma. Another concern of palliative RT for the pelvic tumor is acute GI and GU toxicity. Picardi et al reported that Grade 1–2 GI and GU toxicity was observed in 39% of patients after palliative RT of 25 Gy 5 fractions for advanced rectal cancer [ 7 ]. The incidence of grade 1 GI and GU toxicity of the present study is 12% (4 of 34 patients), which seems to be adequately low. In this study, 71% of patients (24 of 34 patients) had primary pelvic tumors. To avoid unnecessary dose to surrounding GI tract when tumor located at central area of pelvis, we used beams from multi-directions rather than anterior-posterior opposite beams. The median number of beams of RT was 5 for the patients with primary pelvic tumors. We think that one of the reasons of low incidence of low GI toxicity is the delivery of beams from multi-direction to spare surrounding GI tract. Our findings suggest that 25 Gy/5 fractions of palliative RT with careful attention to reduce unnecessary doses to surrounding GI tract is a tolerable option for pelvic tumors. Limitations of this study should be noted. This was a retrospective study with a relatively small patient cohort, which may have led to sample bias with respect to tumor types and other patient characteristics. Toxicity and treatment responses were not evaluated with fixed schedules, which may have produced uncertainty in the results. Also, the unfixed evaluation method and patients’ short follow-up period made it difficult to evaluate the duration of effects. Therefore, AEs and treatment responses should be evaluated with stricter criteria in a future prospective trial. We did not apply IMRT or SBRT in this study due to the lack of machine and human resources to perform these high precision RT for palliative purpose. Dose to the surrounding normal tissue could be reduced or dose to the tumor could be increased with these techniques. Further study to clarify the effect and safety of these advanced RT techniques for palliation of pelvic tumors. Conclusions In this study, hemostatic response was observed in 82% of patients (14 of 17 patients) and pain relief response was observed in 78% of patients (14 of 18 patients) with no severe acute adverse events. We think that 25 Gy of palliative RT in 5 fractions seems to be safe and effective for symptomatic pelvic tumor, similar to conventional palliative RT schedules. List Of Abbreviations RT; radiotherapy, Hb; hemoglobin, NRS; numerical rating scale, AEs; adverse effects, BED; biologically effective dose, GTV; gross tumor volume, CTV; clinical target volume, PTV; planning target volume, GI toxicity; gastro-intestinal toxicity, and GU toxicity; genitourinary toxicity. Declarations Ethics approval and patients' consent to participate This study was approved by the Institutional Review Board of International Medical Center, Saitama Medical University (Reference number: 20-091). Consent for publication Informed consent for publication was obtained from all patients in this study. Availability of data and materials The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request. Competing interests The authors declare that they have no competing interests. Funding The authors received no funding specifically for this study. Authors' contribution TA and TA designed the study. MI, SS, TA, YR, TO, MI, RH, YK, SN, and SK contributed to the acquisition and analysis of data. TA performed the statistical analysis. TA, TA, and SK created the manuscript. All authors read and approved the final manuscript. Acknowledgements The institutional review board of the Saitama Medical University International Medical Center approved this study (20-091). We thank Marla Brunker, from Edanz Group (https://en-author-services.edanz.com/ac) for editing a draft of this manuscript. References Spencer K, Parrish R, Barton R, Henry A. Palliative radiotherapy. BMJ. 2018;360:k821. NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) Palliative Care Version 1.2022. https://www.nccn.org/professionals/physician_gls/pdf/palliative.pdf . Accessed, 27 June, 2022. Cameron MG, Kersten C, Vistad I, Fosså S, Guren MG. Palliative pelvic radiotherapy of symptomatic incurable rectal cancer - a systematic review. Acta Oncol. 2014;53:164–73. van Lonkhuijzen L, Thomas G. Palliative radiotherapy for cervical carcinoma, a systematic review. Radiother Oncol. 2011;98:287–91. Eleje GU, Eke AC, Igberase GO, Igwegbe AO, Eleje LI. Palliative interventions for controlling vaginal bleeding in advanced cervical cancer. Cochrane Database Syst Rev. 2019;3:CD011000. Kim DH, Lee JH, Ki YK, Nam JH, Kim WT, Jeon HS, et al. Short-course palliative radiotherapy for uterine cervical cancer. Radiat Oncol J. 2013;31:216–21. Picardi V, Deodato F, Guido A, Giaccherini L, Macchia G, Frazzoni L, et al. Palliative Short-Course Radiation Therapy in Rectal Cancer: A Phase 2 Study. Int J Radiat Oncol Biol Phys. 2016;95:1184–90. Shuja M, Nazli S, Mansha MA, Iqbal A, Mohamed R, Tunio MA,et al. Bleeding in locally invasive pelvic malignancies: is hypofractionated radiation therapy a safe and effective non-invasive option for securing hemostasis? a single institution perspective. Cureus. 2018;10:e2137. Butala AA, Lee DY, Patel RR, Latif NA, Haggerty AF, Paydar I, et al. Retrospective Study of Rapid Symptom Response in Bleeding Gynecologic Malignancies With Short Course Palliative Radiation Therapy: Less is More. J Pain Symptom Manage. 2021;61:377 – 83.e2. Viani GA, Arruda CV, Hamamura AC, Faustino AC, Danelichen AFB, Matsuura FK, et al. Palliative radiotherapy for gastric cancer: Is there a dose relationship between bleeding response and radiotherapy? Clinics (Sao Paulo). 2020;75: e1644. Saito T, Yamaguchi K, Toya R, Oya N. Single- Versus Multiple-Fraction Radiation Therapy for Painful Bone Metastases: A Systematic Review and Meta-analysis of Nonrandomized Studies. Adv Radiat Oncol. 2019;4:706–15. Rich SE, Chow R, Raman S, Liang Zeng K, Lutz S, Lam H, et al. Update of the systematic review of palliative radiation therapy fractionation for bone metastases. Radiother Oncol. 2018;126:547–57. Rhomberg W. The radiation response of sarcomas by histologic subtypes: a review with special emphasis given to results achieved with razoxane. Sarcoma. 2006;2006:87367. Yang G, Yuan Z, Ahmed K, Welsh EA, Fulp WJ, Gonzalez RJ, et al. Genomic identification of sarcoma radiosensitivity and the clinical implications for radiation dose personalization. Transl Oncol. 2021;14:101165. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About In Review Editorial Policies Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-1810085","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":117586096,"identity":"e43a647f-9a9d-4634-ac13-c18e155c734f","order_by":0,"name":"Tomomi Aoshika","email":"","orcid":"","institution":"Saitama Medical University","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Tomomi","middleName":"","lastName":"Aoshika","suffix":""},{"id":117586097,"identity":"fa8e65fa-444d-46f7-be10-d86b2d55b141","order_by":1,"name":"Takanori Abe","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA4klEQVRIiWNgGAWjYJACxgYGCR429gYGZpiIAX4NzCAtFnL8PAdI01JhLDkjAaEFL9Cdff7gxxk1Eokbbr4x/FxQYcPA397AUFyAR4vZuWRmyQ3HgFpu5xhLzziTxiBx5gCD8Qx8Ws4wM0g+YANrMZDmbTvMYCCRwGDMg18L888H/0AOO2P8m1gtbJIb2ySA3ucxI9oWM8uZfRLAQE4rs+Y5k8YjceZgAwG/MD6+2fOtDhiVhzff5qmwkeNvbz5mjC/EkAAHOAKBTmJsMyZOBwP7AxiL+TGRWkbBKBgFo2BkAAA4HkejIQbbHAAAAABJRU5ErkJggg==","orcid":"","institution":"Saitama Medical University","correspondingAuthor":true,"submittingAuthor":false,"prefix":"","firstName":"Takanori","middleName":"","lastName":"Abe","suffix":""},{"id":117586098,"identity":"4fbeb6cb-c8a8-4c75-a113-52db54c6f6f8","order_by":2,"name":"Misaki Iino","email":"","orcid":"","institution":"Saitama Medical University","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Misaki","middleName":"","lastName":"Iino","suffix":""},{"id":117586099,"identity":"41cf911b-a6c4-4e60-80b8-b7fd5a43b58e","order_by":3,"name":"Satoshi Saito","email":"","orcid":"","institution":"Saitama Medical University","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Satoshi","middleName":"","lastName":"Saito","suffix":""},{"id":117586100,"identity":"a2f8ef94-1b6e-436d-a615-38e7230e6d87","order_by":4,"name":"Yasuhiro Ryuno","email":"","orcid":"","institution":"Saitama Medical University","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Yasuhiro","middleName":"","lastName":"Ryuno","suffix":""},{"id":117586101,"identity":"9462816d-aeb2-4fea-ad1e-151a19554c0d","order_by":5,"name":"Tomohiro Ohta","email":"","orcid":"","institution":"Saitama Medical University","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Tomohiro","middleName":"","lastName":"Ohta","suffix":""},{"id":117586102,"identity":"1fc07f3f-43b9-427b-9efe-d19e0668a917","order_by":6,"name":"Mitsunobu Igari","email":"","orcid":"","institution":"Saitama Medical University","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Mitsunobu","middleName":"","lastName":"Igari","suffix":""},{"id":117586103,"identity":"71d57d71-7acd-4684-a2f9-ed12e9329705","order_by":7,"name":"Ryuta Hirai","email":"","orcid":"","institution":"Saitama Medical University","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Ryuta","middleName":"","lastName":"Hirai","suffix":""},{"id":117586104,"identity":"8d4cb42e-e660-4163-b21d-73a06cb76138","order_by":8,"name":"Yu Kumazaki","email":"","orcid":"","institution":"Saitama Medical University","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Yu","middleName":"","lastName":"Kumazaki","suffix":""},{"id":117586105,"identity":"6e16ce88-6b3d-4f2d-916b-11892441a67f","order_by":9,"name":"Shin-ei Noda","email":"","orcid":"","institution":"Saitama Medical University","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Shin-ei","middleName":"","lastName":"Noda","suffix":""},{"id":117586106,"identity":"6c62c65a-7449-42bc-81d2-ae16885fd713","order_by":10,"name":"Shingo Kato","email":"","orcid":"","institution":"Saitama Medical University","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Shingo","middleName":"","lastName":"Kato","suffix":""}],"badges":[],"createdAt":"2022-06-30 05:44:10","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-1810085/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-1810085/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":23638416,"identity":"55644bdc-7f88-4f77-8118-b50772232921","added_by":"auto","created_at":"2022-07-08 16:06:24","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":201595,"visible":true,"origin":"","legend":"\u003cp\u003eTreatment plan of representative patient was shown. Patient has recurrence of ovarian cancer at vaginal stump which cause bleeding. Light blue line showed tumor. Beams from 5 directions were applied to cover tumor with sparing rectum as much as possible. Red thin line showed 95% of prescribed dose (25 Gy in 5 fractions).\u003c/p\u003e","description":"","filename":"Figure1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-1810085/v1/66b7633817bc9e06cf010198.jpg"},{"id":23638415,"identity":"3ce28c81-6f82-4bf9-9554-1049c036d0a8","added_by":"auto","created_at":"2022-07-08 16:06:24","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":125735,"visible":true,"origin":"","legend":"\u003cp\u003eDiagnostic computed tomography image with contrast media of same patient taken 6 months after treatment was shown. Tumor shrunk well and bleeding was controlled so far.\u003c/p\u003e","description":"","filename":"Figure2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-1810085/v1/f521a80142b55920a160589f.jpg"},{"id":23962485,"identity":"d5632df7-919b-4bf6-926e-b87d87cf8638","added_by":"auto","created_at":"2022-07-18 05:44:37","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":391349,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-1810085/v1/a4b5ced2-4f75-415f-a27f-3f49ab566034.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Safety and efficacy of 25 Gy in 5 fractions of palliative radiotherapy for symptomatic pelvic tumors","fulltext":[{"header":"Background","content":"\u003cp\u003eRadiotherapy (RT) has an established role in palliative care for various cancer [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. It was also applied for advanced pelvic tumors such as rectal cancer, and uterine cervical cancer which often present complicated symptoms including bleeding and pain [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. There are various patterns of dose-fractionation schedule for palliative RT for pelvic tumors from single fraction to 30 fractions [\u003cspan additionalcitationids=\"CR4 CR5 CR6 CR7 CR8\" citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e], which could be determined individually considering each patient\u0026rsquo;s condition, tumor characteristics and resources of each hospital [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. A 20 Gy in 5 fractions or 30 Gy in 10 fractions of palliative RT are conventionally used dose-fractionation schedule for various type of tumor and tumor-related symptoms [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Recently, a 25 Gy in 5 fractions of palliative RT has been proposed from some facilities as slightly modified dose-fractionation schedule of these conventional schedule (eg, 20 Gy in 5 fractions or 30 Gy in 10 fractions) [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Palliative RT regimen of 25 Gy/5 fractions has greater biologically effective dose (BED) than 8 Gy/1 fraction or 20 Gy/5 fractions; and has almost the same BED as 30 Gy/10 fractions, with a shorter treatment period. Kim et al reported the efficacy of 25 Gy in 5 fractions of palliative RT for symptomatic uterine cervical cancer [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Picardi et al reported that 25 Gy in 5 fractions of palliative RT was effective and tolerable for patients with advanced rectal cancer [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. We applied 25 Gy/5 fractions of palliative RT for various tumors at pelvis utilizing its advantage of shorter treatment period than 30 Gy/10 fractions with almost same biological effect. However, increasing acute adverse events are a concern with high-dose (\u0026lt;\u0026thinsp;5 Gy/fraction) therapy and the efficacy of 25 Gy in 5 fractions of palliative RT for various pelvic conditions and various tumor are also unknown. Therefore, in this study, we assessed the safety and efficacy of 25 Gy/5 fractions of palliative RT for symptomatic pelvic tumors.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003ePatients\u003c/h2\u003e \u003cp\u003e We retrospectively analyzed patients who were treated with 25 Gy in 5 fractions of palliative RT for symptomatic pelvic tumors between July 2016 and August 2021, under the approval of our institutional review board (reference number: 20\u0026ndash;091). Pelvic tumors in this study included as both primary tumors at the pelvis and metastatic tumors at the pelvic bone and lymph node.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eRadiotherapy\u003c/h2\u003e \u003cp\u003eTreatment was delivered by a linear accelerator with 3-dimentional conformal RT technique. Gross tumor volume (GTV) was defined on computed tomography images with 2.5-mm thickness. A 5 mm of the clinical target volume (CTV) margin was added to GTV and 5 mm of planning target volume (PTV) margin was added to CTV. Generally, beams from 4\u0026ndash;5 directions were used and doses were prescribed at isocenter of beam. Commercially available software (XiO) was used for treatment planning and dose calculation. The dose-calculation algorithm was Superposition. The maximum dose of cauda equina should be less than 25 Gy.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eEvaluation of treatment response\u003c/h2\u003e \u003cp\u003eAll patients were assessed for pain using the Numerical Rating Scale (NRS) prior to the start of radiation therapy. Also, pain relief was evaluated by a numerical rating scale (NRS) before RT and after RT. Radiotherapy pain relief is considered to require 2\u0026ndash;4 weeks after irradiation, so the patients were reevaluated as needed during radiotherapy, and analgesics were readjusted aggressively. Pain relief was evaluated by numerical rating scale (NRS) before RT and after RT. If post-treatment NRS was decreased compared with pre-treatment NRS, we determined that there is a treatment response for pain relief. Hemostatic effect of RT was evaluated with pre and post treatment hemoglobin (Hb) values. If the Hb level reached nadir and increased thereafter, we considered that there is a hemostatic response. Additional endpoints for hemostatic effect were also examined for the presence or absence of blood transfusion within 4 months of radiotherapy. We evaluated adverse events at every patient\u0026rsquo;s visit to the hospital after palliative RT. Adverse events (AEs) were evaluated using the Common Terminology Criteria for Adverse Events, version 5. Diarrhea or nausea were classified as gastro-intestinal toxicity (GI toxicity) and urinary frequency as classified as genitourinary toxicity (GU toxicity).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eStatistical analysis\u003c/h2\u003e \u003cp\u003eThe median value of 2 groups were compared with Mann-Whitney's U test and relationships between categorical characteristics and treatment responses were examined using the Chi-square test. Statistical analyses were performed with SPSS, version 26 (IBM: Armonk, NY, USA). \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05 was considered significant and all tests were two sided.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003ePatient and tumor characteristics\u003c/h2\u003e \u003cp\u003eWe identified and analyzed 34 patients (gynecological cancer: \u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;14, rectal cancer: \u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;5, metastatic pelvic bone tumor: \u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;7, metastatic pelvic lymph node tumor: n\u0026thinsp;=\u0026thinsp;5, synovial sarcoma of the pelvis: \u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;1, prostate cancer: n\u0026thinsp;=\u0026thinsp;1, and urothelial cancer: \u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;1, who were treated between July 2016 and July 2021. Representative patients were shown in Figs.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e and \u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e. Histological type of the tumor was adenocarcinoma in 19 patients, squamous cell carcinoma in 6 patients, sarcoma in 5 patients, neuroendocrine carcinoma in 2 patients, urothelial carcinoma in 1 patient and undifferentiated carcinoma in 1 patient. Primary tumors of metastatic bone tumors were lung cancer in 3 patients, breast cancer in 2 patients and renal cell carcinoma in 2 patients. Primary tumors of metastatic lymph node tumors were lung cancer in 2 patients, uterine carcinosarcoma in 1 patient, ovarian cancer in 1 patient, and pelvic solitary fibrous tumor in 1 patient. Their symptoms were bleeding in 16 patients, pain in 17 patients and both bleeding and pain in 1 patient. The median PTV volume was 253.3 cc (range; 20.8\u0026ndash;1049.0). These characteristics are summarized in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003ePatient and tumor characteristics (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;34)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCharacteristic\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge, years, median (range)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e73 (45\u0026ndash;92)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSex, \u003cem\u003en\u003c/em\u003e (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10 (29)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e24 (71)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIrradiated tumor, \u003cem\u003en\u003c/em\u003e (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUterine cervical cancer\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7 (20)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRectal cancer\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5 (15)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUterine sarcoma\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 (6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOvarian cancer\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 (6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eVaginal cancer\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eEndometrial cancer\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eValva cancer\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUrotherial caner\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eProstate cancer\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSynovial sarcoma of pelvis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMetastatic bone tumor\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7 (20)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMetastatic lymph node tumor\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5 (15)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHistological type, \u003cem\u003en\u003c/em\u003e (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAdenocarcinoma\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e19 (56)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSquamous cell carcinoma\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6 (17)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSarcoma\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5 (15)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNeuroendocrine carcinoma\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 (6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUrothelial carcinoma\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUndifferentiated carcinoma\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1(3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePerformance status, \u003cem\u003en\u003c/em\u003e (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3 (9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e19 (56)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10 (29)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 (4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSymptom, \u003cem\u003en\u003c/em\u003e (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePain\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e17 (50)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBleeding\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e16 (47)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePain and bleeding\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVolume of planning target volume, (cc)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003emedian (range)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e253.3 (20.8\u0026ndash;1049.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003eTreatment response and toxicity\u003c/h2\u003e \u003cp\u003eThe median follow-up period was 4 months. At last follow up, 8 patients were died with a median survival period of 4 months. Among 17 patients with bleeding, the median pre-treatment Hb level was 10.1 g/dL while the post-treatment Hb level was 10.3 g/dL (p\u0026thinsp;=\u0026thinsp;0.812). A 14 patient of 17 patients (82%) showed hemostatic response. Ten patients had blood transfusions prior to the start of radiotherapy, and only one patient with uterine sarcoma required continued blood transfusions after radiotherapy. All patients were on oral analgesics for pain control prior to initiation of radiotherapy. Of the 18 patients with pain, 11 were on opioid analgesics and 7 on non-opioid analgesics. One patient experienced worsening pain during radiotherapy, which was thought to be a flare phenomenon, and was controllable with increased doses of analgesics. Among 18 patients with pain, the median pre-treatment NRS was 5 while the median post-treatment NRS was 2.5 (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.001). Among 18 patients with pain, 4 patients (22%) did not show pain relief response after treatment. Histological types of these 4 patients were sarcoma in 3 patients (16%) and renal cell carcinoma in 1 patient (5%). As a result, pain relief response rate was 78% (14 of 18 patients). However, there were no cases in which analgesics could be reduced within 4 months after radiotherapy. Acute adverse effects (AEs) included grade 1 diarrhea: \u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;3, grade 1 dermatitis: \u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;1, and grade 1 urinary frequency: \u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;1; grade 2 or greater acute toxicity were not observed so far.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003eFactors related to treatment response\u003c/h2\u003e \u003cp\u003eAmong 18 patients with pain, 4 patients did not show pain relief response after treatment. Histological type of these 4 patients were sarcoma in 3 patients (16%) and renal cell carcinoma in 1 patient (5%). We found that sarcoma significantly correlated with refractoriness to palliative RT for pain relief response (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.004). Other factors such as age, performance status, primary tumors or metastatic tumors did not correlate with pain relief response. These results were summarized in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e. Regarding hemostatic response, histological type, age, performance status, primary tumors or metastatic tumors did not correlate with treatment response.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eFactors related with pain relief response (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;18)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCharacteristics\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003epain relief response (+)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003epain relief response (-)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cem\u003ep\u003c/em\u003e-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSex\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003emale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e1.000\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003efemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026ge;\u0026thinsp;72 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.257\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;72 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHistological type\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003esarcoma\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.004\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eothers\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePerformance status\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0 or 1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 or 3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSite of tumor\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePrimary tumor\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.261\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003emetastatic tumor\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eIn this study, 14 of 17 patients (82%) of patients showed hemostatic response. Although 3 patients showed no hemostatic response by our definition, decrease of Hb level of these 3 patients became slow and these patients could be discharged from hospital without necessity of blood transfusion. Kim et al reported that 94% of patient (15 of 16 patients) with bleeding showed hemostatic response after 20\u0026ndash;25 Gy in 5 fractions of palliative RT for uterine cervical cancer [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Picardi et al reported that 25 Gy in 5 fractions of palliative RT for advanced rectal cancer achieved 100% (9 of 9 patients) of hemostatic response rate [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Our present study similarly showed achieved adequate hemostatic purpose as Kim et al and Picardi et al although our study included various cancer besides uterine cervical cancer or rectal cancer. Although few reports mention hemostasis-dose-response relationships, a meta-analysis suggests that a minimum of 30 Gy\u003csub\u003eEQD2\u003c/sub\u003e is necessary for hemostatic radiation therapy for gastric cancer [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. A 25 Gy in 5 fractions deserves 31.25 Gy \u003csub\u003eEQD2\u003c/sub\u003e, which was higher than this cut-off value. We think that 25 Gy in 5 fractions of palliative radiotherapy has adequate hemostatic effect for pelvic tumors.\u003c/p\u003e \u003cp\u003eIn this study, pain relief response rate was 78% (14 of 18 patients). Picardi et al reported that pain relief response rate was 87% with 25 Gy in 5 fractions of palliative RT for rectal cancer [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Our study showed same tendency that pain relief response rates were relatively lower compared with hemostatic response rates. However, pain relief response rate was still adequate given the reported pain relief response rate (61\u0026ndash;70%) of palliative RT for various cancer [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. In this study, 4 of 18 patients showed no pain relief response. Histological types of these 4 patients were sarcoma in 3 patients and renal cell carcinoma in 1 patient. Histological types of sarcoma significantly correlated with refractoriness to palliative RT for pain relief purpose (p\u0026thinsp;=\u0026thinsp;0.004) while sex age, PS and primary or metastatic tumor did not show a significant difference. Same tendency was observed in patients with bleeding. Among 17 patients with bleeding, 1 patient with uterine sarcoma could not be free from blood transfusion. Generally, sarcoma showed refractoriness to RT [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. Further study with a larger number of patients is warranted to clarify optimal dose-fractionation schedule of palliative RT for sarcoma.\u003c/p\u003e \u003cp\u003eAnother concern of palliative RT for the pelvic tumor is acute GI and GU toxicity. Picardi et al reported that Grade 1\u0026ndash;2 GI and GU toxicity was observed in 39% of patients after palliative RT of 25 Gy 5 fractions for advanced rectal cancer [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. The incidence of grade 1 GI and GU toxicity of the present study is 12% (4 of 34 patients), which seems to be adequately low. In this study, 71% of patients (24 of 34 patients) had primary pelvic tumors. To avoid unnecessary dose to surrounding GI tract when tumor located at central area of pelvis, we used beams from multi-directions rather than anterior-posterior opposite beams. The median number of beams of RT was 5 for the patients with primary pelvic tumors. We think that one of the reasons of low incidence of low GI toxicity is the delivery of beams from multi-direction to spare surrounding GI tract. Our findings suggest that 25 Gy/5 fractions of palliative RT with careful attention to reduce unnecessary doses to surrounding GI tract is a tolerable option for pelvic tumors.\u003c/p\u003e \u003cp\u003eLimitations of this study should be noted. This was a retrospective study with a relatively small patient cohort, which may have led to sample bias with respect to tumor types and other patient characteristics. Toxicity and treatment responses were not evaluated with fixed schedules, which may have produced uncertainty in the results. Also, the unfixed evaluation method and patients\u0026rsquo; short follow-up period made it difficult to evaluate the duration of effects. Therefore, AEs and treatment responses should be evaluated with stricter criteria in a future prospective trial. We did not apply IMRT or SBRT in this study due to the lack of machine and human resources to perform these high precision RT for palliative purpose. Dose to the surrounding normal tissue could be reduced or dose to the tumor could be increased with these techniques. Further study to clarify the effect and safety of these advanced RT techniques for palliation of pelvic tumors.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eIn this study, hemostatic response was observed in 82% of patients (14 of 17 patients) and pain relief response was observed in 78% of patients (14 of 18 patients) with no severe acute adverse events. We think that 25 Gy of palliative RT in 5 fractions seems to be safe and effective for symptomatic pelvic tumor, similar to conventional palliative RT schedules.\u003c/p\u003e"},{"header":"List Of Abbreviations","content":"\u003cp\u003eRT; radiotherapy, Hb; hemoglobin, NRS; numerical rating scale, AEs; adverse effects, BED; biologically effective dose, GTV; gross tumor volume, CTV; clinical target volume, PTV; planning target volume, GI toxicity; gastro-intestinal toxicity, and GU toxicity; genitourinary toxicity.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and patients\u0026apos; consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was approved by the Institutional Review Board of International Medical Center, Saitama Medical University (Reference number: 20-091).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eInformed consent for publication was obtained from all patients in this study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors received no funding specifically for this study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; contribution\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTA and TA designed the study. MI, SS, TA, YR, TO, MI, RH, YK, SN, and SK contributed to the acquisition and analysis of data. TA performed the statistical analysis. TA, TA, and SK created the manuscript. All authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe institutional review board of the Saitama Medical University International Medical Center approved this study (20-091).\u003c/p\u003e\n\u003cp\u003eWe thank Marla Brunker, from Edanz Group (https://en-author-services.edanz.com/ac) for editing a draft of this manuscript.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eSpencer K, Parrish R, Barton R, Henry A. Palliative radiotherapy. BMJ. 2018;360:k821.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines\u0026reg;) Palliative Care Version 1.2022. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.nccn.org/professionals/physician_gls/pdf/palliative.pdf\u003c/span\u003e\u003cspan address=\"https://www.nccn.org/professionals/physician_gls/pdf/palliative.pdf\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Accessed, 27 June, 2022.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCameron MG, Kersten C, Vistad I, Foss\u0026aring; S, Guren MG. Palliative pelvic radiotherapy of symptomatic incurable rectal cancer - a systematic review. Acta Oncol. 2014;53:164\u0026ndash;73.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003evan Lonkhuijzen L, Thomas G. Palliative radiotherapy for cervical carcinoma, a systematic review. Radiother Oncol. 2011;98:287\u0026ndash;91.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eEleje GU, Eke AC, Igberase GO, Igwegbe AO, Eleje LI. Palliative interventions for controlling vaginal bleeding in advanced cervical cancer. Cochrane Database Syst Rev. 2019;3:CD011000.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKim DH, Lee JH, Ki YK, Nam JH, Kim WT, Jeon HS, et al. Short-course palliative radiotherapy for uterine cervical cancer. Radiat Oncol J. 2013;31:216\u0026ndash;21.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePicardi V, Deodato F, Guido A, Giaccherini L, Macchia G, Frazzoni L, et al. Palliative Short-Course Radiation Therapy in Rectal Cancer: A Phase 2 Study. Int J Radiat Oncol Biol Phys. 2016;95:1184\u0026ndash;90.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eShuja M, Nazli S, Mansha MA, Iqbal A, Mohamed R, Tunio MA,et al. Bleeding in locally invasive pelvic malignancies: is hypofractionated radiation therapy a safe and effective non-invasive option for securing hemostasis? a single institution perspective. Cureus. 2018;10:e2137.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eButala AA, Lee DY, Patel RR, Latif NA, Haggerty AF, Paydar I, et al. Retrospective Study of Rapid Symptom Response in Bleeding Gynecologic Malignancies With Short Course Palliative Radiation Therapy: Less is More. J Pain Symptom Manage. 2021;61:377 \u0026ndash; 83.e2.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eViani GA, Arruda CV, Hamamura AC, Faustino AC, Danelichen AFB, Matsuura FK, et al. Palliative radiotherapy for gastric cancer: Is there a dose relationship between bleeding response and radiotherapy? Clinics (Sao Paulo). 2020;75: e1644.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSaito T, Yamaguchi K, Toya R, Oya N. Single- Versus Multiple-Fraction Radiation Therapy for Painful Bone Metastases: A Systematic Review and Meta-analysis of Nonrandomized Studies. Adv Radiat Oncol. 2019;4:706\u0026ndash;15.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRich SE, Chow R, Raman S, Liang Zeng K, Lutz S, Lam H, et al. Update of the systematic review of palliative radiation therapy fractionation for bone metastases. Radiother Oncol. 2018;126:547\u0026ndash;57.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRhomberg W. The radiation response of sarcomas by histologic subtypes: a review with special emphasis given to results achieved with razoxane. Sarcoma. 2006;2006:87367.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eYang G, Yuan Z, Ahmed K, Welsh EA, Fulp WJ, Gonzalez RJ, et al. Genomic identification of sarcoma radiosensitivity and the clinical implications for radiation dose personalization. Transl Oncol. 2021;14:101165.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Palliative radiotherapy, 25Gy/5fr, Pelvic tumors","lastPublishedDoi":"10.21203/rs.3.rs-1810085/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-1810085/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003ePalliative radiotherapy is one of the effective treatments for pelvic tumor with bleeding or pain. In this study, we evaluated the safety and efficacy of palliative radiotherapy (RT) for symptomatic pelvic tumors when delivered as 25 Gy in 5 fractions.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eWe retrospectively analyzed 34 patients (gynecological cancer: \u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;14, rectal cancer: \u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;5, metastatic pelvic bone tumor: \u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;7, metastatic pelvic lymph node tumor: n\u0026thinsp;=\u0026thinsp;5, synovial sarcoma of the pelvis: \u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;1, prostate cancer: n\u0026thinsp;=\u0026thinsp;1, and urothelial cancer: \u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;1, who were treated between July 2016 and July 2021. Their symptoms were bleeding in 16 patients, pain in 17 patients, and both bleeding and pain in 1 patient. Hemostatic effect of RT was evaluated with pre and post treatment hemoglobin (Hb) values. If the Hb level reached a nadir and increased thereafter, we considered that there is a hemostatic response. Pain was evaluated with a numerical rating scale (NRS) and treatment response was defined as a decrease in NRS.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eTheir median follow-up period was 4 months. Hemostatic response was observed in 82% of patients (14 of 17 patients). Pain relief response was observed in 78% of patients (14 of 18 patients). Acute adverse effects (AEs) included grade 1 diarrhea: \u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;3, grade 1 dermatitis: \u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;1, and grade 1 urinary frequency: \u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;1; late AEs were not observed so far.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eWe think that 25 Gy of palliative RT in 5 fractions seems to be safe and effective for symptomatic pelvic tumors, similar to conventional palliative RT schedules.\u003c/p\u003e","manuscriptTitle":"Safety and efficacy of 25 Gy in 5 fractions of palliative radiotherapy for symptomatic pelvic tumors","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2022-07-08 16:06:22","doi":"10.21203/rs.3.rs-1810085/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"03bc83dc-c776-433c-aaa2-45dee4ec58d5","owner":[],"postedDate":"July 8th, 2022","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2022-07-18T05:44:27+00:00","versionOfRecord":[],"versionCreatedAt":"2022-07-08 16:06:22","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-1810085","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-1810085","identity":"rs-1810085","version":["v1"]},"buildId":"re_ckhLnmML6MCF96OHNJ","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}