This study revealed a significant improvement in the required number of RBC transfusions between pre- and post-radiotherapy. Repeated blood transfusions can result in post-transfusion iron overload syndrome, which causes iron-related toxicity as well as multiple organ damage due to iron deposition in tissues(12). A greater number of transfused units is also a risk factor for febrile non-hemolytic transfusion reaction, which is an immune reaction of recipient antibodies reacting to donor-derived antigens (13). Moreover, transfusion itself imposes a load on the respiratory and circulatory systems and causes transfusion-related acute lung injury and/or transfusion-associated circulatory overload (14). In clinical practice, Sirianni et al. reported that transfusions in palliative care units were infrequent because of the lack of definitive evidence about its utility (15). Considering this background, we believe that reducing the frequency of blood transfusions would be of great benefit to patients in palliative care.
Surgical intervention to remove bleeding tissues or ligate blood vessels is the most direct method of treatment for tumor bleeding. However, this form of intervention is often technically difficult due to the abnormal structure of the tumor and the general condition of the patient being not good enough to withstand surgery. Therefore, careful patient selection is essential (16). Krouse et al. insisted that patients and their families who underwent surgical intervention in the palliative care unit should be aware of the risks of high morbidity and mortality (17).
Trans-arterial embolization, the intentional blocking of arteries with small particles or mechanical devices, is another treatment modality used as a palliative treatment to reduce bleeding. It is also used as a palliative treatment to reduce pain associated with symptomatic bone metastases (18). Although the embolization procedure has been used to treat bleeding from many tumor sites with excellent results, there are potential limiting factors such as the inability to access the vessel of the tumor with a catheter owing to its location and degree of invasion(19, 20). There are also risks such as damage to peripheral organs and the possibility of ischemic organ damage. Post-embolization syndrome is characterized by fever, nausea and vomiting, and flu-like symptoms caused by an immune response to necrotic tissue, which may last for several days after embolization(21). Therefore, patients should be provided with adequate explanation about this procedure by an interventional radiology specialist.
Endoscopic treatment has proven to be effective for bleeding from the gastrointestinal tract, lungs, and bladder(22, 23). This method has the advantage of being able to see the bleeding site directly, allowing for both diagnostic biopsy and therapeutic intervention. The bleeding site can be treated by clipping, thermal cauterization, laser coagulation, or topical application of thrombin or fibrinogen(24). This technique targets only organs that can be reached endoscopically and is associated with endoscopic pain and distress with only mild sedation.
Systemic agents such as octreotide, vitamin K, vasopressin, tranexamic acid, and aminocaproic acid are used in the treatment of malignant bleeding(25). In patients with poor performance status, these drug administrations are less invasive procedures; however, their efficacy is very limited(26). Complementary procedures, such as discontinuation of anticoagulants and antiplatelet agents, may also be employed.
The present study has some limitations. The primary limitation is the small sample size, which might affect the reliability of the results, with a higher risk of several types of bias. The second limitation is the treatment heterogeneity in the radiotherapy schedule, such as total dose and fractionation. Third, our results were obtained based on the information present in the medical records of our hospital, which might have been imperfect to yield detailed information about the patients, such as physical condition and comorbidity.
In conclusion, the present study revealed a reduction in the frequency of RBC transfusion after palliative radiotherapy in patients with malignant tumor bleeding. We believe that reducing the number of blood transfusions in patients with terminal conditions would have significant clinical benefits. Therefore, future studies on this topic are warranted to elucidate the efficacy and safety of palliative radiotherapy.