Perfuse Bleeding Following Interstitial Brachytherapy (ISBT) for Cervical Cancer Requiring Surgical Intervention

Purpose: Cervical cancer is the 3rd leading cause of cancer deaths in women worldwide. Vaginal bleeding is common in women with advanced cervical cancer, with a prevalence of 84.0% and immediate cause of death rate of 6%(1). Interstitial brachytherapy (ISBT) is an established method in the management of cervical cancer. Vascular injury instance in ISBT for cervical carcinoma reported to be up to 5.2%(2). Persistent bleeding that failed traditional measures is rare but could be life-threatening and requires innovative ways to stop hemorrhage.

Methodology: Herein, we report the treatment complication of a 40-year-old female with stage IVB (p16+, HPV+) cervical SCC. The patient was treated with EBRT followed by 5 HDR ISBT. During the third brachytherapy treatment, profuse vaginal bleeding was noted after the removal of needles. After packing with gauze and cylinder, patient was intubated and sent to the ED where she was found to be hypotensive and tachycardic with a Hgb of 8.1. She received 2 units of pRBCs. CTA showed no evidence of active arterial bleeding. The patient was admitted to the MICU for close monitoring and discharged the next day once determined to be hemodynamically stable. The placement of device for the final 2 fractions were done in an OR. Upon the needle removal, bleeding was noted once again. Hemostasis was established with pressure and packing, and hemodynamically stable was achieved with resuscitation. The next day, the patient started hemorrhaging again with approximately >1000 cc blood loss. She was transferred immediately to the OR for pelvic exam under anesthesia. Subsequently, she underwent angiography with embolization of bilateral internal iliac arteries. 2 units of pRBC and crystalloid bolus were also administered, after which the patient become hemodynamically stable . She was discharged three days after without any complications.

Results: Majority of vaginal bleeding cases are successfully managed with packing. In rare cases, such as the one above, traditional measures do not achieve adequate bleeding control. Although angiography did not show any obvious vascular injury, the embolization of the bilateral internal iliac arteries successfully controlled the hemorrhage.

Conclusions: Multiple topical options exist for controlling vaginal bleeding. These include Mohs’ paste, Monsel’s solution (ferric subsulfate) and 4% formalin. However, when these options fail to be effective, embolization of the internal iliac arteries could be a valid option to control vaginal bleeding, even when angiography does not show vascular injury.

References: (1) Ping Q, Zeng J, Sun P, Qu P, Jiang S, Hu Y. Efficacy of preoperative brachytherapy for controlling vaginal bleeding in early-stage cervical cancer: a retrospective study. Transl Cancer Res. 2021 Jul;10(7):3259-3267. doi: 10.21037/tcr-21-467.
(2) Aggarwal V, Chuprin A, Aggarwal A, Vingan H, Crandley E. Bleeding after interstitial brachytherapy for cervical cancer requiring embolization. Radiol Case Rep. 2018 Sep 13;13(6):1141-1145. doi: 10.1016/j.radcr.2018.07.033.