The patient was a 66-year-old man who was diagnosed with LARC in the upper middle rectum (T4aN1M0, stage IIIB). He had a 13-year history of liver cirrhosis after contracting hepatitis B and exhibited symptoms of hypersplenism, including thrombocytopenia and leukopenia. No spontaneous bleeding events had happened in the past 10 years. Given the high risk of severe complications, radical surgery, chemotherapy, or targeted therapy could not be performed. However, the patient and his family had a strong desire for treatment and came to our radiotherapy department in October 2017, requesting that radiotherapy be attempted.
The test results before radiotherapy were as follows: A routine blood test of the patient on October 26, 2017, showed that his platelet count was 32 x 109/L, white blood cell (WBC) count was 3.79 x 109/L, and red blood cell (RBC) count was 3.57 x 1012/L; meanwhile, blood coagulation function was in the normal range (prothrombin time [PT], 13.7 seconds; activated partial thromboplastin time [APTT], 39.1 seconds; thrombin time [TT], 16.60 seconds; international normalized ratio [INR], 1.06). His hepatitis B was in a stable condition (HBsAg(+), HBsAb(-), HBeAg(-), HBeAb(-), and HBcAb(+)), and no hepatitis C virus (HCV) infection was detected (HCVAb(-)). Liver function was Child-Pugh class A (no hepatic encephalopathy; no ascites; total bilirubin [TBIL], 21.9 micromol/L; albumin (ALB), 38.9 g/L; PT prolong, <3 seconds). An ultrasound test of the liver revealed a normal size with rough surface and blunt border; intrahepatic echogenicity was enhanced, with scattering echoless points in the right lobe; and the hepatic vein was circuitous, with a rough wall. The volume of the spleen was abnormally large: 13.8 cm in length and 5.3 cm in thickness. An imaging examination of the patient showed no bone metastasis of the tumor. Moreover, the patient had shown no symptoms of spontaneous bleeding, such as petechiae or errhysis, in the past 10 years. The doctors involved had a comprehensive discussion about the patient's condition with his family, informing them that blood transfusions and supporting therapy would be required and that there would be a risk involved in the process of radiotherapy. A routine blood test on October 30, 2017, showed that his platelet count was 32 x 109/L, WBC count was 4.03 x 109/L, and RBC count was 3.65 x 1012/L. A pelvic-abdominal computed tomography (CT) simulation with intravenous injection contrast was obtained in the supine position. The high-risk clinical target volume (CTV-HR) included the entire mesorectum and presacral region at involved levels, with a 2-cm sup/inf margin on the gross tumor volume (GTV). The standard risk CTV (CTV-SR) covered the elective node subsites, depending on the tumor stage and location, including presacral space, mesorectum, posterior lateral lymph nodes, and anterior lateral lymph nodes of this patient. The planning target volume (PTV) of CTV-SR is generated by three-dimensional expanding CTV-SR with 1-cm margin plus in the sup/inf directions and 0.7-cm margin plus in the anterior/posterior/right/left directions. Volumetric modulated arc therapy (VMAT) radiation with 50 Gy in 25 fractions was planned for PTV delivery. After that, a CTV-HR boost above 54 Gy (final total dose) was planned since the patient was unable to undergo surgery. The CTV-HR and CTV-SR are shown in Figure 1. The patient started the first treatment on October 31, 2017. We paid close attention to platelet count changes during the treatment process. On November 3, 2017, his platelet count was 30 x 109/L (WBC, 3.38 x 109/L; RBC, 3.48 x 109/L), and this had decreased to 25 x 109/L on November 7, 2017 (WBC, 3.31 x 109/L; RBC, 3.46 x 109/L). Since the platelet count decline was obvious, we recommended the injection of thrombopoietin (TPO; 3Sbio Inc., Shenyang, Liaoning, China). However, the cost of this treatment was prohibitively high for the patient. Taking into account these factors, we instead chose subcutaneous injections of 3 mg recombinant human interleukin 11 (IL-11; Qilu Pharmaceutical, Jinan, Shandong, China) per day, starting on November 7, 2017, and continuing for 5 days. On November 9, 2017, the platelet count decreased to 16 x 109/L, WBC count was 3.08 x 109/L, RBC count was 2.99 x 1012/L, and the patient showed no signs of abnormal bleeding. At that time, he had received 2 Gy x 7 fractions of radiotherapy on PTV (from October 31, 2017, to November 3, 2017, and from November 6, 2017, to November 8, 2017), and the treatment was discontinued. He then underwent 1 U platelet transfusions on November 9 and 11, 2017. After that, his platelet count was 27 x 109/L on November 10, 2017, and 19 x 109/L on November 11, 2017. The number stabilized at 24-25 x 109/L during the following 5 days, but decreased to 22 x 109/L on November 17, 2017, and then remained at about 20 x 109/L for 3 days and failed to reach the previous levels. The counts of WBC and RBC showed no significant changes. Blood cell changes during treatment are shown in Figure 2. The patient and his family were informed that the radiotherapy might be continued if his platelet count could be maintained by platelet transfusion, but they finally decided to abandon the treatment.
A written informed consent has been provided by this patient to have the case details published.