Etiology and management of nasopharyngeal hemorrhage after radiotherapy for nasopharyngeal carcinoma

Figures & data

Table 1 Physico-pathological characteristics of NPC patients

Characteristic	Category	Patients (n)
Age (years)	Median	62
	Range	46–75
Bleeding time (months)	Median	31
	Range	6–96
Bleeding time (hours)	Median	1.5
	Range	1–3
Sex, n (%)	Male	12 (70.6)
	Female	5 (29.4)
Radiotherapy courses, n (%)	1	10 (58.8)
	2	7 (41.2)
Clinical stage, n (%)	II	2 (11.8)
	III	5 (29.4)
	IV	10 (58.8)
Anemia, n (%)	<120 g/l	12 (70.6)
	<60 g/L	3 (17.6)
Mouth opening, n (%)	Limited	14 (82.4)
	Normal	3 (17.6)
Distant metastases, n (%)	Yes	3 (17.6)
	No	14 (82.4)

Abbreviation: NPC, nasopharyngeal carcinoma.

Table 2 Imaging of skull base bone destruction

Number	Bone destruction in the sphenoid bone slope area	Bone destruction in the basal part of sphenoid bone	Bone destruction in the petrous part of temporal bone	Bone destruction of occipital bone
1	Yes	No	No	No
2	Yes	No	No	No
3	Yes	Yes	No	No
4	No	No	Yes	Yes
5	Yes	No	No	No
6	No	No	No	Yes
7	No	Yes	No	No
8	No	No	Yes	Yes
9	No	No	No	No
10	No	Yes	No	No
11	Yes	No	No	No
12	No	No	Yes	No
13	Yes	No	No	No
14	No	Yes	No	No
15	No	No	Yes	No
16	Yes	No	No	No
17	No	No	Yes	No

Table 3 The features of 17 NPC patients with nasopharyngeal hemorrhage

Number	Difficulty in opening mouth	Pre-bleeding symptoms			Hemoglobin level on hospitalization (g/L)	Nasal hemorrhage
		Stench from mouth and nose	Recurrent headache	A few nosebleeds one week before		Unilateral	Bilateral
1	No	Yes	Yes	Yes	83	Yes	No
2	No	Yes	No	No	125	Yes	No
3	Yes	Yes	No	No	105	Yes	No
4	Yes	Yes	Yes	Yes	74	No	Yes
5	Yes	No	Yes	No	112	Yes	No
6	Yes	No	Yes	No	43	Yes	No
7	Yes	Yes	Yes	No	133	Yes	No
8	Yes	Yes	No	Yes	89	Yes	No
9	Yes	No	Yes	No	97	Yes	No
10	Yes	Yes	No	No	101	Yes	No
11	Yes	Yes	Yes	Yes	79	Yes	No
12	Yes	No	No	Yes	56	No	Yes
13	Yes	Yes	Yes	No	67	Yes	No
14	Yes	Yes	No	No	110	Yes	No
15	No	Yes	Yes	No	104	Yes	No
16	Yes	No	No	No	112	Yes	No
17	Yes	Yes	Yes	Yes	51	Yes	No

Abbreviation: NPC, nasopharyngeal carcinoma.

Table 4 Demographics and outcomes of 17 NPC patients with nasopharyngeal hemorrhage

Number	Sex	Age (years)	Nasopharyngeal features under endoscope	The time of massive hemorrhage after radiotherapy (years)	Clinical stage	RNPC for two-stage radiotherapy	Therapy	Affected artery	Survival
1	F	46	OR	0.5	IVa	Yes	NP + EE	SA	Alive
2	M	49	OR	2	III	Yes	NP	BOECA	Alive
3	M	63	OR	3	II	No	NP	ROICA	Alive
4	M	75	OR	0.75	IVa	Yes	NP	undefined	DLBS
5	F	58	MN	3	IVa	Yes	NP	BOECA	Alive
6	M	59	OR	1	IVa	Yes	NP + TR	undefined	DLB
7	F	66	No	8	III	No	NP	POICA	Alive
8	M	57	OR	4	III	No	NP + TR	undefined	DLB
9	M	64	No	3	III	No	NP	BOECA	Alive
10	M	52	OR	6	IVa	No	NP + EE	PNSA	Alive
11	M	65	MN	2	III	No	NP	BOECA	Alive
12	M	69	OR	4	Iva	No	NP	POICA	MODS
13	F	62	No	2	IVa	No	NP	BOECA	Alive
14	M	73	OR	2	IVa	No	NP + EE	SA	Alive
15	M	56	MN	3	II	No	NP	BOECA	Alive
16	M	74	No	0.5	IVa	Yes	NP	ROICA	Alive
17	F	61	OR	1	IVa	Yes	NP	BOECA	Alive

Abbreviations: DLB, died of loss of blood; DLBS, died of loss of blood and suffocation; IMA, internal maxillary artery; NP, nasal packing; NPC, nasopharyngeal carcinoma; TR, tracheostomy; APS, the arteriae pharyngea ascendens of the external carotid artery; EE, endoscopic electrocoagulation; POICA, pseudoaneurysm of internal carotid artery; OR, osteoradionecrosis; MN, member necrosis; RNPC, recurrent nasopharyngeal carcinoma; SA, sphenopalatine artery; DSA, digital subtraction angiography; PNSA, posterior nasal septum artery; BOECA, branch of external carotid artery; ROICA, rupture of internal carotid artery; MODS, multiple organ dysfunction.

Table 5 Clinical characteristics of 10 NPC patients with just 1 course of RT

Number	Sex	Age (years)	Stage	Skull base erosion at diagnosis	GTV volume of the primary cancer (cm^3)	RT dose	GTV Vol >105% (cm^3)	Chemotherapy manner	Cycles of chemotherapy	Trismus before the incidence of bleeding	Hypertension	Diabetic	Use of TCM	Nasopharynx irrigation	Use of brachytherapy	Surgical intervention
1	M	63	II	No	50.6	70 Gy/30F	20.1	None	None	Yes	Yes	No	No	None	No	No
2	F	66	III	Yes	88.9	70 Gy/32F	29.8	C+A	4	Yes	No	Yes	No	KDI	No	No
3	M	57	III	Yes	135.6	70 Gy/32F	91.5	C+A	4	Yes	No	No	No	None	No	No
4	M	64	III	No	87.4	70 Gy/31F	72.5	Cc	2	Yes	No	Yes	No	KDI	No	No
5	M	52	IVa	Yes	107.9	70 Gy/32F	67.2	C+A	5	Yes	Yes	No	No	ODI	No	No
6	M	65	III	Yes	62.7	70 Gy/31F	28.1	C+A	4	Yes	Yes	No	No	ODI	No	No
7	M	69	IVa	Yes	165.8	70 Gy/35F	94.2	C+A	6	Yes	No	Yes	No	None	No	No
8	F	62	IVa	Yes	145.6	70 Gy/32F	99.2	C+A	6	Yes	No	No	No	ODI	No	No
9	M	73	IVa	Yes	107.2	70 Gy/32F	71.1	C+A	6	Yes	Yes	Yes	No	None	No	No
10	M	56	II	No	49.2	69 Gy/30F	39.6	None	None	No	No	No	No	None	No	No

Notes: Concurrent chemotherapy program consisted of cisplatin; the adjuvant chemotherapy program consisted of cisplatin and 5-fluorouracil.

Abbreviations: GTV, gross tumor volume; KDI, keep doing irrigation; NPC, nasopharyngeal carcinoma; ODI, occasionally doing irrigation; RT, radiotherapy; TCM, traditional Chinese medicine; C+A, concurrent + adjuvant; Cc, concurrent chemotherapy.

Figure 1 External carotid artery angiogram showing the bleeding sites on the internal maxillary artery (indicated by the arrow).

Figure 2 Post-embolization internal maxillary artery angiograms revealing total occlusion of the artery (indicated by the arrow).

Figure 3 External carotid artery branch angiogram showing the bleeding sites on ascending pharyngeal artery (indicated by the arrow).

Note: L= blood vessel on the left.

Figure 4 Post-embolization ascending pharyngeal artery angiogram revealing total occlusion of the artery (indicated by the arrow).

Note: L= blood vessel on the left.

Figure 5 Right lateral internal carotid artery angiogram showing radiation arteritis with pseudoaneurysm (indicated by the arrow).

Note: RCCA=right common carotid artery.

Figure 6 Vascular imaging of the pseudoaneurysm after 3D reconstruction (indicated by the arrow).