Toplam Sayfa Görüntüleme Sayısı

27 Haziran 2014 Cuma

Role of hyperbaric oxygen therapy in the treatment of chronic complications arising from treatment with radiation therapy in cancer patients. Physical, technical and clinical

Role of hyperbaric oxygen therapy in the treatment of chronic complications arising from treatment with radiation therapy in cancer patients. Physical, technical and clinical


M. Caeiro MuñozI; A. Calderón gonzalezi; Cairn OjeaII A. M. L. López LóuzaraI; J. R. Fernández BernárdezII;
I. Alonso AlonsoII; M. L. Vázquez of torrei; C. Rodríguez CerdeiraI; V. M. Muñoz Garzoni; R. C. Hermida DomínguezII

School of Engineering in Telecommunications from the University of Vigo
IHospital do Meixoeiro
IIUnidad Chronobiology. Department of Signal Theory and Telecommunications


Increasing indications for radiotherapy (RT) as first-line treatment in certain oncological processes, the need to increase the dose intensity for adequate local control and greater social awareness of the value of the quality of life of patients, have prompted the search for supportive treatments to prevent and treat complications more effectively and at a reasonable cost.
The hyperbaric oxygen (HBO) technique was introduced 80 years ago in the treatment of "diving accident" has also been used in related ischemia / necrosis processes. These background that researchers and clinicians who treat cancer patients, have opened a line of work that could benefit a selected group of patients.
In this review we describe the physical basis, technical and pathophysiological regarding radiation therapy (RT). Also make a basic review of the indications for HBO, according to the anatomical area affected.

Keywords: hyperbaric oxygen. Radiotherapy. Chronic Toxicity. Cancer.


The increase increasing Indications of radiation therapy (RT) as treatment of choice in specific oncological Processes, the need to Increase the intensity for an adequate tumor control and to social Greater sensitivity about the value of the patients quality of life, impelled the search of supportive treatments to Prevent and treat complications in the radiotherapy to more Effective Manner, and at a reasonable cost.
The technique of the hyperbaric oxygen (HBO) therapy was Introduced 80 years ago for the treatment of diving accidents, and has Also Been used in Processes related to ischemia / necrosis. These background drove the Researchers and clinicians treating cancer patients to open a working line that Could benefit a selected group of patients.
In this review we describe the physical, technical and physiological basis of radiation therapy (RT). We Also make a basic review of the Indications of HBO therapy ACCORDING to the Affected anatomical area.

Key words: Oxygen therapy. Hyperbaric. Radiation therapy. Late toxicity. Cancer.


The hyperbaric oxygen (HBO) therapy is a noninvasive modality, which is based on obtaining high partial pressures of oxygen, breathing pure oxygen inside a hyperbaric chamber at a higher atmosférica1, 2 pressure.

The therapy is designed primarily to get the supply of oxygen to ischemic tissues or patients who respond to increased oxygen levels. The second basic or mechanical effect of hyperbaric oxygen in the human body is to reduce the size of the bubble in cylindrical shape and circular in diving accidents where nitrogen levels increase, either by exposure outside the limits or to rise to the surface too fast. It is therefore a drug therapy, the range of application is determined by the maximum pressure reached, the duration of inhalation and the frequency and total number of exposures.

The therapy is effective in a significant number of pathologies, with a cost / benefit ratio right. In recent years there has been use in the field of oncology, especially in the treatment and prevention of complications resulting from the use of radiotherapy (RT).

Historia1, 2

HBO is a technology known for more than 300 years ago, when the laws of gas compression 1676 (Boyle's Law) were established, although only used with property from about 30 years ago. Previous documents and testimonies to 1961 have only historical or anecdotal value. In the second half of the last century in Europe and in the first quarter century in the U.S., HBO received wide publicity but not always with sufficient scientific rigor.

The first documented use of hyperbaric chamber predates the discovery of oxygen. The British physician Henshaw appears to have used compressed air medical preparations in 1662. Barometric pressure data with oxygen, as such date from 1775, after Priestley discovered oxygen and identify. Junod In 1834, he built a camera for treating lung conditions. In 1837 Pravaz developed a hyperbaric chamber to treat up to 50 patients. The first chamber built in the Americas was in Oshawa (Canada) in 1860. Cuninghan in 1921 used the high partial pressure of oxygen to treat hypoxic conditions. In 1917, in Germany Drager design a system to treat diving accidents. In 1937 Behenke and Shaw, used hyperbaric oxygen for treatment of decompression accidents. Boerema in Amsterdam in 1959, first linked the possible therapeutic effect of high concentrations of oxygen plasma with diseases caused by anaerobic bacteria. It was Gray in 1953 who introduced the application of HBO in radiotherapy using an animal tumor model. But it was Churchill-Davidson who first used a hyperbaric chamber to treat patients with radiotherapy.

In recent years, after a period of publications in scientific rigor that led to the questioning of the effectiveness of the technique, there have been published in a variety of fields allowed to reconsider its application in such complex areas such as Oncology .

Technical basis, physical, and fisiopatológicas1-4

A. Technical Bases (Type Cameras)

A1. Monoplaza cameras

They are small in volume and for a single patient per session. These are pressurized with pure oxygen. Most of these cameras consist of large steel structures and acrylic, resistant to effect the necessary treatments that are usually three atmospheres absolute pressure (ATA) maximum pressure. Patients are constantly monitored (video cameras, audio). Due to high concentrations of oxygen in this type of cameras, there is a greater risk of explosion.

A2. Multiplaza cameras

These chambers are pressurized with compressed air and can accommodate several patients at once. These are equipped with diving suits or tight for oxygen nasofaciales. He oxygen within the chamber is maintained close to atmospheric values ​​and the patient is almost 100% oxygen. In the chamber multiplaza medical and paramedical personnel, can enter with patients if necessary and make appropriate medical techniques in each case.

B. Physico-Chemical Bases

B1. Volumetric Effect (Boyle's Law)

Under Boyle's Law, at constant temperature the volume of gas is inversely proportional to pressure. Therefore, raising the ambient pressure decreases the volume of the organ cavities that are not in contact with the respiratorias3 4 way.

B2. Solumétrico Effect (Henry's Law)

According to this, hyperbaric oxygen breathing means a progressive increase in arterial oxygen pressure can exceed 2000 mm Hg, an environmental value of three atmospheres absolute (ATA) is produced.

The volume of dissolved oxygen and transported by the minimum atmospheric pressure plasma increases more than 22 times. It follows as a direct action, an increase in venous pressure of oxygen, which can exceed 600 mmHg, and tissue oxygen pressure can exceed 400 mmHg.

The body is protected from the excessive amount of oxygen to produce oxygen free radicals, for which purpose a modulator HBO, experiencing dose dependent peripheral vasoconstriction. Despite the decreased flow it entails the great hyperoxia always able to maintain in all cases, a positive oxygen balance, ie, it is a no hipoxemiante vasoconstriction. Studies by Saltzman in 1968 showed, in fundus examinations performed in a hyperbaric atmosphere, that despite the marked vasoconstriction hyperoxygenation was manifest.

More recently Matrhieu and Wattel have confirmed these hypotheses using techniques capillaroscopy in patients with vascular events during treatment with HBO.

C) Basis pathophysiological

The presence of arterial, venous, and tissue hyperoxia, especially the large increase in the plasma transport and oxygen availability, provide a possible therapeutic effect in all diseases in which there was a phenomenon of general local tissue hypoxia or as etiopathogenic factor leading or rather a pathophysiological oxidependiente courtship. HBO provides an additional contribution carried by the plasma and red cell mass not. Is an oxygen available to terminals capillary ischemic territories and it is transferred for diffusion gradient simple1-5.

HBO produces effects on angiogenesis, stimulating and neocolagenización microvasculature. Its mechanism of action is related to facilitating the hydroxylation of proline and finally forming an exuberant granulation tissue in states in which it causes hypoxic was braking, for example, in irradiated tissues. Furthermore alternating hypoxia / normoxia constitutes a significant angiogenic stimulus. Both mechanisms are now well studied and evidenced with modern iconographic techniques.

By similar mechanisms, HBO has also shown some effect on calcium and phosphorus metabolism, which has led to some experimental studies trying to explain a known positive effect on calcification delays ósea1-5.

OHB effects regarding complications RT

Approximately 50% of patients diagnosed with cancer come to receive RT as part of the overall strategy of treating your disease. Of these, 50% will be long survivors. Approximately 5% of irradiated patients severe complications can occur, which can appear after a latent period ranging from several months to several years after radiation treatment administered.

The etiology of late effects that irradiation produces on healthy tissues is closely related to the oxygen effect. The radiation induced tissue damage affecting the vascular endothelium, causing: hypoxia, progressive inflammation, fibrosis, and subsequently ischemia interstitium tissue necrosis, in a period of six months or more after administration of the same. Secondary infection frequently committed to healthy tissue, especially in the presence of decreased circulation.

The occurrence of severe damage by radiation sequelae, accompanied by an entourage of symptoms, which vary depending on the organ or affected organs and, in some cases, may compromise the patient's life, but in a large majority, produce worsening of their quality of life.

Role of HBO in the complications of RT by location

1. Area Head and Neck

1.1. Mandibular osteoradionecrosis (ORN)

The jaw is a dense, poorly vascularized and particularly vulnerable to radiation in the area of ​​head and neck bone. Considering the properties of O2 at high pressure have been no clinical studies with HBO as:

- Prophylaxis of mandibular Osteoradionecrosis.

Marx et al. (1985) in a randomized comparative study with 74 patients, showed a significant clinical benefit in patients with OHB group, 5.4% versus 29.9% ORN in the group that did not receive HBO (7).

- Treatment of established mandibular Osteoradionecrosis (ORN)

The OHB utilization above 2.0 atmospheres of pressure (ATA) for 90-120 minutes, with 02 to 100% has led to the best results. This has been seen in the work of Marx et al. (1984) 70 patients with levels reaching 100% resolution and Tobey et al. (1979) associated with aggressive surgery in 12 patients, of whom I had significant clinical improvement.

Other studies Mainous, Hart, Farmer, Mounsey, Mackenzie, and David Curi encouraging results. A single study, Maier et al. (2000) in 41 patients has shown no clinical benefit.

Conclusion we can establish the recommendation to use HBO as elective treatment in ORN7, 9.

1.2 radionecrosis of soft tissues of the head and neck

The bulk of the studies are mainly laryngeal necrosis: results of the series of Davis (1979), Ferguson (1987), Feldmeier (1993), Filintisis (2000), Narozny (2001) and, above all, Marx (1999) with 160 patients (nonrandomized comparative study), demonstrate a clinical improvement in all the series analyzed.

We conclude that HBO is an elective therapy in soft tissue radionecrosis in the head and neck area, especially in the jaw and Osterradionecrosis laríngea7 necrosis.

1.3 Other indications, such as "Dental implants" have recently been introduced, performing in previously irradiated patients; or who is going to make them a previously dentaría31 extraction.

Two. Area of Central Nervous System (CNS) and Peripheral Nervous System (PNS) System

HBO regarding CNS complications has been studied in a very limited way. These techniques are fundamentally associated Stereotactic Radiosurgery and interstitial brachytherapy in the case of Conventional Radiotherapy brain and spinal cord and brachial plexopathy.

2.1. HBO in myelopathy (myelitis actinic)

Glassbarm and others published a series with 9 patients. In 6 of them was no improvement with HBO. Angibaud and others reviewed the role of HBO in the post-irradiation myelopathy with reasonable results (7.10).

2.2. HBO on Brain Actinic (Necrosiscerebral)

The OHB role has been studied in a series of 10 pediatric patients and analyzed by Chuba other. The results found showed that neurological symptoms improved in 10 patients, 8 of whom had cerebral11 necrosis.

2.3. HBO on the toxicity of nerve and optic chiasm

Guy and Shotz in 4 patients with severe optic neuropathy showed significant improvement in 50% of the mismos7, 12.

Roden and others, including a total of 13 patients with OHB and corticosteroids. The analysis of the results showed no significant improvement of the association in most patients.7, 12.

2.4. The OHB in RT-induced brachial plexopathy

Pritchard and others, in a phase II randomized double-blind study with 34 patients, found no significant differences in neuropsychological tests between patients who received HBOT versus patients who received a mixture of air at atmospheric pressure. But if a significant delay in the onset of symptoms in the group treated with HBO therapy group versus the control group was seen. The 6 subjects investigated in coexisting chronic lymphedema of the arm, improved it.

In conclusion, with the current data, HBO has not demonstrated a clear clinical benefit, although it would have to investigate further, since any subgroup of patients could beneficiarse13.

Three. Area Thoracic (Chest Wall and Breast)

3.1. chest wall

Feldmeier and others perform a retrospective review of 23 patients who had been treated with HBOT as adjuvant therapy for radio-induced necrosis of the chest wall. In 8 patients, involvement was only soft tissue necrosis and 15 had associated bone and soft tissue necrosis. When only the soft tissue was affected, the association of non-surgical debridement and HBO was highly effective. All patients in this group had no disease, resolved their necrosis. Of the group of patients who had necrosis of soft tissue and bone, a total of 8 of the 15 patients had resolved their radiotherapy damage. Of the 6 that failed, in 3 had not performed a surgical resection, and two had undergone aggressive debridement. The authors established a recommendation:

- Necrosis of the soft tissues of the chest wall can be treated with HBO exclusively.

- Patients who carry associated necrosis of bone (ribs, sternum) surgical debridement is necessary to remove the entire bone necrótico14.

3.2. mamma

Conservative treatment of the breast is the standard treatment for most stage I and II breast cancer. A significant percentage of cases presented late sequelae consisting of edema, pain and skin changes.

Based on series of isolated, Carl and other cases initiated a nonrandomized comparison with 44 patients, of whom 32 received HBO in multiplaza camera, with a median of 25 sessions (range 7-60) study. 02 was administered to 100% at 2.4 ATA in 90-minute sessions, 5 times per week. The control group consisted of 12 patients who refused HBO therapy. A significant reduction of symptoms (pain, swelling and erythema), compared with control group (p <0.001). In 7 of the 32 women there were no symptoms, compared to the remaining 12 of the control group remained sintomáticas15.

April. Area abdominopelvic

4.1. HBO in radiation enteritis

Radiation therapy is usually applied as a primary or adjunctive treatment of pancreatic cancer, biliary tract, gastric and colon diseases. Were observed in this location up to 19% of serious complications. These usually appear after 6 months and are typically the result of hypoxia secondary to reactive fibrosis process - endarteritis, which develop in the stroma of irradiated tissues.

The treatment of complications, in its most severe form, often requires surgical intervention. Many complications can also mean or mean lower quality of life for cancer survivors.

Feldmeier et al conducted a retrospective study on a total of 44 patients who were treated from 1979, of which 41 patients were analyzed. The locations were affected abdominal wall, large intestine, small intestine and pelvic bones. It was observed that a total of 26 patients were cured, six failed to cure and 9 had an inappropriate course of treatment. Especially interesting was the resolution of fistulas in 6 of 8 patients, of which only three required surgery for cierre16.

Gouëllo et al conducted a retrospective study of 36 patients with digestive tract necrosis (radiation enteritis, radiation proctitis and perianal abscesses). In 21 patients (66%) had clinical benefit. A short term 19 patients (53%) improved and 17 (47%) failed. A long-term total of 32 patients were evaluated, of these 9 patients experienced cure all your symptoms and 12 patients experienced significant improvement in the long term. The other 11 (34%) fallaron17.

Nakada et al reported a case of radiation enteritis in the large intestine (sigmoid colon) with major bleeding and endoscopic and histological findings characteristic. OHB administration was followed by disappearance of gastrointestinal bleeding and reversion and anatomopatológicos18 endoscopic findings.

Experience in combination therapies for the repair of abdominal and sequelae of radiation therapy treatments - pelvic is very limited. Brandon and colleagues in an attempt to improve the results of surgery, associated with the administration of HBO. A total of 5 cases, patients who had serious sequelae in soft tissue after being treated with RT and who were scheduled for abdominal surgery were previously subjected to HBO with a car camera. The end result was that patients experienced a clinically significant improvement in symptoms associated with digestive and urologic complications that accompany abdominal RT and pélvica19.

Feldmeier et al conducted a study in C3H mice to determine the role of HBO managed to prevent chronic radiation enteropathy. A total of 50 mice divided into two groups, received 30 Gy of abdominal-pelvic irradiation in 10 fractions. The study group received a course of 30 sessions of HBO started 7 weeks after exposure to radiation. The control group received only outpatient care and nutritional support. A third group of three animals received no irradiation or HBO. All animals were slaughtered 7 months after radiation. A gross inspection was performed to objectify enteropathy. A measurement system was used to quantify the narrowness and rigidity of ileum near the ileocecal valve. Animals receiving HBO had few signs of actinic enteropathy and was having less and less stiff narrow intestinal segments collected than did not, being statistically significativos20 findings.

4.2. The OHB level anorectal

A work of others and Gouëllo17 Feldmeier16 that quantified the degree of severity of symptoms and findings anatomapatológicos through a scale, most publications are very heterogeneous series of cases, both in the inclusion criteria, as in the method OHB8 administration. Warren and colleagues published in 1997 a series of 14 patients with chronic radiation-induced proctitis. Nine patients were treated with HBO in car camera 2 atmospheres (2 ATA) and 5 patients were treated with HBO at 2.36 ATA. The results showed that 8 patients experienced complete disappearance of symptoms and one patient had substantial improvement, which was a total of 64% of the responses. The follow-up range was 5-35 months (median 17). A total of 5 patients were considered nonresponders. Three experienced significant improvement during treatment but relapsed as soon as the therapy was discontinued. The other two showed no improvement at any time. In sigmoidoscopy performed after therapy was documented endoscopic improvement over the non-responders who did not presentaban21.

Seng Chong Woo et al published a retrospective review of 18 patients diagnosed with proctitis treated with HBOT lies. The main symptoms were bleeding, diarrhea, incontinence and pain. In more than half of these symptoms resolved partially or totalmente22.

Bem et al, reported 2 cases of anorectal complications with anal carcinoma directly related to actinic anorrectitis. In both cases the OHB was introduced following the diagnosis of actinic anorectitis. The management model OHB was 2.4 ATA for 90 minutes, 5 days a week. Both patients experienced gradual improvement, being free of symptoms at 3 months and 4 years after the last treatment.23.

Kitta et al report a series of 4 patients diagnosed with prostate cancer, who had an chronic radiation proctitis and were treated with HBO. All patients completed treatment with HBO to 100% in a multiplaza camera for 60 minutes a day, 5 days a week. The number of sessions varied depending on the clinical response. A fully improved patient symptomatology of rectal bleeding. Another patient remained minimal rectal bleeding. Another patient of his rectal bleeding recurred at 3 months of HBO finalized. In the fourth patient there was no improvement and remained with severe anal pain. We can say that a moderate clinical benefit with HBOT was obtained estadísticamente24 not quantified.

Johnston and others, conducted a review of the role of HBO in the treatment of late complications of pelvic radiotherapy to the anus and rectum. The authors concluded that the main cause of this condition is closely related to ischemia, resulting in an unstable neovascularization, causing rectal bleeding. HBO application produces a reversal of the fibrotic component and stimulates neovascularization in the area. In his review noted that 65% of patients with severe proctitis lies improved, although a proportion of these may have long-term recurrences. In its final recommendations establish the need for a multicentre large clinical trial and, if possible, internacional25.

Denton et al conducted a systematic review of the role of HBO in the general context of non-surgical interventions for the management of late proctitis lies, in order to establish therapeutic recommendations regarding the methodology of the Evidence-Based Medicine. In his review stated that there are at least 9 relevant references, with a total of 86 cases. A total of 8 sets were analyzed. Only one was a prospective study, the others were case series with heterogeneous characteristics. In only two of these works, Feldmeier (1996) and Gouëllo (1999) had developed a system to quantify the degree of chronic radiation proctitis with a scale Midia degree of histologic findings and symptoms. The number of treatments depends on the degree of established disease. Quantification of the response was initially made ​​with a vague description of the resolution of the symptoms and not regulated by statistical analysis. The duration of response was collected inconsistently and or data quality of life scales are not collected in any report. Side effects were published in eight, all in conjunction with acoustic mild barotrauma.

The final conclusions of this review, even though HBO apparently can influence changes secondary to radiation in the large intestine that are refractory to other treatments, the degree of clinical benefit and the duration of response has not been quantified by both the methodology used and the lack of quality scales life.8, 26.

4.3. HBO in treating hemorrhagic cystitis caused by RT

Hemorrhagic cystitis is known as a possible side effect of the RT administered in a series of pelvic disease. Patients may experience symptoms such as pain, bleeding, and urinary retention. Several palliative treatments have been established with different results. Del Pizzo and others, HBO treated a total of 11 patients with radiation-induced hemorrhagic cystitis. Presenting symptoms were hematuria and other partners, suprapubic pain and urinary urgency and All received 100% O2 at 2 ATA multiplaza chamber for 90 minutes for 5 days in a week. The average number of treatment sessions was 40 (range, 28-64) in a total of 11 patients. 3 (27%) were free of symptoms and 3 (27%) had persistent symptoms that required supravesical urinary diversion. The other 5 patients initially responded to HBO but had recurrence in the long term and have needed other definitivas27 therapies.

Mathews and others, reviewed a total of 17 patients with hemorrhagic cystitis who received HBO after failure of other standard therapeutic modalities. HBO was administered only once a day (average of 21). The hematuria resolved in 11/17 (64%), only 2 had gross hematuria and 2 had only residual microscopic hematuria, 3 patients had improved but died prematurely of cancer-related complications after treatment with HBO and 2 had recurrence of or frank hematuria. Early application of HBO was associated with a rapid resolution of hemorrágica28 cystitis.

4.4. HBO in the treatment of complications of RT in gynecological tissues

Williams et al, saw 14 patients with soft tissue necrosis and had failed conservative treatment, at least three months after it ended. The technique used was a single-seat chamber at 2.0 ATA, with a concentration of 100% O2. They received a total of 15 treatments. Patients who had vaginal radionecrosis isolated or in association with rectovaginal fistula achieved complete resolution of the necrosis HBO. Only one patient had treatment failure. In this study, a clinical benefit was demonstrated OHB29.

May. HBO to treat secondary complications extremities RT

Feldmeier et al retrospectively reviewed 17 patients (9 women and 8 men) treated between 1979 and 1997 by radionecrosis of the extremities within previously irradiated fields for different malignancies, mostly, followed by soft tissue sarcoma cancers skin. HBO therapy was administered using a camera multiplaza 2.4 ATA, administered daily, for 90 minutes at 100% oxygen pressure. A total of 11 patients (65%) healed completely, while 5 (29%) did not improve in 1 (6%) was lost to follow.En 3 (60%) de las pacientes que fallaron, se vio que tenían recurrencia local y/o a distancia de su tumor de manera precoz, y hubo que discontinuar la administración de OHB.El paciente que se había perdido seguimiento, en su último control había mejorado de los síntomas pero no llegaron a desaparecer los mismos.De los que fallaron, 4 pacientes requirieron amputación (2 pacientes con recurrencia asociada).Si se excluye los pacientes con recurrencia y el paciente perdido de seguimiento, la tasa de mejoría es 11/13 (85%), que evitaron la amputación.El 80% de los 5 fallos, requirieron amputación de la extremidad afecta30.


Podemos afirmar que la OHB es una técnica segura, fácil de administrar, con tasas de efectividad que la podrían convertir en una técnica estándar en las complicaciones crónicas de la RT de determinadas localizaciones anatómicas.

El nivel de evidencia es alto a nivel del área de cabeza y cuello, especialmente en las osteorradionecrosis de mandíbula, el cual puede considerarse tratamiento de elección. A nivel del sistema nervioso ha demostrado un nivel de eficacia elevado en las necrosis cerebrales, siendo mucho menor en las mielopatías y pares craneales aunque se ha podido demostrar beneficio clínico en un número importante de pacientes. En nervio periférico (plexo braquial) no hemos podido demostrar un claro beneficio clínico como tratamiento paliativo, pero podría tener un papel más destacado como tratamiento profiláctico.

En las complicaciones severas localizadas en la pared torácica, la OHB con o sin cirugía pueden resolver el daño de la RT en mayor ó menor grado en función del grado necrosis ósea asociado. En la mama, existe un claro beneficio en la mayor parte de los síntomas asociados (edema, dolor, eritema) pero no se demostró mejoría en los síntomas dependientes de la plexopatía braquial.

En la localización abdominal, tanto en la enteropatía, proctitis, cistitis, fístulas recto-vaginales, vesico-vaginales, etc, los diferentes estudios analizados han concluido que puede ser una técnica alternativa a otras tanto de carácter conservador como de carácter invasivo. En algunas ocasiones esta técnica puede complementar a otras, en especial a la cirugía cuando se administra de manera profiláctica.

Otro grupo de complicaciones son las localizadas en las extremidades tratadas con RT. En éstas se ha podido ver que hay un beneficio importante cuando va asociada a control de enfermedad, pero si hay enfermedad persistente o recurrencia va acompañada de un alto porcentaje de fracaso que muy posiblemente acaben en amputación de la extremidad.

Como recomendación final y dada la dificultad práctica de incluir a estos pacientes dentro de ensayos clínicos controlados, podríamos considerar la disponibilidad de esta arma terapéutica en nuestro arsenal de tratamientos paliativos reparadores y con ello contribuir a la mejora de su calidad de vida.


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 Dirección para correspondencia
Dr. M Caeiro Muñoz
O Fuxon, 14
E-36958 Pontevedra

Recibido: 18.01.05
Aceptado: 01.02.05

Programa de doutoramento: bases científicas e clínicas da investigación en medicina
Proyecto: OHB, Complicaciones RT, Cáncer; REF: OHBCOMPRT. DOC,21/06/2004