History, preliminary results, complications, and future prospects of intraoperative radiotherapy

First Intraoperative Radiation Therapy Center in Africa: First 2 Years in Operation, Including COVID-19 Experiences

PURPOSE

There is a shortage of radiation therapy service centers in low- to middle-income countries. TARGIT–intraoperative radiation therapy (IORT) may offer a viable alternative to improve radiation treatment efficiency and alleviate hospital patient loads. The Breast Care Unit in Johannesburg became the first facility in Africa to offer TARGIT-IORT, and the purpose of this study was to present a retrospective review of patients receiving IORT at this center between November 2017 and May 2020.

PATIENTS AND METHODS

Patient selection criteria were based mainly on the latest American Society of Radiation Oncology guidelines. Selection criteria included early-stage breast carcinoma (luminal A) and luminal B with negative upfront sentinel lymph node biopsy that negated external-beam radiation therapy (EBRT). Patient characteristics, reasons for choosing IORT, histology, and use of oncoplastic surgery that resulted in complications were recorded.

RESULTS

One hundred seven patients successfully received IORT/TARGIT-IORT. Mean age was 60.8 years (standard deviation, 9.3 years). A total of 73.8% of patients presented with luminal A, 15.0% with luminal B, and 5.6% with triple-negative cancer. One patient who presented with locally advanced breast cancer (T4N2) opted for IORT as a boost in addition to planned EBRT. Eighty-seven patients underwent wide local excision (WLE) with mastopexy, and 12 underwent WLE with parenchymal. Primary reasons for selecting IORT/TARGIT-IORT were distance from the hospital (43.9%), choice (40.2%), and age (10.3%).

CONCLUSION

This retrospective study of IORT/TARGIT-IORT performed in Africa confirms its viability, with low complication rates and no detrimental effects with breast conservation, resulting in positive acceptance and the potential to reduce Oncology Center patient loads. Limitations of the study include the fact that only short-term data on local recurrence were available. Health and socioeconomic value models must still be addressed in the African setting.

Technologic innovations in surgery: a philosophic reflection on their impact on operations for cancer

Technologic advances this past half-century have clearly had a positive effect on our ability to both diagnose and treat human cancer as well as on the operative treatment of other diseases. However, the impact of these innovations on the surgical treatment of cancer is not as clear as it is for many other problems that are managed surgically. This review is an "opinion piece" that attempts to assess the successes and failures of technologic innovations that have been introduced for the purpose of improving the operative treatment of cancer.

The effect of ischemic preconditioning prior to intraoperative radiotherapy on ischemic and on reperfused rat liver

BACKGROUND

The purpose of this study was to increase the tolerance of the liver to radiation injury with the proven effect of ischemic precondition (IP) in decreasing oxygen-derived free radicals, and to compare the effect of intraoperative radiotherapy (IORT) during ischemia and during reperfusion on rat liver.

MATERIALS AND METHODS

Two hundred fifty to 280 g male Wistar rats underwent 45 min of normothermic, segmental liver ischemia with or without IP/5 min ischemia and 10 min reperfusion, in two cycles. During ischemia or reperfusion, IORT doses of 0, 25, or 50 Gy were applied to the ischemic liver lobe. Hepatic microcirculation was monitored by laser Doppler flowmeter. Short- and long-term histological, alkaline phosphatase, bilirubin and tumor necrosis factor-alpha levels, liver tissue, and serum antioxidant alterations were measured.

RESULTS

Histological, laboratory, as well as flowmetry alterations caused by 25 Gy were reversible after 6 mo. Three mo following IORT, histological examination revealed parenchymal fibrosis, bridging, liver cell atrophy, and bile duct proliferation in the group that was irradiated with 50 Gy during reperfusion, without IP. In this group, the changes were present 6 mo following IORT, and also the levels of tumor necrosis factor-alpha and oxygen-derived free radicals after reperfusion were increased. All these changes were significantly milder in groups with IP, especially those that were irradiated during ischemia.

CONCLUSIONS

IORT to the liver, up to 25 Gy, can be applied without short- or long-term treatment morbidity. Doses of up to 50 Gy are tolerated with IP, which has never been described before. Irradiation during ischemia is less toxic for the liver tissue.

The short and long term effects of intraoperative electron beam radiotherapy (IORT) on thoracic organs after pneumonectomy an experimental study in the canine model

PURPOSE

The tolerance of mediastinal structures and thoracic organs to intraoperative radiotherapy (IORT) was investigated in the canine model.

METHODS AND MATERIALS

Twenty-two adult beagles divided into three groups were subjected to a left pneumonectomy and IORT (10 MeV electrons) at doses of 20 Gy (n = 9), 25 Gy (n = 4), or 30 Gy (n = 9). Intraoperative electron beam radiotherapy was delivered through a 5 cm circular lucite cone encompassing a mediastinal field including the bronchial stump, aorta, esophagus, heart, phrenic nerve, contralateral hilar structures, and lung. Clinical monitoring was performed with regular chest X-ray, ECG, bronchoscopy, esofagoscopy, and fluoroscopy. From the different treatment dose groups, dogs were electively sacrificed at 1.5, 6, 12, and 72 months with complete autopsies.

RESULTS

There was no bronchial stump dehiscence or acute morbidity. Four dogs developed radiation induced esophagitis (18%), one in the 20 Gy IORT group (11%) and three in the 30 Gy IORT group (33%). There were six IORT related mortalities (27.5%), one esophagoaortic fistula (4.5%) and five bronchovascular fistulas (23%): two in the 20 Gy IORT group (22%), two in the 25 Gy IORT group (50%) and two in the 30 Gy IORT group (22%). Histopathological findings in uncomplicated follow-up showed marked myointimal fibrosis in the muscular arteries, submucosal fibrosis of the esophagus, and interstitial fibrosis of bronchial and lung tissue, especially in the higher dose group.

CONCLUSION

The mediastinal vascular, bronchial and esophageal structures are relatively sensitive to doses > 20Gy IORT. The IORT related morbidity found in this study may be lower when the current clinically used IORT doses of 10-15 Gy are applied. Further clinical application of IORT in the future treatment strategies for resectable nonsmall cell lung cancer may be worthwhile to investigate.

Vincenz Czerny: carrying concepts into the 21st century

Vincenz Czerny, as a pupil of Theodor Billroth and as head of the surgical departments of the Universities of Freiburg and Heidelberg between 1871 and 1906, markedly influenced the surgical development of the 19th century. Major contributions to the field of surgery included hernia operations, abdominal surgery and vaginal hysterectomy. Most importantly he recognized that surgery alone would not be able to control cancer and he developed concepts for multimodality treatment.

Hemipelvectomy and intraoperative radiotherapy for bone and soft tissue sarcomas of the pelvic girdle

Current treatment of locally advanced bone and soft tissue sarcomas of the pelvic girdle are associated with a high local and distant failure rate, and local tumor control after hemipelvectomy can be a significant problem. IORT has been used in conjunction with hemipelvectomy, both conventional (seven patients) and limb-sparing internal hemipelvectomy (one patient), in seven males and one female, median age 27 (range 24-57) years with locally extensive high grade bone (seven patients) or soft tissue (one patient) sarcomas. IORT (15-30 Gy, 8-16 MeV) was delivered to sacral resection margins and surrounding soft tissues considered likely to harbor microscopically residual disease. Four patients received 46-54 Gy postoperative radiotherapy in addition to IORT. During a median follow-up of 33 months (range 6-131 months) two patients developed a local recurrence (25%), and five patients distant metastases (62%). Three patients with pelvic girdle sarcomas remained free of tumor (37%) with a mean follow-up of 100 (range 49-131) months. There was no treatment-related mortality. Two patients developed radiation-induced necrosis of the coccyx (25%). On the basis of this preliminary experience, it appears that IORT may substantially help to control local recurrence and survival in patients with marginally resectable sarcomas of the pelvic girdle after hemipelvectomy. Since the majority of the patients die from metastatic disease, there is a need for adjuvant systemic treatment.

Effect of irradiation on healing of newly made colonic anastomoses in the rat

PURPOSE

Short-term effects of radiotherapy on the healing process of newly made colonic anastomoses are investigated by measuring the anastomotic strength in a rat model.

METHODS AND MATERIALS

Four groups of Wistar rats were used. In all groups, rats underwent a 1 cm sigmoid resection with end-to-end anastomosis. Group I served as a control group. In group II the anastomosis was irradiated after closure of the abdominal wall with a single dose of 20 Gy of 250 kV x rays. Group III was irradiated with a single dose of 20 Gy while the abdominal wall was not closed, and the surrounding tissues were carefully covered by a lead plate, simulating intra-operative radiotherapy. Group IV was treated as group III, but a larger dose of 25 Gy was applied. Animals were sacrificed 3 or 7 days after the operation. General condition of the rats was determined by observation, weight loss, serum protein and albumin at sacrifice. Anastomotic healing was evaluated by inspection, bursting pressure, hydroxyproline and protein contents of the anastomotic segment.

RESULTS

Direct postoperative externally irradiated rats (group II) showed a marked weight loss, hypoproteinaemia and hypo-albuminaemia because of involvement of small bowel in the irradiated volume. With respect to anastomotic healing there were no significant differences between control and irradiated groups.

CONCLUSION

These data suggest that the application of a single dose of irradiation (20 and 25 Gy) on colonic anastomoses given in a direct postoperative or intraoperative model has no measurable side effect on the early healing of newly made colonic anastomoses. Direct postoperative external irradiation results in unwanted side effects in the adjacent bowel.

Tissue tolerance of normal and surgically manipulated canine liver to intraoperative radiation therapy (IORT)

PURPOSE

The purpose of the study is to obtain dose guidelines for the delivery of intraoperative radiotherapy to the liver of patients with colorectal liver metastases. Following partial resection of the liver, a single high dose of 10, 20, 25, and 30 Gy intraoperative radiotherapy was applied to both the resection plane as well as a nonsurgically manipulated part of the liver of 25 beagles. The temporal sequence of histological and ultrastructural changes of these irradiated parts of the liver tissue was investigated.

METHODS AND MATERIALS

The feasibility of delivering single large dose of intraoperative electron beam radiotherapy to the normal and partially hepatectomized liver was experimentally investigated in a canine study.

RESULTS

There were no postoperative complications, no morbidity or mortality with a minimal follow-up of 1 year. Autopsy performed 3 months following irradiation showed only mild histopathological changes. One year following intraoperative radiotherapy more distinct histopathological changes consisting of capsular thickening, diffuse parenchymal fibrosis and subcapsular hepatocellular atrophy were found. The liver function remained intact.

CONCLUSION

This study demonstrated that intraoperative radiotherapy to part of the liver in the canine model can be safely applied and doses up to 30 Gy are well tolerated.

Limb-sparing treatment with surgery and intraoperative radiotherapy (IORT) for a second local recurrence of myxoid liposarcoma in the popliteal region, after previous surgery and high-dose radiation

A 46-year-old man with a second local recurrence of a myxoid liposarcoma in the fossa poplitea, after surgery and high-dose external beam radiotherapy, was successfully treated by a limb-sparing procedure combining marginal excision, intraoperative radiotherapy and reconstructive surgery. After a 48-month follow-up, there was no evidence of disease, and the function of the leg and knee was normal.

Intraoperative radiation therapy for recurrent head and neck cancer

Forty-seven patients with recurrent head and neck cancer in a previously irradiated field were treated with surgical resection and intraoperative radiation therapy (IORT). Recurrent disease occurred at a median of 18 months from primary treatment, and was at the primary tumor site in 31 and metastatic to regional lymph nodes in 16. Recurrences were squamous cell carcinomas in 42 and adenoid cystic in five. Surgical resection left microscopic residual disease in 41 and gross residual in six. All patients received IORT with a median of 20 Gy. Two-year actuarial survival is 54.9%, and 15 patients are alive and disease free with a median survival of 29 months. Two-year actuarial local control is 61.5%. A trend toward increased survival (P less than 0.09) and local recurrence control (P = 0.05) was noticed when treating microscopic residual disease as opposed to gross residual disease. Perioperative mortality was seen in 8.5% and there was no increase in morbidity secondary to IORT. The authors believe that surgical resection and IORT is an effective treatment modality for head and neck cancers recurrent in previously irradiated fields and is adaptable to tertiary care hospitals.

Morbidity and mortality associated with intraoperative radiotherapy

From May 1984 through July 1988, 67 patients have been treated with intraoperative radiation therapy (IORT) at LDS Hospital. We conducted a detailed evaluation of the morbidity and mortality related to our intraoperative experience. Major complications were classified as those requiring reoperation or resulting in death. Minor complications included all others that could not be attributed to tumor growth or recurrence. Of twelve major complications, three resulted in death. Nonfatal complications included anastomotic leak (5), wound dehiscence (1), gastric outlet obstruction (1), and bowel obstruction (1). When compared with historical controls undergoing comparable surgery at this institution prior to the availability of IORT, complication rates were similar. We feel in our institution, intraoperative radiotherapy has not added to morbidity of aggressive abdominal surgery.

Intraoperative radiotherapy for recurrent and/or residual colorectal cancer

Intraoperative radiotherapy (IORT) is an attractive boosting modality in the combined treatment of recurrent and/or residual colorectal cancer. Twenty seven patients treated with IORT are analysed. Residual disease following resection of the primary tumor was treated in 11 cases (group I). Localized recurrent disease without previous radiotherapy was treated in 11 cases (group II). IORT was used in five additional patients with local recurrences in previously irradiated areas (group III). The treatment program consisted of maximal tumor resection, IORT (10-30 Gy) to the area of residual disease and external beam radiotherapy (46-50 Gy). The median follow-up time for the entire series of patients is 11 months. Local tumor control rates are 90% in group I, 63% in group II and 60% in group III. Toxicity and complications related to IORT observed in this initial experience have been pelvic pain (29%) and lower extremity neuropathy (3%). These early clinical results suggest that the IORT combined with surgery and external beam radiotherapy is feasible in primary and recurrent disease. Local control rates obtained in patients not suitable for curative surgery are encouraging.