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Sethi A, Gros S, Brodin P, Ghavidel B, Chai X, Popovic M, Tomé WA, Trichter S, Yang X, Zhang H, Uhl V. Intraoperative radiation therapy with 50 kV x-rays: A multi-institutional review. J Appl Clin Med Phys 2024; 25:e14272. [PMID: 38279520 DOI: 10.1002/acm2.14272] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2023] [Revised: 11/16/2023] [Accepted: 01/01/2024] [Indexed: 01/28/2024] Open
Abstract
This report covers clinical implementation of a low kV intraoperative radiation therapy (IORT) program with the INTRABEAM® System (Carl Zeiss Meditec AG, Jena, Germany). Based on collective user experience from eight institutions, we discuss best methods of INTRABEAM quality assurance (QA) tests, commissioning measurements, clinical workflow, treatment planning, and potential avenues for research. The guide provides pertinent background information and clinical justification for IORT. It describes the INTRABEAM system and commissioning measurements along with a TG100 risk management analysis to ensure safety and accuracy of the IORT program. Following safety checks, dosimetry measurements are performed for verification of field flatness and symmetry, x-ray output, and depth dose. Also discussed are dose linearity checks, beam isotropy, ion chamber measurements, calibration protocols, and in-vivo dosimetry with optically stimulated luminescence dosimeters OSLDs, and radiochromic film. Emphasis is placed on the importance of routine QA procedures (daily, monthly, and annual) performed at regular intervals for a successful IORT program. For safe and accurate dose delivery, tests of important components of IORT clinical workflow are emphasized, such as, dose prescription, pre-treatment QA, treatment setup, safety checks, radiation surveys, and independent checks of delivered dose. Challenges associated with in-vivo dose measurements are discussed, along with special treatment procedures and shielding requirements. The importance of treatment planning in IORT is reviewed with reference to a Monte Carlo-based commercial treatment planning system highlighting its main features and limitations. The report concludes with suggested topics for research including CT-based image-guided treatment planning and improved prescription dose accuracy. We hope that this multi-institutional report will serve as a guidance document on the clinical implementation and use of INTRABEAM IORT.
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Affiliation(s)
- Anil Sethi
- Department of Radiation Oncology, Stritch School of Medicine, Loyola University Chicago, Maywood, Illinois, USA
| | - Sebastien Gros
- Department of Radiation Oncology, Stritch School of Medicine, Loyola University Chicago, Maywood, Illinois, USA
| | - Patrik Brodin
- Department of Radiation Oncology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York, USA
| | - Beth Ghavidel
- Department of Radiation Oncology, Winship Cancer Institute, Emory University, Atlanta, Georgia, USA
| | - Xuedong Chai
- Department of Radiation Oncology, Stanford University School of Medicine, Stanford, California, USA
| | - Marija Popovic
- Department of Medical Physics, McGill University Health Center, Montreal, Quebec, Canada
| | - Wolfgang Axel Tomé
- Department of Radiation Oncology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York, USA
| | - Samuel Trichter
- Department of Radiation Oncology, Weill Cornell Medical Center, New York-Presbyterian Hospital, New York, New York, USA
| | - Xiaofeng Yang
- Department of Radiation Oncology, Winship Cancer Institute, Emory University, Atlanta, Georgia, USA
| | - Hualin Zhang
- Department of Radiation Oncology, University of Southern California, Los Angeles, California, USA
| | - Valery Uhl
- Department of Radiation Oncology, Summit Medical Center, Emeryville, California, USA
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Villafuerte CVL, Ylananb AMD, Wong HVT, Cañal JPA, Fragante EJV. Systematic review of intraoperative radiation therapy for head and neck cancer. Ecancermedicalscience 2022; 16:1488. [PMID: 36819819 PMCID: PMC9934972 DOI: 10.3332/ecancer.2022.1488] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2022] [Indexed: 12/14/2022] Open
Abstract
Multidisciplinary treatments with surgery, radiation therapy, and chemotherapy are the cornerstones in the management of locally advanced head and neck malignancies. In most cases, radiation is delivered via external beam radiation therapy (EBRT). Intraoperative radiation therapy (IORT), on the other hand, is the delivery of precise doses of radiation to selected target volumes within the exposed surgical field while at the operating room. Most studies on its use on head and neck cancers are limited to single-institutional retrospective case series. We performed a systematic review to consolidate the existing literature on IORT for head and neck malignancies. Fifty-two studies representing a mixed population of 2,389 patients were included in this review. IORT via electrons (intraoperative electron radiation therapy), brachytherapy (intraoperative high dose-rate brachytherapy) or photons was administered in numerous settings, but most commonly as part of a reirradiation regimen following salvage surgery for recurrent tumours. Often, additional EBRT was also planned postoperatively. This review illustrates that IORT is a promising treatment modality in head and neck cancer. Multiple single-institutional studies spanning several decades have demonstrated benefit in terms of local control with reasonable toxicity. However, randomised trials comparing it with current standards of care are still needed.
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Yang Y, Li L, Zheng Y, Liu Q, Wei X, Gong X, Wang W, Lin P. A prospective, single-arm, phase II clinical trial of intraoperative radiotherapy using a low-energy X-ray source for local advanced Laryngocarcinoma (ILAL): a study protocol. BMC Cancer 2020; 20:734. [PMID: 32762662 PMCID: PMC7409502 DOI: 10.1186/s12885-020-07233-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Accepted: 07/28/2020] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Laryngocarcinoma (LC), in most cases a squamous cell carcinoma, accounts for 1 ~ 5% of the incidence of all tumors. At present, laryngocarcinoma is mainly managed with the integration of surgery and radio- and chemo-therapies. The current development trend of treatment is to improve the local control rate of tumor and the quality of life of patients. Intraoperative radiation therapy (IORT) is a radiotherapy that delivers single high dose irradiation at a close range to the tumor bed during the surgical operation process. It has particular radiobiological advantages in protecting normal surrounding tissues by directly applying the irradiation dose to the high-risk tumor bed area. Two forms of IORT, i.e., high dose rate (HDR) brachytherapy and external beam radiotherapy (EBRT, including electron and photono IORT), had been studied before the treatment of head and neck tumors (including laryngocarcinoma). However, no relevant assessment had been carried out on 50KV low-energy X-ray. We are convinced by certain arguments that the application of low-energy X-ray for intraoperative local radiotherapy of laryngocarcinoma can not only achieve the therapeutic effect of IORT but also reduce the incidence of high-energy irradiation related toxic and side effects. The purpose of this study is to observe the safety and short-term efficacy of IORT when used in conjunction with standard of care for the treatment of local advanced laryngocarcinoma (LAL). METHODS/DESIGN In consideration of the applications of precise targeted IORT in oncosurgery and in line with the application range and reference clinical medical guidances approved by SFDA (ZEISS radiosurgical operation system has been used for the treatment of solid tumors since 31 December, 2013 with an approval from SFDA), we have preliminarily planned the tumors suitable for IORT, determined the members of MDT in our hospital, improved the MDT diagnosis and treatment processes for the tumors, established the standards, indications and contraindications for the application of IORT, determined the indicators to be observed after the treatment of tumors with surgical operations plus IORT, and carried out follow-up visits and statistical analysis. This is a single-arm, prospective Phase II clinical trial of the treatment of LAL patients with IORT + EBRT. The study subjects are followed up for statistics and information of their acute/chronic toxic reactions and local control rate, DFS, and OS etc. The safety and short-term efficacy of the application of IORT as SIB for the treatment of LAL. The sample size of the study is 125 subjects. DISCUSSION The safety and efficacy of IORT for the treatment of head and neck cancers have been proven in studies by multiple institutions (1-3). The purpose of this study is to investigate the maximum safe dose and short-term efficacy of IORT for providing a theoretical basis for clinical trials. TRIAL REGISTRATION Trial registration: Clinicaltrials.gov , NCT04278638. Registered 18 February 2020 - prospectively registered, https://clinicaltrials.gov/ct2/show/NCT04278638.
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Affiliation(s)
- Yining Yang
- Department of Radiotherapy and Department of Otorhinolaryngology Head and Neck Surgery, Tianjin First Central Hospital, No.24 FuKang Road, Nankai District, Tianjin, 300192, China
| | - Li Li
- Department of Radiotherapy and Department of Otorhinolaryngology Head and Neck Surgery, Tianjin First Central Hospital, No.24 FuKang Road, Nankai District, Tianjin, 300192, China
- Institute of Otolaryngology of Tianjin, Tianjin, China
- Key Laboratory of Auditory Speech and Balance Medicine, Tianjin, China
- Key Clinical Discipline of Tianjin (Otolaryngology), Tianjin, China
- Otolaryngology Clinical Quality Control Centre, Tianjin, China
| | - Yongzhe Zheng
- Department of Radiotherapy and Department of Otorhinolaryngology Head and Neck Surgery, Tianjin First Central Hospital, No.24 FuKang Road, Nankai District, Tianjin, 300192, China
- Institute of Otolaryngology of Tianjin, Tianjin, China
- Key Laboratory of Auditory Speech and Balance Medicine, Tianjin, China
- Key Clinical Discipline of Tianjin (Otolaryngology), Tianjin, China
- Otolaryngology Clinical Quality Control Centre, Tianjin, China
| | - Qingfeng Liu
- Department of Radiotherapy, Tumor Hospital of the Chinese Academy of Medical Sciences, Beijing, China
| | - Xianfeng Wei
- Department of Radiotherapy and Department of Otorhinolaryngology Head and Neck Surgery, Tianjin First Central Hospital, No.24 FuKang Road, Nankai District, Tianjin, 300192, China
- Institute of Otolaryngology of Tianjin, Tianjin, China
- Key Laboratory of Auditory Speech and Balance Medicine, Tianjin, China
- Key Clinical Discipline of Tianjin (Otolaryngology), Tianjin, China
- Otolaryngology Clinical Quality Control Centre, Tianjin, China
| | - Xinyuan Gong
- Department of Radiotherapy and Department of Otorhinolaryngology Head and Neck Surgery, Tianjin First Central Hospital, No.24 FuKang Road, Nankai District, Tianjin, 300192, China
| | - Wei Wang
- Department of Radiotherapy and Department of Otorhinolaryngology Head and Neck Surgery, Tianjin First Central Hospital, No.24 FuKang Road, Nankai District, Tianjin, 300192, China.
- Institute of Otolaryngology of Tianjin, Tianjin, China.
- Key Laboratory of Auditory Speech and Balance Medicine, Tianjin, China.
- Key Clinical Discipline of Tianjin (Otolaryngology), Tianjin, China.
- Otolaryngology Clinical Quality Control Centre, Tianjin, China.
| | - Peng Lin
- Department of Radiotherapy and Department of Otorhinolaryngology Head and Neck Surgery, Tianjin First Central Hospital, No.24 FuKang Road, Nankai District, Tianjin, 300192, China.
- Institute of Otolaryngology of Tianjin, Tianjin, China.
- Key Laboratory of Auditory Speech and Balance Medicine, Tianjin, China.
- Key Clinical Discipline of Tianjin (Otolaryngology), Tianjin, China.
- Otolaryngology Clinical Quality Control Centre, Tianjin, China.
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