Oscar Abuchaibe

Intraoperative radiotherapy in locally advanced recurrent colorectal cancer

PURPOSEnIn an effort to promote local control and improve quality of life in patients with recurrent colorectal cancer, a multimodality approach has been used.nnnMETHODS AND MATERIALSnTwenty-seven patients were treated with moderate doses of pre/postoperative radiotherapy with/without simultaneous systemic chemotherapy, surgical re-resection and IORT electron boost over areas at high risk for local recurrence.nnnRESULTSnThe 2-year actuarial disease-free and local relapse-free survival for the entire group were 14% and 26%, respectively. The most important factor predicting a favorable outcome was the radicality of surgical procedure. The determinate local control rate and the actuarial 2-year local relapse-free, and disease-free survival for patients undergoing complete resections were 50%, 56%, and 34%, respectively, whereas for patients undergoing partial resections these figures were 16%, 13%, and 6%. The radicality of surgical procedure was influenced by both tumoral size and previous treatment with irradiation. Complete resection rate was higher in patients with tumors less than 5 cm vs. more than 5 cm (40% vs. 22%), and in patients without previous radiotherapy versus those with previous radiotherapy (40% vs. 28%). Distant metastasis rate was high (41%). The most significant toxicities attributable to the whole treatment protocol were enteritis (37%), hydronephrosis (30%), and pelvic neuropathy (52%).nnnCONCLUSIONnCurrently, our policy is to recommend IORT in patients with favorable factors such as: absence of previous pelvic radiotherapy, single previous surgical procedure, and complete resections.

Intraoperative and external radiotherapy in resected gastric cancer: Updated report of a phase II trial

From September 1984 to August 1991, 48 evaluable patients with resected gastric cancer and apparent disease confined to locoregional area were treated with intraoperative electron beam boost to the celiac axis and peripancreatic nodal areas (15 Gy) and external irradiation (40 to 46 Gy in 4 to 5 weeks) including the gastric bed and upper abdominal nodal draining regions. At the time of evaluation for IORT, the disease was primary in 38 cases, recurrent but resectable in four (anastomosis), and unresectable in four (nodal). Post operative complications were reversible. Acute tolerance to the complete treatment program was acceptable. Late complications included life-threatening events: Six episodes of gastro intestinal bleeding (three of them had an arteriographic documentation of arterioenteric fistula) and nine with severe enteritis (five required reoperation). Other long-term treatment related complications were six cases of vertebral collapse. The median follow-up time for the entire group is 22 months. Locoregional recurrence/persistence of disease has been identified in five patients (three with residual and/or recurrent postsurgical tumor). Systemic tumor progression has been detected in 15 patients (11 in intra-abdominal sites). Overall actuarial survival for patients with positive or negative serosal involvement was 33% versus 56%. It is concluded that the treatment program described is able to induce a high locoregional tumor control rate (100%) when used strictly in an adjuvant setting and might control long term, a small portion of patients not amenable for curative surgery (2 out of 8 patients with confirmed residual post-surgical disease). Gastrointestinal bleeding and enteritis are findings that indicate treatment intensity at the upper limits of tissue tolerance. Assessment of long term tolerance of pancreatic parenchyma and large blood vessels (tissues included in the IRORT field) are pending for longer follow-up and the appropriate selective studies.

Intraoperative radiotherapy during lung cancer surgery: Technical description and early clinical results

A phase I-II study of intraoperative radiotherapy (IORT) for Stage III lung cancer was performed in 34 patients during a period of 58 months. Loco-regional treatment included tumor resection if technically feasible, IORT boost of electron beams using moderate single doses (10-15 Gy) to tumor bearing areas and external photon beam irradiation (46-50 Gy in 5 weeks) using conventional fields. Indications for this study were unresectable hiliar tumors (14, 41%), and mediastinal, hiliar and/or chest wall residual disease following resection (20, 59%). Thirty-four procedures, with 40 IORT fields, have been analyzed to describe the relevant technical aspects and the toxicity. IORT was delivered using acrylic transparent cones of different diameters. Surgical approach consisted in a lateral thoracotomy in all patients (21 right side and 13 left side). Tissues included within the IORT field were: tumor or residual tumor tissues (34, 100%), collapsed lung parenchyma and main bronchus not surgically manipulated (14, 41%), bronchial stump and vascular suture following resection (19, 55%), mediastinal structures (20, 58%), and brachial plexus (1, 3%). The bronchial suture was covered with pleural or pericardial flap after IORT in 10 cases (29%). Life threatening toxicity related to IORT consisted in broncho-pleural fistula (1, 3%) and massive hemoptysis (1, 3%). Other reversible toxic events were acute pneumonitis (12, 85%) and esophagitis (10, 50%). Long term asymptomatic lung fibrosis was detected in 11 cases (32%). Median survival time for the entire group has been 12 months. With a median follow-up time of 12 months the freedom from thoracic recurrence rate is 30% (65% in cases with tumor resection). Projected actuarial survival rates at 4 years were 28% for resected group and 7% for unresected cases. This experience supports IORT as a feasible alternative modality to be used in the management of locally advanced lung cancer. Tolerance of thoracic organs to moderate doses of IORT appeared to be adequate and local control is achieved in certain patients. These results deserve further investigation and confirmation trials.

Intraoperative and external beam radiotherapy in invasive bladder cancer: pathological findings following cystectomy.

The pathological findings observed following intraoperative radiotherapy (IORT) boost (15Gy) to the whole bladder, external beam fractionated irradiation (46Gy in 5 weeks), and planned radical cystectomy in patients with deep invasive bladder carcinoma are analyzed. Clinical pretreatment stage of disease was T3 (16 cases) and T4 (two cases). No evidence of residual tumor (pT0) was demonstrated in 11 cystectomy specimens (61%) and residual tumor (pT1) was observed in seven (39%). Toxicity and complications related to the treatment approaches were minor and reversible. It is concluded that IORT is a feasible boosting modality in the management of invasive bladder cancer, able to induce high rates of pT0 cystectomy specimens, and might be considered as a valuable technique for organ preservation treatment programs.

Head and Neck Cancer

The possible role of IORT in the management of head and neck tumors has rarely been explored, an exception being the large series at the Methodist Hospital of Indiana (Garrett et al. 1989). IORT can be introduced in the multidisciplinary management of head and neck cancer as a boosting modality in areas of residual disease or close surgical margins in patients with locally advanced tumor, in an effort to promote local tumor control. The potential advantages of IORT in these tumor locations do not derive from normal tissue sparing, but from better definition of high risk areas for recurrence and the simultaneous combination of high dose radiotherapy and surgical debulking.

Ewing’s Sarcoma

Ewing’s sarcoma is a malignant disease that requires multimodal treatment to obtain high cure rates (Malwer et al. 1989). Radiation therapy is an important component of the treatment of the primary lesion. The reported rates of local control attributed to radiation therapy vary widely (Halperin et al. 1989). Tumor volume and the site of the primary tumor have been related to major differences in local tumor control. Thus isolated local recurrences have been reported in 15% of patients with lesions of the extremities, in 47% with rib primaries, and in 69% with pelvic tumors (Brown et al. 1987). The rate of local persistence/ tumor recurrence, as evaluated by clinical and autopsy findings, was reported by Tepper et al. (1980) to be 35%, 25%, and 7% in patients treated with primary radiation therapy for central, proximal extremity, and distal extremity lesions respectively (Tepper et al. 1980). Overall rates of local tumor control with radiotherapy are in the region of 90% for lesions less than 8 cm in maximum diameter, and 70% for those more than 8 cm in maximum diameter (Marcus and Million 1984).

Retroperitoneal and Other Central Soft Tissue Sarcomas

Soft tissue sarcomas involving anatomic zones other than the extremities are rare and have generally been treated by surgical resection. Since the production of evidence that radiation therapy can increase local control in soft tissue sarcomas of the extremities (Rosenberg et al. 1982), radiotherapy has been used more frequently postoperatively. Surgical resection of soft tissue sarcomas of the retroperitoneum, head and neck, trunk, or pelvis will achieve clear margins in only a few cases. Success in this respect depends not only on tumor size and technical skills but also on the anatomic site involved by tumor.

Intraoperative radiotherapy of upper abdominal tumours

AbstractsThirty patients with malignant tumours in the upper abdomen underwent surgery and intraoperalive radiation (IORT), using electron beam, to: the surgical bed, residual or unresected tumour. The technical aspects and results of this treatment are described. Renal, adrenal, bile duct and gastrointestinal tumours were treated. along with several other lesions. The surgical procedure consisted in 10 cases simply of exposure of the tumour for IORT and in 20 the tumour was resected. The TORT dose ranged from 10 to: 20 Gv. In 13 patients, external beam radiation was also given to: residual tumour or to: areas of high risk for recurrence. Chemotherapy was given to: 10 patients. Tolerance to: the combined treatment was acceptable; with few complications related to: IORT.The median follow-up and survival time 23 months (range 4-more than 70 months). Local tumour control rate (or tumour stabilisation) is 90%. Distant metastases developed in 19 patients (63%). The actuarial survival rate for the group projected at 70 months (maximum follow-up) is 37%. IORT in useful in the management of tumours arising in the upper abdominal organs, for palliation surgery or when resectability of the tumour is in doubt. Indications for IORT include patients with uncommon tumours of the upper abdomen who are not be candidates for standardised cancer treatment.