The Role of Intraoperative Radiotherapy (iort) in The Management of Patients with Pancreatic

Although the advances in the modern surgery, the outcome for patients suffering from pancreatic adenocarcinoma or periampullary adenocarcinoma is still bad. Recently, IORT was introduced into the multimodality management approach to improve local control and survival.

The aim of work is to report our preliminary single-center experience with surgical resection plus IORT and the feasibility of IORT as a part of management in pancreatic and periampullary cancer patients and its effect on morbidity, mortality and local recurrence.

This study was conducted at King Faisal Specialist Hospital and Research Center, Riyadh, Kingdom of Saudi Arabia. Data were collected retrospectively. A total of six patients were included in the study I the period from November 2013 until April 2017. All surgeries were operated by the same surgeon.

The average age was 60 year (50-71). The Gender was four males and two females. Five patients underwent complete surgical resection (pancreaticoduodenectomy) combined with IORT. One patient had a locally advanced pancreatic tumor which was beyond surgical resectability. This patient underwent surgical bypass to overcome the biliary obstruction combined with IORT. Two patients died from disease progression and liver metastases and the remaining patients are alive without evidence of recurrence on follow-up.
Pancreatic adenocarcinoma is considered the 4th common cause of death from cancer (1). It has a 5-year survival rate of less than 5% (2). Patients with resected pancreatic adenocarcinoma have their 5-year survival rate of approximately 10% (3). Pancreaticoduodenectomy is considered the treatment of choice for resectable tumors achieving the best cure rate (3). Patients who have a resectable tumor for the aim of cure at time of presentation were low and represents only 20%. About 40% of patients at presentation have their tumors beyond curative resection, however, about 40% of patients present with metastatic disease (4).

The advances in surgical management have improved the resection rate with more favorable postoperative management accompanied with a lower rate of both surgical related morbidity and mortality, however, this improvement did not have its impact to improve the long-term survival (4). This was attributed to, although the resection sounds to be complete, yet these patients usually have advanced stages of cancer that entail the inclusion of all tissues that has tumor cells in the resected specimen. This must include all the draining lymph nodes and the tissues around the blood vessels and neural plexus (5, 6). By histological evaluation in some studies, it was found that less than 15% of the patients undergoing R0 resection have a pathological negative lymph node. Moreover, positive lymph nodes were found in about 50% of specimens and infiltration of tissues around the pancreas including the nerve plexus was found in about 50% (7, 8). Multidisciplinary management including complete surgical resection with neoadjuvant chemotherapy or combined with chemo-radiotherapy is considered the proper treatment for those patients (7, 9). Local recurrence of the tumor and liver metastases are the leading causes of treatment failure after surgery. The recurrence rate for resected tumors with advanced disease can range from 50-80% (6).

This is a retrospective study for patients presented to King Faisal Specialist Hospital and Research Center, Riyadh, KSA and was suffering from pancreatic and periampullary adenocarcinoma and was treated with combined surgical resection and IORT. From November 2013 until April 2017, a total of 6 patients had periampullary and pancreatic cancer operated by the same surgeon. Collected data include age, sex, and type of cancer were listed in (Table. 1). Preoperative workup for all patients included, full history taking, physical examination, laboratory investigations including routine laboratory tests, liver function tests, tumor markers (CA19-9, CEA) and radiological images (CT scan chest and abdomen or MRI abdomen), endoscopic retrograde cholangiopancreatography (ERCP), Stent and biopsy for five patients, upper endoscopy and biopsy for one patient. Metastases were not detected in any of the included patients in the study at the time of surgery. IORT was done using the Mobetron machine. IORT data were listed in (Table. 2). The survival rate was detected from the date of operation till the last time the patient presented during the follow up of the patient’s death.

IORT is a feasible and safe procedure. Patients can tolerate it well without additional morbidities or mortalities. Although our results are favorable, however, a final conclusion needs its application on a larger number of patients with longer periods of follow-up.