Intraoperative radiotherapy given as a boost for early breast cancer: long-term clinical and cosmetic results

PURPOSE: The standard radiotherapy (RT) of breast cancer consists of 50 Gy external beam RT (EBRT) to the whole breast followed by an electron boost of 10-16 Gy to the tumor bed, but this has several cosmetic disadvantages. Intraoperative radiotherapy (IORT) could be an alternative to overcome these. METHODS AND MATERIALS: We evaluated 50 women with early breast cancer operated on in a dedicated IORT facility. Median dose of 10 Gy was delivered using 9-MeV electron beams. All patients received postoperative EBRT (50 Gy in 2 Gy fractions). Late toxicity and cosmetic results were assessed independently by two physicians according to the Common Terminology Criteria for Adverse Event v3.0 grading system and the European Organization for Research and Treatment of Cancer questionnaires. RESULTS: After a median follow-up of 9.1 years (range, 5-15 years), two local recurrences were observed within the primary tumor bed. At the time of analysis, 45 patients are alive with (n = 1) or without disease. Among the 42 disease-free remaining patients, 6 experienced Grade 2 late subcutaneous fibrosis within the boost area. Overall, the scores indicated a very good quality of life and cosmesis was good to excellent in the evaluated patients. CONCLUSION: Our results confirm that IORT given as a boost after breast-conserving surgery is a reliable alternative to conventional postoperative fractionated boost radiation.     

Intraoperative radiotherapy (IORT) for breast cancer using the Intrabeam system

INTRODUCTION: Intraoperative radiotherapy (IORT) with low-energy X-rays (30-50 KV) is an innovative technique that can be used both for accelerated partial breast irradiation (APBI) and intraoperative boosting in patients affected by breast cancer. Immediately after tumor resection the tumor bed can be treated with low-distance X-rays by a single high dose. Whereas often a geographic miss in covering the boost target occurs with external beam boost radiotherapy (EBRT), the purpose of IORT is to cover the tumor bed safely. This report will focus on the feasibility and technical aspects of the Intrabeam device and will summarize our experience with side effects and local control. MATERIALS AND METHODS: Between February 2002 and June 2003 57 breast cancer patients, all eligible for breast conserving surgery (BCS), were treated at the Mannheim Medical Center with IORT using the mobile X-ray system Intrabeam. The patient population in this feasibility study was not homogeneous consisting of 49 patients with primary stage I or II breast cancer, seven with local recurrence after previous EBRT and one with a second primary in a previously irradiated breast. The selection criteria for referral for IORT included tumor size, tumor cavity size, margin status and absence of an extensive intraductal component. The previously irradiated patients with local recurrences and 16 others received IORT as single modality. In all other cases IORT was followed by EBRT with a total dose of 46 Gy in 2-Gy fractions. The intraoperatively delivered dose after tumor resection was 20 Gy prescribed to the applicator surface. EBRT was delivered with a standard two-tangential-field technique using linear accelerators with 6- or 18-MV photons. Patients were assessed every three months by their radiation oncologist or surgeon during the first year after treatment and every six months thereafter. Breast ultrasound for follow-up was done every six months and mammographies once yearly. Acute side effects were scored according to the CTC/EORTC score and late side effects according to the Lent-Soma classification. RESULTS: Twenty-four patients received IORT only; eight patients because they had received previous radiotherapy, 16 because of a very favorable risk profile or their own preference. Thirty-three patients with tumor sizes between 1 and 30 mm and no risk factors were treated by IORT as a boost followed by EBRT. The Intrabeam system was used for IORT. The Intrabeam source produces 30-50 KV X-rays and the prescribed dose is delivered in an isotropic dose distribution around spherical applicators. Treatment time ranged between 20 and 48 minutes. No severe acute side effects or complications were observed during the first postoperative days or after 12 months. One local recurrence occurred 10 months after surgery plus IORT followed by EBRT. In two patients distant metastases were diagnosed shortly after BCS. DISCUSSION: IORT with the Intrabeam system is a feasible method to deliver a single high radiation dose to breast cancer patients. As a preliminary boost it has the advantage of reducing the EBRT course by 1.5 weeks, and as APBI it might be a promising tool for patients with a low risk of recurrence. The treatment is well tolerated and does not cause greater damage than the expected late reaction in normal tissue.     

Intraoperative radiotherapy (IORT) as a boost in patients with early-stage breast cancer -- acute toxicity

BACKGROUND: We report on acute toxicities as well as the early cosmetic outcome of patients receiving intraoperative radiotherapy (IORT) followed by whole-breast radiotherapy (WBRT) compared to patients treated with standard WBRT alone. PATIENTS AND METHODS: From 2/2002 until 2/2005, 84 breast cancer patients were treated with IORT during breast-conserving surgery (BCS) as a boost (20 Gy/50 kV X-rays) followed by WBRT. After wound healing, all IORT patients were treated with WBRT at a total dose of 46 Gy. For the purpose of comparison, 53 patients treated consecutively between 1/2003 and 12/2004 in our institution with BCS followed by WBRT at a total dose of 50-66 Gy, were analyzed. All patients had a defined followup schedule. Toxicities were prospectively documented using the CTC/EORTC Score. Cosmesis was evaluated after 6 months using a 1-4 score. RESULTS: Treatment was well tolerated with no grade 3/4 acute toxicity. Rare adverse effects following IORT included wound healing problems (2%), erythema grade I-II (3%), palpable seroma (6%) and mastitis (2-4%). The number of patients with induration of the tumor bed was comparably low. CONCLUSION: IORT with the IntrabeamTM system applied as a boost during BCS, followed by 46 Gy WBRT, exerts similar acute toxicity as standard WBRT. Further follow-up is needed to assess long-term toxicity and efficacy.     

Breast-conserving Surgery with Intra-operative Radiotherapy: The Right Approach for the 21st Century?

Wide local excision followed by external beam radiation therapy (EBRT) to the whole breast has become the standard of care for most patients with localised 'early' breast cancer in the UK, Europe, and the USA. Local relapse rates are low, and overall survival figures have improved during the past decade, with the advent of more effective systemic endocrine- and chemo-therapy. A policy of EBRT for every patient undergoing breast conserving surgery (BCS) is however associated with a number of practical difficulties, acute radiation side effects and longer term toxicity, all of which detract from the obvious benefits of EBRT. In addition, with a disease as common as early breast cancer and a treatment programme typically requiring sophisticated radiation planning and many fractions of treatment, the policy of BCS plus EBRT has enormous resource implications within departments of oncology, greatly contributing to lengthy pre-treatment delays. For all these reasons, we and others have developed an increasing interest in techniques of partial breast irradiation, with an emphasis in our own Department on the emerging technique of intra-operative radiotherapy (IORT), which we initially employed as a boost to the tumour bed for use in conjunction with EBRT to the whole breast. To test the possibility of replacing the whole of the EBRT 3-6 week programme by a single application of IORT at the time of surgery, we and others have commenced a large scale prospectively randomised clinical trail in selected patients. Nine international centres are currently participating, and 350 patients have now been randomised to receive either IORT as part of the initial surgical excision or conventional EBRT with a pragmatic dose policy according to the preference of the contributing centre. The majority of patients undergoing IORT receive this at the time of initial surgery but it is also permissible within the trial programme to randomise suitable patients after the excised specimen has been histologically examined, thus avoiding any unsuitable patients - for example, those with a lobular carcinoma. These patients will be stratified and assessed separately from the 'pre-pathology' group, whose surgery and IORT is completed within a single session; if the latter patients are found to have unfavourable histology we have the facility, within the trial, to add EBRT. The trial is ongoing and our early experience has been encouraging. We have also recently assessed the long term local failure rate in patients offered IORT as a tumour bed boost, in conjunction with conventional EBRT. This methodology will also be the subject of a future randomised clinical trial.     

Clinical analysis of intraoperative radiotherapy during breast-conserving surgery of early breast cancer in the Chinese Han population

Purpose

While results of intraoperative radiotherapy (IORT) during breast-conserving surgery (BCS) have been reported when used either as a boost at the time of surgery or as the sole radiation treatment, the clinical safety and cosmetic outcome of IORT in the Chinese Han population has not. This report reviews oncologic and cosmetic outcomes for Chinese Han breast cancer patients who received IORT either as a boost or as their sole radiation treatment at our hospital.

Method

From July 2008 to December 2012, 50 early-stage Chinese Han breast cancer patients received BCS and IORT, either as boost or as their sole radiation treatment. Patients received adjuvant chemotherapy or hormonal therapy, according to our institution''s guidelines. Patients were followed to determine oncologic events, short-term toxicity and overall cosmesis.

Results

With a median follow-up of 51.8 months (range 22.6 months to 75.7 months), 2 patients (4.0%) developed local relapses and were salvaged by mastectomy. There were no metastases and no deaths. The average wound healing time was 17 days. Three patients (6.0%) developed postoperative infection, 5 patients (10.0%) had delayed wound healing, and 2 patients (4.0%) experienced wound edema. There were no lyponecrosis or hematomas observed. The evaluation of cosmetic outcome showed 44 patients (88.0%) graded as excellent or good while 6 patients (12.0%) were graded as fair or poor. No patients experienced radiotherapy related acute hematological toxicity, but 3 patients (6.0%), all IORT boost patients, developed skin pigmentation.

Conclusion

For early-stage breast cancer patients, intraoperative radiotherapy after breast-conserving surgery in the Chinese Han population is both safe and reliable and has resulted in very acceptable cosmetic outcomes.     

乳腺癌保乳术中近距离瘤床放疗的临床应用评估

目的:探讨早期乳腺癌保乳术中采用近距离瘤床放疗取代常规术后全乳放疗后瘤床加量外照射的安全性和可行性.方法:共入组30例患者,其中15例早期乳腺癌患者接受保乳术中近距离瘤床放疗,术后常规行全乳放疗;另选择15例早期乳腺癌患者作为配对,接受保乳手术及术后全乳和瘤床加量放疗.比较2组患者术后24～48 h残腔引流量、切口Ⅰ期愈合率、术后住院天数和乳房外形满意度.结果:研究组与对照组的术后24～48 h残腔引流量、切口Ⅰ期愈合率、平均住院天数及辅助化疗开始时间的差异均无统计学意义(P＞0.05).2组患者的短期随访结果显示,均能保持满意的乳房外形.结论:早期乳腺癌保乳术中近距离瘤床放疗具有较好的安全性和临床可操作性.     

The script concordance test in radiation oncology: validation study of a new tool to assess clinical reasoning

Purpose

To retrospectively evaluate the results after a regimen of surgery, IORT (intraoperative radiotherapy), and EBRT (external beam radiotherapy) for soft-tissue sarcomas

Methods

38 consecutive patients underwent IORT for soft-tissue sarcoma; 29 were treated for primary tumours, 9 for recurrences. There were 14 cases with liposarcomas, 8 with leiomyosarcomas, 7 with malignant fibrous histiocytomas. 27/38 tumours were located in the extremities, the remaining ones in the retroperitoneum or the chest. Radical resection was attempted in all patients; a R0-resection was achieved in 15/38 patients, R1 in 12/38 pats and R2 in 4/38 pats. IORT was performed using a J-125 source and a HDR (high dose rate) afterloading machine after suturing silicone flaps to the tumour bed. The total dose applied ranged from 8–15 Gy/0.5 cm tissue depth measured from the flap surface. After wound healing external beam radiotherapy (EBRT) was applied in 31/38 patients with total doses of 23–56 Gy dependent on resection status and wound situation. The mean duration of follow-up was 2.3 years.

Results

A local recurrence was found in 10/36 patients, lymph node metastases in 2/35, and distant metastases in 6/35 patients. The actuarial local control rate was 63%/5 years. The overall survival rate was 57%/5 years. There was no statistically significant difference between the results after treatment for primaries or for recurrences. Late toxicity to the skin was found in 13/31 patients, wound healing problems in 5/31 patients. A neuropathy was never seen.

Conclusion

The combination of surgery, IORT, and EBRT yields favourable local control and survival data which are well within the range of the results reported in the literature. The complication rates, however, are considerable although the complications are not severe, they should be taken into account when therapy decisions are made.     

早期乳腺癌保乳术后全乳大分割照射同步瘤床加量的临床分析

目的：观察早期乳腺癌保乳术后全乳大分割照射同步瘤床加量的短期疗效与不良反应。方法64例早期乳腺癌患者保乳术后行两野切线全乳照射,全乳腺照射40．5 Gy／15 f,单次剂量2．7 Gy／f,同步瘤床推量至48 Gy／15 f,单次剂量3．2 Gy／f,总疗程3周,观察分析患者局部复发情况、美容效果及不良反应。结果中位随访时间17月,随访率为100％,无局部复发情况发生。3例患者表现乳腺中度胀痛;Ⅰ、Ⅱ、Ⅲ级急性皮肤反应发生率分别为17．2％、4．7％、1．6％;Ⅰ级血小板下降发生率与Ⅰ～Ⅱ级中性粒细胞减少发生率分别为1．6％、4．7％;放疗完成后4、7月美容优良率分别为90．6％、87．5％。结论早期乳腺癌保乳术后全乳放疗同步瘤床加量的短期疗效与以往常规放疗方式相似,缩短放疗时间,不会增加皮肤不良反应及降低美容效果。     

Long-term toxicity of an intraoperative radiotherapy boost using low energy X-rays during breast-conserving surgery

PURPOSE: Intraoperative radiotherapy (IORT) as a boost for breast cancer delivers a high single dose of radiation to a late-reacting tissue; therefore late toxicity is of particular interest, and long-term follow-up is warranted. To date there are only limited data available on breast cancer patients treated with IORT using low energy X-rays. We analyzed toxicity and cosmesis after IORT as a boost with a minimum follow-up of 18 months. METHODS AND MATERIALS: A total of 73 patients treated with IORT (20 Gy/50 kV X-rays; INTRABEAM [Carl Zeiss Surgical, Oberkochen, Germany]) to the tumor bed during breast-conserving surgery as a boost followed by whole-breast radiotherapy (WBRT, 46 Gy) underwent a prospective, predefined follow-up (median, 25 months; range 18-44 months), including clinical examination and breast ultrasound at 6-months and mammographies at 1-year intervals. Toxicities were documented using the common toxicity criteria (CTC)/European Organization for Research and Treatment of Cancer and the LENT-SOMA score. Cosmesis was evaluated with a score from 1 to 4. RESULTS: The IORT in combination with WBRT was well tolerated, with no Grade 3 or 4 skin toxicities and no telangiectasias. Fibrosis of the entire breast was observed in 5% of the patients. A circumscribed fibrosis around the tumor bed was palpable in up to 27% with a peak around 18 months after therapy and a decline thereafter. The observed toxicitiy rates were not influenced by age, tumor stage, or systemic therapy. The cosmetic outcome was good to excellent in>or=90% of cases. CONCLUSIONS: After IORT of the breast using low-energy X-rays, no unexpected toxicity rates were observed during long-term-follow-up.     

A preliminary report of intraoperative radiotherapy (IORT) in limited-stage breast cancers that are conservatively treated

Local recurrences after breast conserving surgery occur mostly in the quadrant harbouring the primary carcinoma. The main objective of postoperative radiotherapy should be the sterilisation of residual cancer cells in the operative area, while irradiation of the whole breast may be avoided. We have developed a new technique of intra-operative radiotherapy (IORT) of a breast quadrant after the removal of the primary carcinoma. A mobile linear accelerator (linac) with a robotic arm is utilised delivering electron beams able to produce energies from 3 to 9 MeV. Through a perspex applicator, the radiation is delivered directly to the mammary gland and to spare the skin from the radiation, the skin margins are stretched out of the radiation field. To protect the thoracic wall, an aluminium-lead disc is placed between the gland and the pectoralis muscle. Different dose levels were tested from 10 to 21 Gy without important side-effects. We estimated that a single fraction of 21 Gy is equivalent to 60 Gy delivered in 30 fractions at 2 Gy/fraction. Seventeen patients received a dose of IORT of 10 to 15 Gy as an anticipated boost to external radiotherapy, while 86 patients received a dose of 17–19–21 Gy intra-operatively as their whole treatment. The follow-up time of the 101 patients varied from 1 to 17 months (mean follow-up time was 8 months). The IORT treatment was very well accepted by all of our patients, either due to the rapidity of the radiation course in cases where IORT was given as the whole treatment or to the shortening of the subsequent external radiotherapy in cases where IORT was given as an anticipated boost. We believe that single dose IORT after breast resection for small mammary carcinomas may be an excellent alternative to the traditional postoperative radiotherapy. However, a longer follow-up is needed for a better evaluation of the possible late side-effects.     

A study of radiotherapy modalities combined with continuous 5-FU infusion for locally advanced gastrointestinal malignancies.

AIM: We describe the feasibility of combining infusional 5-fluorouracil (5-FU) with intraoperative radiation therapy (IORT). METHODS: Patients with surgically resectable locally advanced gastrointestinal cancers were treated concurrently during surgery with IORT and a 72 h infusion of 5-FU. Patients without previous external beam radiation therapy (EBRT) were subsequently treated with EBRT (40-50Gy) concurrent with a 21-day continuous infusion of 5-FU. Pancreatic, gastric, duodenal, ampullary, recurrent colorectal, and recurrent anal cancer were included. RESULTS: During IORT/5-FU, no chemotherapy-related grade III or IV hematologic or gastrointestinal toxicity was noted. Post-surgical recovery or wound healing was not affected. One of nine patients who received post-operative radiation required a treatment break. During follow-up, there were more complications in patients with pelvic tumours, especially those with previous radiation. Nine patients have had local and/or local regional recurrences, two of these in the IORT field. CONCLUSIONS: Treatment with a combination of IORT and 5-FU followed by EBRT and 5-FU is feasible. However, long-term complications may be increased in previously irradiated recurrent pelvic tumours.     

Patient preferences regarding intraoperative versus external beam radiotherapy following breast-conserving surgery

The TARGIT-A Trial is an international randomized, prospective trial comparing intraoperative radiotherapy (IORT) for equivalence to external beam radiotherapy (EBRT) following lumpectomy for invasive breast cancer in selected low-risk patients; early results suggest that outcomes are similar. In addition to effectiveness data and cost considerations, the preferences of patients should help inform practice. This study was undertaken to explore and quantify preference in choosing between IORT and the current standard, EBRT. Eligible subjects were current or past candidates for breast-conserving surgery and radiation being seen at the University of California, San Francisco Breast Care Center. A trade-off technique varying the risk of local recurrence for IORT was used to quantify any additional accepted risk that these patients would accept to receive either treatment. Patients were first presented with a slideshow comparing EBRT with the experimental IORT option before being asked their preferences given hypothetical 10-year local recurrence risks. Patients were then given a questionnaire on demographic, social and clinical factors. Data from 81 patients were analyzed. The median additional accepted risk to have IORT was 2.3 % (?9 to 39 %), mean 3.2 %. Only 7 patients chose to accept additional risk for EBRT; 22 accepted IORT at no additional risk; and the remaining 52 chose IORT with some additional risk. Patients weigh trade-offs of risks and benefits when presented with medical treatment choices. Our results show that the majority of breast cancer patients will accept a small increment of local risk for a simpler delivery of radiation. Further studies that incorporate outcome and side effect data from the TARGIT-A trial clarify the expected consequences of a local recurrence, and include an expanded range of radiation options that could help guide clinical decision making in this area.     

软组织肉瘤手术加术中放疗的临床研究

目的:探讨软组织肉瘤术中放疗的意义。方法:对39例软组织肉瘤患者行根治或姑息性手术,术中放疗在术中放疗手术室进行,术中根据肿瘤大小,选择不同术中放疗限光筒及6～12MeV电子线1次照射15～25Gy,姑息手术者剂量加大至36Gy。术后辅以外照射治疗,常规设野,5/周,2Gy/次,总量40～50Gy。初发病灶10例,术后复发29例。结果:39例患者随访12～64个月,3、5年局控率分别为71.8%和64.1%。3年生存率为82.0%。结论:术中放疗具有较高的局控率,比之其他治疗具有许多优点,将获得较高的生存率。     

High dose, external beam and intraoperative radiotherapy in the treatment of resectable and unresectable pancreatic cancer

Ninety patients with pancreatic cancer were treated by external beam radiotherapy (EBRT) and/or intraoperative radiotherapy (IORT) with or without surgical resection of the tumor, and the results were compared with those of a historical control comprising 112 patients treated by surgery alone. At an early stage of this study, postoperative EBRT (50-60 Gy) or IORT (25-33 Gy) was given alone, but recently the two modalities have been combined. The combination of high doses of EBRT and IORT was well tolerated provided that the gastrointestinal tract was not irradiated during IORT. Although EBRT plus IORT appeared to yield better results than either EBRT or IORT alone, the difference was not significant on multivariate analysis, and patients receiving EBRT, IORT, or EBRT + IORT were grouped together. Patients receiving radiotherapy in addition to macroscopically curative surgery had a slightly longer median survival time (14 months) than those receiving curative surgery alone (10 months), but the 3-year survival rate was similar (21% vs. 19%). In patients who underwent noncurative resection, the median survival time was significantly longer for the irradiated group (12 months) than for the control group (6.5 months). Also, in patients with unresectable lesions but no distant metastases, irradiation prolonged the median survival time significantly (8 vs. 3.5 months). In this group, there was one 5-year survivor, who received EBRT of 55 Gy plus IORT of 30 Gy to his unresectable pancreatic body lesion. Patients with metastases were also treated for palliation of symptoms, but it was found that irradiation prolonged the median survival time even in such cases (4.5 vs. 2.5 months). Based on these results, we plan to use EBRT plus IORT in all pancreatic cancer patients with no metastases.     

Moderate dose intraoperative and external beam radiotherapy for locally recurrent rectal carcinoma.

BACKGROUND AND PURPOSE: Late adverse effects (i.e. neuropathy, chronic bowel obstruction) limit the effective dose given in intraoperative radiotherapy (IORT) and external beam radiotherapy (EBRT). Initial results of a multi-modality treatment approach using moderate dose IORT and moderate dose EBRT are presented. PATIENTS AND METHODS: Thirty-one consecutive patients with recurrent rectal carcinomas had IORT and EBRT after complete (R0, n = 14) or incomplete resection (R1, n = 9; R2, n = 8). The mean [ORT dose was 13.7 Gy (range 12-20 Gy) supplemented with an EBRT dose of 41.4 Gy. Twenty-two patients had preoperative EBRT and 22 patients had concomitant chemotherapy (5-FU, Leucovorine). RESULTS: After a median follow-up of 28 months, 16 patients had re-recurrent disease and 11 patients had died. Nine patients failed locally (four in-field, four marginal and one anastomotic re-recurrence), three combined with distant metastasis, resulting in overall and IORT infield local control rates of 71% and 87%, respectively. Distant metastases alone were found in seven patients. The 4-year overall and relapse-free survival rates were 58% and 48%, respectively. After incomplete resection the local failure rate increased (R0 21%, R1/2 35%) and the 4-year relapse-free survival rate decreased significantly (29% versus 71%) due to a markedly increased distant metastasis rate (53% versus 7%). Acute and late toxicities were not increased. CONCLUSION: The combination of moderate dose IORT and EBRT is a safe and efficacious component in a multi-modality treatment approach.     

The novel technique of delivering targeted intraoperative radiotherapy (Targit) for early breast cancer.

AIM: We believe that conservative treatment of early breast cancer may not require radiotherapy that encompasses the whole breast in all patients. We have developed a novel therapeutic approach that allows targeted intraoperative radiotherapy (Targit) to be safely and accurately delivered in a standard operating theatre. We are currently recruiting for a randomized trial testing whether Targit can replace the whole 6 weeks of post-operative radiotherapy after breast conserving surgery. METHODS: This paper describes the operative technique. It employs a miniature electron-beam-driven X-ray source called INTRABEAM (PeC) that emits soft X-rays (50 kV) from within the breast. The X-rays are emitted from the tip of a 10 cm x 3.2 mm diameter probe, that is enclosed in a spherical applicator (available in 2.5-5 cm diameter sizes), which in turn is inserted in the tumour bed and intraoperative radiotherapy is delivered in about 25 min. The prescribed dose is 5 and 20 Gy at 1 cm and 0.2 cm respectively, from the tumour bed. RESULTS: The biologically effective dose is 7-53 Gy for alpha/beta=10 and 20-120 Gy for alpha/beta=1.5. The quick attenuation of the radiation reduces the damage to normal tissues and allows radiotherapy to be delivered in a standard operating theatre. Tungsten impregnated rubber sheets, cut to size, are placed on the chest wall to protect the heart/lungs and over the wound to stop stray radiation. The skin dose is monitored with thermoluminescent detectors (TLDs). After wide local excision of the tumour and good haemostasis, a spherical applicator is inserted in the tumour bed and the target breast tissues are wrapped around it with a purse-string suture. Thus, true conformation of the target around the applicator source is achieved in real time. CONCLUSION: As a tumour bed boost, this technique has the potential to reduce local recurrence by avoiding geographical misses and achieving excellent dosimetry. In patients with low risk of local recurrence, it has the potential to replace the full 6 weeks of post-operative radiotherapy with considerable implications to patients and hospitals.     

Surgical management of retroperitoneal sarcomas associated with external and intraoperative electron beam radiotherapy.

AIMS: To report outcomes of adults with retroperitoneal sarcoma (RS) treated by surgery, external beam radiotherapy (EBRT) and intraoperative electron beam radiotherapy (IORT). METHODS: From July 1988 to February 2001; 24 patients with primary and recurrent RS were diagnosed and treated. The median dose and energy of IORT delivered was 15 Gy/9meV. EBRT dose varies between 45-50 Gy. RESULTS: There were five primary and 19 recurrent tumours. One primary and five recurrent tumours underwent R0 resection. There were 12 liposarcomas and 19 grade I tumours; 13 patients developed local recurrence and three developed distant metastases.Twenty-two patients received IORT associated with EBRT: 11 developed recurrences. Six patients developed Neurotoxicity (4 grade II and 2 grade III). Disease free survival and overall survival at 5 years was 28 and 56% respectively. CONCLUSIONS: EBRT with IORT treatment is a promising technique for local control. Lower recurrence rates are associated with radical (R0) surgical procedures.     

乳腺癌保乳术+化疗后动态调强放疗的临床观察

目的 观察乳腺癌保乳术+化疗后动态调强放疗的疗效和美容效果.方法 117例乳腺癌患者保乳术后先行4～6周期化疗再三维适形(6例)和动态调强放疗(111例).化疗分别采用CAF(环磷酰胺+多柔比星+氟尿嘧啶)、AC(多柔比星+环磷酰胺)、TA(紫杉醇+多柔比星)、NE(长春瑞滨+表阿霉素)、TX(紫杉醇+卡培他滨)方案.放疗采用6 MV-X线全乳腺调强放疗50Gy,瘤床电子线外照射加量10 Gy;其中68例患者锁骨上预防性照射50 Gy,42例肿块位于内侧象限的同时照射内乳淋巴引流区,锁骨上区、内乳区及胸壁均包在一个靶区里.雌、孕激素受体阳性加用内分泌治疗.治疗结束后6～12个月由2位医师评分评价美容效果.结果 随访至2009年9月,随访率为94.0%,随访满3、5年者分别为114、91例.全组3生存率为99.1%,5年生存率为96%,5年无瘤生存率为88%,局部复发率为3.6%,美容效果满意者为100%.放疗中及放疗结束后未出现明显放射性心肺等重要脏器损伤.结论 乳腺保乳术+化疗后胸壁动态调强放疗使靶区得到更均匀照射,有望提高局部控制率和生存率并降低正常组织并发症、肿瘤复发率.     

Radiation therapy of pancreatic cancer]

We have been using external beam radiotherapy (EBRT) and intraoperative radiotherapy (IORT) for both resectable and unresectable pancreatic cancer patients. EBRT (50-60 Gy) was combined with IORT (25-33 Gy) whenever possible, but otherwise EBRT or IORT was given alone. In patients with unresectable tumor but no distant metastasis, the median survival time (MST) was 7.5 months (M) for the EBRT group and 9 M for the EBRT+IORT group. These MST's were significantly longer than the MST of 3 M of patients who had been treated without radiation (historical control). In non-Stage IV patients undergoing non-curative resection, the MST was 12.5 M for the EBRT group, 15.5 M for the EBRT+IORT group, and 7 M for the historical control. In patients undergoing macroscopic curative resection, the MST was 14 M for the EBRT group, 10 M for the EBRT+IORT group, and 10.5 M for the historical control. In Stage IV patients (with distant metastasis), the MST was 4.5 M for the EBRT group, 4 M for the EBRT+IORT group, 2 M for the IORT group, and 2.5 M for the historical control. Thus, radiotherapy appeared useful especially in non-Stage IV patients undergoing non-curative or no resection. A decrease or relief of pain was obtained in 90% of patients with unresectable lesions. Radiotherapy seems to play an important role in the treatment of pancreatic cancer but more aggressive combined treatment seems to be necessary to further improve the dismal prognosis of pancreatic cancer patients.     

Targeted intraoperative radiotherapy (TARGIT) yields very low recurrence rates when given as a boost

PURPOSE: Patients undergoing breast-conserving surgery were offered boost radiotherapy with targeted intraoperative radiotherapy (TARGIT) using the Intrabeam system to test the feasibility, safety, and efficacy of the new approach. METHODS AND MATERIALS: We treated 302 cancers in 301 unselected patients. This was not a low-risk group. One-third of patients (98/301) were younger than 51 years of age. More than half of the tumors (172, 57%) were between 1 cm and 2 cm, and one-fifth (62, 21%) were >2 cm; 29% (86) had a Grade 3 tumor and, in 29% (87), axillary lymph nodes contained metastasis. After primary surgery, 20 Gy was delivered intraoperatively to the surface of the tumor bed, followed by external-beam radiotherapy (EBRT), but excluding the usual boost. RESULTS: The treatment was well tolerated. The follow-up ranged from 3 to 80 months (164 and 90 patients completed 2 and 3 years follow-up, respectively). Four patients (1.3%) had local recurrence. The Kaplan-Meier estimate of local recurrence is 2.6% (SE = 1.7) at 5 years. This compares favorably with the 4.3% recurrence rate in boosted patients from the EORTC boost study, in which only 8.1% patients were node-positive, as opposed to 29% in our series. CONCLUSION: Targeted intraoperative radiotherapy combined with EBRT results in a low local recurrence rate. This could be attributed to both accurate targeting and timeliness of the treatment. These data support the need for a randomized trial to test whether the TARGIT boost is superior to conventional external boost, especially in high-risk women.