The its effect on morbidity, mortality and local recurrence.

The role of Intraoperative radiotherapy (IORT) in the
management of patients with pancreatic and periampullary cancer: A single
center experience

Abstract

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Background: 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.

Aims of Work: 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.

Methods and patients: 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.

Results: 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 locally advanced pancreatic tumor which was
beyond surgical respectability. 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 still alive
without evidence of recurrence on follow-up.

Conclusion: 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.

Keywords:

IORT, pancreatic cancer, periampullary cancer,
intraoperative radiotherapy

 

Introduction:

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). Pancreticoduodenectomy is considered the treatment of
choice for resectable tumors achieving the best cure rate (3). Patients who have 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 has improved the resection rate with more favorable
postoperative management accompanied with 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
entails 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 was 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. Recurrence rate for resected tumors with
advanced disease can range between 50-80% (6).

Patients and Methods:

The current study is a retrospective study carried on
patients presented to King Faisal Specialist Hospital and Research Center,
Riyadh, KSA who 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 was not detected in any
of the included patients in the study at the time of surgery. IORT was done using
Mobetron machine. IORT data were listed in (Table. 2). The survival rate
was detected from the date of operation till last time the patient presented
during the follow up of the patient’s death

Results:

The average age was 60 year (50-71). The gender was four
males and two females. The type of cancer was, one duodenal, two ampullary and
three pancreatic. Five patients underwent surgical resection
(pancreaticoduodenectomy) combined with IORT. One patient was found to have
locally advanced tumor which was difficult to be resected. This patient underwent
surgical bypass and IORT. The median operative time was 4.5 hours (range 4 – 6
hours), histopathology results demonstrated in the (Table. 3), average
postoperative hospital stay was 13.5 days (range 10– 17 days). All patient tolerated
the procedure without in-hospital morbidity or mortality. No patient received
preoperative chemotherapy, and only four patients received postoperative
chemotherapy. Follow up of these patients was done every 3 months for the first
2 years then every 6 months for the next 2 years then annually. This follows up
included laboratory investigations, tumor markers, and CT scan abdomen to rule
out recurrence.

Two patients died
from disease progression and liver metastases, both of them
having pancreatic cancer and in addition to surgery and IORT, they received
chemotherapy, the one had locally advanced disease survived for 14 months. And
the other one survived 17 months, but he had recurrent parathyroid cancer that
was operated twice before pancreatic surgery and even after surgery developed
lung metastases proven by biopsy to be metastatic parathyroid cancer of origin
and received postoperative chemotherapy.