The IORT. Also to evaluate the feasibility of the

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 both tumor
control and patients survival.

Aim of work: To evaluate
our initial experience with combined surgical resection and IORT. Also to evaluate
the feasibility of the application of IORT 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 during 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 resection for whom surgical bypass was done to overcome the
biliary obstruction combined with IORT. Two patients died from disease
progression and liver metastases. All the remaining patients are survived without
any evidence of local recurrence or metastases on follow-up.

Conclusion: Application
of IORT is safe and feasible. It can be applied without additional morbidities
or mortalities. Although our results are satisfactory, yet, it needs to be
applied on larger number of patients with longer periods of follow-up to get a
final conclusion.

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 patient 5-year survival of less than 5% (2). Patients
with completely resected tumors have their 5-year survival rate around 10% (3). Pancreticoduodenectomy is considered the treatment of
choice for resectable tumors achieving the best cure rate (3).The patients present with a completely resectable tumor
were low and represents only 20%. About 40% of patients at presentation have
their tumors beyond curative resection, however, around 40% of patients present
with their disease metastasizing to other organs (4).  The improvement
in the surgical techniques had their impact on the resection rate with more
favorable postoperative management accompanied with lower rate of surgical
related morbidity and mortality, however this improvement did not improve the patient’s
survival over longer time (4). This is due to the non-inclusion of all tissues that
has tumor cells in the resected specimen. It must include all the draining
lymph nodes and the tissues around the blood vessels and neural plexus (5, 6). By
evaluation of the histo-pathological reports in some studies, it was found that
<15% of the patients undergoing complete tumor resection have a pathologically negative lymph nodes. Moreover, positive lymph nodes was found in about 50% and infiltration of tissues around the pancreas including the nerve plexus was found in about 50% (7, 8). The proper management entails complete surgical resection with neoadjuvant chemotherapy or combined with chemo-radiotherapy (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. It was carried on patients presented to King Faisal Specialist Hospital and Research Center, Riyadh, KSA who had pancreatic or periampullary adenocarcinoma and was treated with surgical resection combined with IORT. From November 2013 until April 2017, a total of 6 patients were included in the study. Collected data were patient's age, gender and the type of cancer. These data 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 diagnostic tools (CT scan of the abdomen and chest or MRI of the abdomen), endoscopic retrograde cholangiopancreatography (ERCP) with taking biopsy and putting a stent in 5 patients, upper gastrointestinal endoscopy and taking a biopsy for one patient. None of the patients had metastases detected preoperatively. IORT was done using Mobetron machine. IORT data were listed in (Table. 2). The survival rate was detected either from the date of operation till last time the patient presented during the follow up or till the patient's death