Results: was 60 year (50-71). The gender was

Results:

The average age of the studied patients was 60 year
(50-71). The gender was 4 males and 2 females. At the time of presentation, the
type of cancer was 3 pancreatic cancer, two ampullary cancer and one duodenal
cancer. From the 6 patients included in the current study, 5 patients had
complete surgical resection with the application of IORT. The last patient was
found to have unresectable tumor. It was difficult for resection so bypass
operation in the form of choledochojejunostomy and gastrojejunostomy were done
combined with IORT. The median operative time was 4.5 hours (range 4 – 6
hours). The histopathological results were demonstrated in (Table. 3). The
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 neoadjuvant chemotherapy. Only 4 patients received
postoperative chemotherapy. Follow up was done every 3 months for the first 2
years then every 6 months for the next 2 years then annually. It included
laboratory investigations, tumor markers, and CT scan of the chest and abdomen
to rule out any tumor recurrence.

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Two patients died
during the follow up period. Both patients
were diagnosed to have pancreatic cancer and in addition to surgery and IORT,
they received postoperative chemotherapy. The patient who had unresectable
tumor survived about 14 months and died from the progression of the disease and
liver metastases.  The other patient survived
about 17 months. This patient had recurrent parathyroid cancer that was
operated twice before presentation. He developed lung metastases after his
operation which was proved by biopsy to be metastases from the parathyroid
cancer. This patient received postoperative chemotherapy.

The remaining
4 patients are still surviving with overall free survival rate 66.6%. They are
on regular follow up. They have no tumor recurrence. The period of follow up range
from 6-41 month.

Discussion:

IORT was discovered since more than 4 decades. Since its discovery,
it was applied in patients with non-metastasizing advanced tumors (10). The idea is to allow the radiation beam to pass from
the radiation machine to the affected area with tumor residual after the
resection or debulking of the tumor. This beam will have direct access to the
affected areas in concentrated dose. This procedure guarantee the
administration of high doses of radiation to the affected areas. This increases
the chance of killing the tumor cells remaining after surgical resection. The nearby
organs and tissues can be shielded or taken away from the radiation beam which
decreases the risk of radiation complications on these organs (11). The earlier
studies that evaluated the effect of the application IORT on the patients with
locally advanced diseases or who have residual diseases concluded that it is of
great effect. This effect includes the control of the residual tumor itself and
also maximizes the period for tumor recurrence (12, 13). These
results also can go in accordance with the patients with resectable pancreatic
and periampullary adenocarcinoma. In cases of locally advanced tumors which are
beyond complete surgical resection, IORT still has the advantages of
controlling the disease locally to decrease its local effect and minimizing
tumor pain resulting from neural plexus infiltration (14).

Most of the studies that recorded the effect of IORT
application for the patients who have pancreatic or periampullary cancer and
who had complete surgical resection are retrospective studies (15-18). Also many studies
have recorded the results in patients who have complete resection combined with
IORT and who had complete resection alone (4).  They concluded
that the application of IORT reduces the disease recurrence. (4). Zerbi et al. (15)  studied the
effect of the application of IORT on patients after complete tumor resection and
compared them with patients who had complete tumor resection alone and they
found IORT application will not add for postoperative patient morbidity and
mortality. Also, the tumor recurrence was only 26% in the group of patients who
received the IORT compared with 56% in the group who had complete resection
alone. Another group conducted the study on 2 groups of patients. The first
group included 127 patients and had complete resection of the tumor with the application
of IORT and the second group include 76 patients who had complete tumor
resection alone. They concluded that there is no difference between the 2
groups regarding the postoperative morbidity and mortality due to the
application of IORT. They also found that the delay in the local recurrence significantly
in the group of IORT application especially in patients who have earlier stages
of the tumor (16). These
results also proved by more recent studies (17, 18).  After the review of the histopathology of our
patients with pancreatic and periampullary cancer and the affection of the localized
tissues and lymph nodes and also after the review of the related literature, we
started to apply IORT as part of the management of pancreatic and periampullary
cancers. The initial results from our center prove the benefit of the
application of IORT as a part of the management of theses tumors.

Conclusion:

IORT is a feasible and safe procedure. The patient can
tolerate it well as it did not affect the postoperative course regarding postoperative
complications and operative related mortalities. Our preliminary results are favorable.
In order to have a rigid recommendation for the application of IORT, the study needs
larger number of patients with long period of follow up.  

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