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, thetype of cancer was 3 pancreatic cancer, two ampullary cancer and one duodenalcancer. From the 6 patients included in the current study, 5 patients hadcomplete surgical resection with the application of IORT. The last patient wasfound to have unresectable tumor. It was difficult for resection so bypassoperation in the form of choledochojejunostomy and gastrojejunostomy were donecombined with IORT.
The median operative time was 4.5 hours (range 4 – 6hours). The histopathological results were demonstrated in (Table. 3). Theaverage postoperative hospital stay was 13.5 days (range 10– 17 days).
Allpatient tolerated the procedure without in-hospital morbidity or mortality. Nopatient received neoadjuvant chemotherapy. Only 4 patients receivedpostoperative chemotherapy. Follow up was done every 3 months for the first 2years then every 6 months for the next 2 years then annually. It includedlaboratory investigations, tumor markers, and CT scan of the chest and abdomento rule out any tumor recurrence.
Two patients diedduring the follow up period. Both patientswere diagnosed to have pancreatic cancer and in addition to surgery and IORT,they received postoperative chemotherapy. The patient who had unresectabletumor survived about 14 months and died from the progression of the disease andliver metastases. The other patient survivedabout 17 months. This patient had recurrent parathyroid cancer that wasoperated twice before presentation. He developed lung metastases after hisoperation which was proved by biopsy to be metastases from the parathyroidcancer.
This patient received postoperative chemotherapy. The remaining4 patients are still surviving with overall free survival rate 66.6%. They areon regular follow up. They have no tumor recurrence.
The period of follow up rangefrom 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 fromthe radiation machine to the affected area with tumor residual after theresection or debulking of the tumor. This beam will have direct access to theaffected areas in concentrated dose. This procedure guarantee theadministration of high doses of radiation to the affected areas. This increasesthe chance of killing the tumor cells remaining after surgical resection. The nearbyorgans and tissues can be shielded or taken away from the radiation beam whichdecreases the risk of radiation complications on these organs (11). The earlierstudies that evaluated the effect of the application IORT on the patients withlocally advanced diseases or who have residual diseases concluded that it is ofgreat effect. This effect includes the control of the residual tumor itself andalso maximizes the period for tumor recurrence (12, 13).
Theseresults also can go in accordance with the patients with resectable pancreaticand periampullary adenocarcinoma. In cases of locally advanced tumors which arebeyond complete surgical resection, IORT still has the advantages ofcontrolling the disease locally to decrease its local effect and minimizingtumor pain resulting from neural plexus infiltration (14). Most of the studies that recorded the effect of IORTapplication for the patients who have pancreatic or periampullary cancer andwho had complete surgical resection are retrospective studies (15-18). Also many studieshave recorded the results in patients who have complete resection combined withIORT and who had complete resection alone (4). They concludedthat the application of IORT reduces the disease recurrence. (4). Zerbi et al.
(15) studied theeffect of the application of IORT on patients after complete tumor resection andcompared them with patients who had complete tumor resection alone and theyfound IORT application will not add for postoperative patient morbidity andmortality. Also, the tumor recurrence was only 26% in the group of patients whoreceived the IORT compared with 56% in the group who had complete resectionalone. Another group conducted the study on 2 groups of patients. The firstgroup included 127 patients and had complete resection of the tumor with the applicationof IORT and the second group include 76 patients who had complete tumorresection alone.
They concluded that there is no difference between the 2groups regarding the postoperative morbidity and mortality due to theapplication of IORT. They also found that the delay in the local recurrence significantlyin the group of IORT application especially in patients who have earlier stagesof the tumor (16). Theseresults also proved by more recent studies (17, 18). After the review of the histopathology of ourpatients with pancreatic and periampullary cancer and the affection of the localizedtissues and lymph nodes and also after the review of the related literature, westarted to apply IORT as part of the management of pancreatic and periampullarycancers. The initial results from our center prove the benefit of theapplication of IORT as a part of the management of theses tumors. Conclusion: IORT is a feasible and safe procedure.
The patient cantolerate it well as it did not affect the postoperative course regarding postoperativecomplications and operative related mortalities. Our preliminary results are favorable.In order to have a rigid recommendation for the application of IORT, the study needslarger number of patients with long period of follow up.