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Cancers
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Intraoperative Radiation Therapy in the Treatment of Cancer
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Intraoperative Radiation Therapy in the Treatment of Cancer

A special issue of Cancers (ISSN 2072-6694). This special issue belongs to the section "Cancer Therapy".

Deadline for manuscript submissions: closed (31 May 2022) | Viewed by 10421

Special Issue Editor

Dr. Renzo Mazzarotto

E-Mail Website
Guest Editor
Department of Radiotherapy, Verona University Hospital, Piazzale A. Stefani, 1-37126 Verona, Italy
Interests: external beam radiation therapy; intraoperative radiation therapy; pancreatic cancer; breast cancer; brain cancer; prostate cancer; stereotactic body radiation therapy (SBRT)
Special Issues, Collections and Topics in MDPI journals

Special Issue Information

Dear Colleagues,

Intraoperative Radiation Therapy (IORT) has a long history in cancer treatment and became part of the armamentarium of radiation oncologists more than a century ago. Given the possibility of directly irradiating the tumour mass/tumour bed under direct visualization, IORT increases treatment accuracy. Furthermore, during surgery, it is possible to displace or shield normal tissue, thus reducing toxicity. The biologic effect of the large dose delivered during surgery is considered to be 2–3 times higher than the same doses delivered with a standard dose/fraction treatment, thus allowing dose escalation with the aim of improving local control, particularly if associated with external beam radiotherapy.

Over recent decades, the development of mobile radiation generating machines, located in shielded operating rooms, made this procedure much easier to perform, obviating the need for patient transferral to the radiotherapy department.

Breast cancer, intra-abdominal cancers, soft tissue sarcomas and many other cancer sites can be treated with IORT.

This Special Issue will focus on the most important experiences with this radiotherapy technique at different cancer sites and debate the possible future developments of this radiotherapy modality.

Dr. Renzo Mazzarotto
Guest Editor

Manuscript Submission Information

Manuscripts should be submitted online at www.mdpi.com by registering and logging in to this website. Once you are registered, click here to go to the submission form. Manuscripts can be submitted until the deadline. All submissions that pass pre-check are peer-reviewed. Accepted papers will be published continuously in the journal (as soon as accepted) and will be listed together on the special issue website. Research articles, review articles as well as short communications are invited. For planned papers, a title and short abstract (about 100 words) can be sent to the Editorial Office for announcement on this website.

Submitted manuscripts should not have been published previously, nor be under consideration for publication elsewhere (except conference proceedings papers). All manuscripts are thoroughly refereed through a single-blind peer-review process. A guide for authors and other relevant information for submission of manuscripts is available on the Instructions for Authors page. Cancers is an international peer-reviewed open access semimonthly journal published by MDPI.

Please visit the Instructions for Authors page before submitting a manuscript. The Article Processing Charge (APC) for publication in this open access journal is 2900 CHF (Swiss Francs). Submitted papers should be well formatted and use good English. Authors may use MDPI's English editing service prior to publication or during author revisions.

Keywords

  • Intraoperative Radiation Therapy (IORT)
  • radiation techniques
  • high-dose radiation therapy
  • local control
  • normal tissues
  • side effect
  • breast cancer
  • pancreatic cancer
  • gynecologic cancer
  • rectal cancer

Published Papers (5 papers)

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Research

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13 pages, 1195 KiB  
Article
Early Outcome, Cosmetic Result and Tolerability of an IOERT-Boost Prior to Adjuvant Whole-Breast Irradiation
by Danny Jazmati, Edwin Bölke, Kati Halfmann, Bálint Tamaskovics, Eugen Ruckhäberle, Tanja Fehm, Jürgen Hoffmann, David Krug, Carolin Nestle Krämling, Stefanie Corradini, Wilfried Budach, Svjetlana Mohrmann, Jan Haussmann and Christiane Matuschek
Cancers 2022, 14(15), 3636; https://doi.org/10.3390/cancers14153636 - 26 Jul 2022
Cited by 2 | Viewed by 1559
Abstract
Background/Aims: Due to its favorable dose distribution and targeting of the region at highest risk of recurrence due to direct visualization of tumor bed, intraoperative electron radiation therapy (IOERT) is used as part of a breast-conserving treatment approach. The aim of this [...] Read more.
Background/Aims: Due to its favorable dose distribution and targeting of the region at highest risk of recurrence due to direct visualization of tumor bed, intraoperative electron radiation therapy (IOERT) is used as part of a breast-conserving treatment approach. The aim of this study was to analyze tumor control and survival, as well as the toxicity profile, and cosmetic outcomes in patients irradiated with an IOERT boost for breast cancer. Materials and Methods: 139 Patients treated at our institution between January 2010 and January 2015 with a single boost dose of 10 Gy to the tumor bed during breast-conserving surgery followed by whole-breast irradiation were retrospectively analyzed. Results: 139 patients were included in this analysis. The median age was 54 years (range 28–83 years). The preferred surgical strategy was segmental resection with sentinel lymphonodectomy (66.5%) or axillary dissection (23.1%). Regarding adjuvant radiotherapy, the vast majority received 5 × 1.8 Gy to 50.4 Gy. At a median follow-up of 33.6 months, recurrence-free and overall survival were 95.5% and 94.9%, respectively. No patient developed an in-field recurrence. Seven patients (5.0%) died during the follow-up period, including two patients due to disease recurrence (non-in-field). High-grade (CTCAE > 2) perioperative adverse events attributable to IOERT included wound healing disorder (N = 1) and hematoma (N = 1). High-grade late adverse events (LENT-SOMA grade III) were reported only in one patient with fat necrosis. Low-grade late adverse events (LENT-SOMA grade I-II) included pain (18.0%), edema (10.5%), fibrosis (21%), telangiectasia (4.5%) and pigmentation change (23.0%). The mean breast retraction assessment score was 1.66 (0–6). Both patients and specialists rated the cosmetic result “excellent/good” in 84.8% and 87.9%, respectively. Conclusion: Our study reports favorable data on the cosmetic outcome as well as the acute and early long-term tolerability for patients treated with an IOERT boost. Our oncologic control rates are comparable to the previous literature. However, prospective investigations on the role of IOERT in comparison to other boost procedures would be desirable. Full article
(This article belongs to the Special Issue Intraoperative Radiation Therapy in the Treatment of Cancer)
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14 pages, 1078 KiB  
Article
Hypofractionated Whole Breast Irradiation and Boost-IOERT in Early Stage Breast Cancer (HIOB): First Clinical Results of a Prospective Multicenter Trial (NCT01343459)
by Gerd Fastner, Roland Reitsamer, Christoph Gaisberger, Wolfgang Hitzl, Bartosz Urbański, Dawid Murawa, Christiane Matuschek, Wilfried Budach, Antonella Ciabattoni, Juliann Reiland, Marie Molnar, Cristiana Vidali, Claudia Schumacher, Felix Sedlmayer and on behalf of the HIOB Trialist Group
Cancers 2022, 14(6), 1396; https://doi.org/10.3390/cancers14061396 - 09 Mar 2022
Cited by 4 | Viewed by 2223
Abstract
Background and purpose: To investigate intraoperative electron radiation therapy (IOERT) as a tumor bed boost during breast conserving surgery (BCS) followed by hypofractionated whole breast irradiation (HWBI) on age-correlated in-breast recurrence (IBR) rates in patients with low- to high-risk invasive breast cancer. Material [...] Read more.
Background and purpose: To investigate intraoperative electron radiation therapy (IOERT) as a tumor bed boost during breast conserving surgery (BCS) followed by hypofractionated whole breast irradiation (HWBI) on age-correlated in-breast recurrence (IBR) rates in patients with low- to high-risk invasive breast cancer. Material and methods: BCS and IOERT (11.1 Gy) preceded a HWBI (40.5 Gy) in 15 fractions. Five-year IBR-rates were compared by a sequential ratio test (SQRT) with best evidences in three age groups (35–40 y and 41–50 y: 3.6%, >50 y: 2%) in a prospective single arm design. Null hypothesis (H0) was defined to undershoot these benchmarks for proof of superiority. Results: Of 1445 enrolled patients, 326 met exclusion criteria, leaving 1119 as eligible for analysis. After a median follow-up of 50 months (range 0.7–104), we detected two local recurrences, both in the age group >50 y. With no observed IBR, superiority was demonstrated for the patient groups 41–50 and >50 y, respectively. For the youngest group (35–40 y), no appropriate statistical evaluation was yet possible due to insufficient recruitment. Conclusions: In terms of five-year IBR-rates, Boost-IOERT followed by HWBI has been demonstrated to be superior in patients older than 50 and in the age group 41–50 when compared to best published evidence until 2010. Full article
(This article belongs to the Special Issue Intraoperative Radiation Therapy in the Treatment of Cancer)
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14 pages, 500 KiB  
Article
Intra-Operative Electron Radiation Therapy (IOERT) Anticipated Boost in Breast Cancer Treatment: An Italian Multicenter Experience
by Antonella Ciabattoni, Fabiana Gregucci, Karen Llange, Marina Alessandro, Francesca Corazzi, Giovanni B. Ivaldi, Paola Zuccoli, Antonio Stefanelli, Agostino Cristaudo, Vincenzo Fusco, Loredana Lapadula, Alba Fiorentino, Daniela Di Cristino, Francesca Salerno, Marco Lioce, Marco Krengli and Cristiana Vidali
Cancers 2022, 14(2), 292; https://doi.org/10.3390/cancers14020292 - 07 Jan 2022
Cited by 9 | Viewed by 2265
Abstract
In breast cancer, the use of a boost to the tumor bed can improve local control. The aim of this research is to evaluate the safety and efficacy of the boost with intra-operative electron radiotherapy (IOERT) in patients with early-stage breast cancer undergoing [...] Read more.
In breast cancer, the use of a boost to the tumor bed can improve local control. The aim of this research is to evaluate the safety and efficacy of the boost with intra-operative electron radiotherapy (IOERT) in patients with early-stage breast cancer undergoing conservative surgery and postoperative whole breast irradiation (WBI). The present retrospective multicenter large data were collected between January 2011 and March 2018 in 8 Italian Radiation Oncology Departments. Acute and late toxicity, objective (obj) and subjective (subj) cosmetic outcomes, in-field local control (LC), out-field LC, disease-free survival (DFS) and overall survival (OS) were evaluated. Overall, 797 patients were enrolled. IOERT-boost was performed in all patients during surgery, followed by WBI. Acute toxicity (≥G2) occurred in 179 patients (22.46%); one patient developed surgical wound infection (G3). No patients reported late toxicity ≥ G2. Obj-cosmetic result was excellent in 45%, good in 35%, fair in 20% and poor in 0% of cases. Subj-cosmetic result was excellent in 10%, good in 20%, fair in 69% and poor in 0.3% of cases. Median follow-up was 57 months (range 12–109 months). At 5 years, in-field LC was 99.2% (95% CI: 98–99.7); out-field LC 98.9% (95% CI: 97.4–99.6); DFS 96.2% (95% CI: 94.2–97.6); OS 98.6% (95% CI: 97.2–99.3). In conclusion, IOERT-boost appears to be safe, providing excellent local control for early-stage breast cancer. The safety and long-term efficacy should encourage use of this treatment, with the potential to reduce local recurrence. Full article
(This article belongs to the Special Issue Intraoperative Radiation Therapy in the Treatment of Cancer)
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Review

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10 pages, 1322 KiB  
Review
Intra-Operative Electron Radiation Therapy: An Update of the Evidence Collected in 40 Years to Search for Models for Electron-FLASH Studies
by Felipe A. Calvo, Javier Serrano, Mauricio Cambeiro, Javier Aristu, Jose Manuel Asencio, Isabel Rubio, Jose Miguel Delgado, Carlos Ferrer, Manuel Desco and Javier Pascau
Cancers 2022, 14(15), 3693; https://doi.org/10.3390/cancers14153693 - 29 Jul 2022
Cited by 6 | Viewed by 2179
Abstract
Introduction: The clinical practice and outcome results of intraoperative electron radiation therapy (IOeRT) in cancer patients have been extensively reported over 4 decades. Electron beams can be delivered in the promising FLASH dose rate. Methods and Materials: Several cancer models were approached by [...] Read more.
Introduction: The clinical practice and outcome results of intraoperative electron radiation therapy (IOeRT) in cancer patients have been extensively reported over 4 decades. Electron beams can be delivered in the promising FLASH dose rate. Methods and Materials: Several cancer models were approached by two alternative radiobiological strategies to optimize local cancer control: boost versus exclusive IOeRT. Clinical outcomes are revisited via a bibliometric search performed for the elaboration of ESTRO/ACROP IORT guidelines. Results: In the period 1982 to 2020, a total of 19,148 patients were registered in 116 publications concerning soft tissue sarcomas (9% of patients), unresected and borderline-resected pancreatic cancer (22%), locally recurrent and locally advanced rectal cancer (22%), and breast cancer (45%). Clinical outcomes following IOeRT doses in the range of 10 to 25 Gy (with or without external beam fractionated radiation therapy) show a wide range of local control from 40 to 100% depending upon cancer site, histology, stage, and treatment intensity. Constraints for normal tissue tolerance are important to maintain tumor control combined with acceptable levels of side effects. Conclusions: IOeRT represents an evidence-based approach for several tumor types. A specific risk analysis for local recurrences supports the identification of cancer models that are candidates for FLASH studies. Full article
(This article belongs to the Special Issue Intraoperative Radiation Therapy in the Treatment of Cancer)
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Other

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6 pages, 227 KiB  
Opinion
Treatment Planning in Intraoperative Radiation Therapy (IORT): Where Should We Go?
by Carlo Cavedon and Renzo Mazzarotto
Cancers 2022, 14(14), 3532; https://doi.org/10.3390/cancers14143532 - 20 Jul 2022
Cited by 3 | Viewed by 1375
Abstract
As opposed to external beam radiation therapy (EBRT), treatment planning systems (TPS) dedicated to intraoperative radiation therapy (IORT) were not subject to radical modifications in the last two decades. However, new treatment regimens such as ultrahigh dose rates and combination with multiple treatment [...] Read more.
As opposed to external beam radiation therapy (EBRT), treatment planning systems (TPS) dedicated to intraoperative radiation therapy (IORT) were not subject to radical modifications in the last two decades. However, new treatment regimens such as ultrahigh dose rates and combination with multiple treatment modalities, as well as the prospected availability of dedicated in-room imaging, call for important new features in the next generation of treatment planning systems in IORT. Dosimetric accuracy should be guaranteed by means of advanced dose calculation algorithms, capable of modelling complex scattering phenomena and accounting for the non-tissue equivalent materials used to shape and compensate electron beams. Kilovoltage X-ray based IORT also presents special needs, including the correct description of extremely steep dose gradients and the accurate simulation of applicators. TPSs dedicated to IORT should also allow real-time imaging to be used for treatment adaptation at the time of irradiation. Other features implemented in TPSs should include deformable registration and capability of radiobiological planning, especially if unconventional irradiation schemes are used. Finally, patient safety requires that the multiple features be integrated in a comprehensive system in order to facilitate control of the whole process. Full article
(This article belongs to the Special Issue Intraoperative Radiation Therapy in the Treatment of Cancer)
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