Results: residual cells remaining after tumor resection. The unaffected

Results:

This study was applied for 6 patients. Their median age
was 60 year (range 50-71). They were four males and two females. Their tumor
were 3 pancreatic cancer, two ampullary cancer and one had its tumor originates
from the duodenum. Five of them had surgical removal of their tumors with the
addition of IORT. The sixth patient was found to have advanced advanced tumor
and bypass operation was performed in addition to IORT. The median of the operative
time was 4.5 hours (range 4- 6 hours). The histopathological results were
demonstrated in (Table. 3). The postoperative hospital stay showed an average
of 13.5 days (range 10– 17 days). All patients tolerated the procedure without
in-hospital morbidity and/or mortality. No patient had received preoperative
chemotherapy. Only 4 patients had postoperative chemotherapy. All patients had regular
follow up. During the follow up visit, all patients had physical examination, complete
laboratory tests with tumor markers and CT scan. This occured every 3 months
for the first 2 years then every 6 months for the next 2 years then annually.

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Two patients died.
Both patients had pancreatic cancer.  The type of treatment they offered was
surgical removal of their tumors plus IORT. They both received postoperative
chemotherapy. The first patient was presented late with advanced disease which
was difficult to resect. The cause of death in this patient is rapid progression
of his disease locally and to other organs. He died after 1 year and 2 months
of follow up. The second patient developed lung metastases from recurrent
parathyroid cancer which led to his death. He died after 1 year and 5 months of
follow up 17 months of follow up.

The remaining
4 patients are still surviving with overall free survival rate 66.6%. Up till
now they developed no sign of recurrence of their tumors. The follow up period showed
a median of 18 months (range 6-41).

Discussion:

IORT was applied since more than 4 decades. It was
discovered in Japan. It can be used in the treatment of patients who had difficult
tumor resection or who had some remaining tumors after resection or who had
advanced unresectable tumors (10). The idea is to permit the passage of radiation beam from
the machine to the residual tumor after incomplete resection. In cases of
surgically removed tumors, it can be directed to the tumor bed. The application
of the radiation beam in a relatively higher amounts to the affected or
potentially affected areas will increase the chance of destroying the residual
cells remaining after tumor resection. The unaffected organs must be taken away
by lead bars which decreases the radiation effect on these organs (11).  The effect of IORT on advanced tumors and
residual tumor after surgical removal was studied by many authors. They
concluded that it is effective on the tumor cells the remains after incomplete
resection and moreover it reduces the incidence of tumor recurrence (12, 13). This was also
studied on patients with resectable pancreatic and periampullary tumors (14). On the other hand, in the cases of unresectable tumors,
IORT can still have a benefit in controlling the local effect of the tumor and decreases
it local effects on the nearby organs and nerves tissues thus decreases the
associated pain (14).

The assessment of IORT and its effect on patients
suffering from pancreatic or periampullary cancer was studied in many
retrospective studies (15-18). Also the
evaluation of surgical resection of the tumor with and without the combination
with IORT was studied (4). They reported that IORT reduces the incidence of tumor
recurrence (4). A different study had evaluated the effect of the
application or non-application of IORT after tumor resection. The final
conclusion showed that IORT is safe and will not add to operative and postoperative
risks of the patients. With regards the recurrence of the resected tumor,  IORT reduced the incidence of tumor
recurrence significantly (15)  Another group
compared the role of IORT when added to the surgical resection. Their results
showed that IORT application reduced tumor recurrence in the studied patients especially
in early stage tumors. (16). Recent
reports from other centers showed similar results (17, 18).  The pathological data of patients who had the
same tumors and resected in our center without the addition of IORT were
reviewed. It was found that the draining lymph nodes were always invaded with
tumor cells. IORT was added as a routine our center in the treatment of
pancreatic cancer and periampullary cancer. Our preliminary supports the use of
IORT application which added much in the treatment of these tumors.

Conclusion:

Adding IORT as a part of management of pancreatic and periampullary
tumors will not increase the patient risks. It did not affect the postoperative
course of the patient regarding morbidity and operative related mortality. Our preliminary
results are favorable but it should be evaluated on more patients with long
follow up periods.