Table Of ContentIntraoperative Irradiation
Second edition
Current Clinical Oncology
Maurie Markman, MD, Series Editor
For other titles published in this series, go to
http://www.springer.com/series/7631
Leonard L. Gunderson Christopher G. Willett
•
Felipe A. Calvo Louis B. Harrison
•
editors
Intraoperative Irradiation
Techniques and Results
Second edition
Editors
Leonard L. Gunderson, M.D., M.S., FASTRo Felipe A. Calvo, M.D.
Department of Radiation oncology Department of oncology
Mayo Clinic College of Medicine and Hospital Gregorio Maranón
Mayo Clinic Arizona, Madrid, Spain
Scottsdale, AZ USA [email protected]
[email protected]
Louis B. Harrison, M.D., FASTRo
Christopher G. Willett, M.D. Department of Radiation oncology
Department of Radiation oncology Continuum Cancer Centers of New York
Duke University Medical Center Beth Israel Medical Center, St Luke’s and
Durham, NC Roosevelt Hospitals, Albert einstein College
USA of Medicine, New York, NY USA
[email protected] [email protected]
ISBN 978-1-61779-014-0 e-ISBN 978-1-61779-015-7
DoI 10.1007/978-1-61779-015-7
Springer New York Dordrecht Heidelberg London
Library of Congress Control Number: 2011924474
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To Katheryn, my wife and best friend, to our children and their spouses (Chad and Chrissy, Whitney
and Jeff, Stacie and Nick, Ryan and Danna, Scott and Cindy) and to our grandchildren (Olivia and
Adam; Rebecca, Andrew, Katie and Matthew; Sam, Anna, Michael and Ellie; Grant; Landon and
Parker) for their love and support
To colleagues in Surgery, Medical Oncology, and Radiation Oncology for the opportunity to work
together as a team in the delivery of multimodality treatment, including IORT, for our patients with
cancer
Leonard L. Gunderson
To Mary Sunday for 25 years of love and support
Christopher G. Willett
To my family: wife Marta and children Almudena, Marta, Maria, Covadonga, Felipe-Angel, Sonsoles,
Francisco and Paloma; beloved parents Lucia and Felipe, brother Elpidio and sister Tuti; my first
love, the school of values in which I learned to understand and serve society
To my teachers, especially Dr Jose Otero and Professor Luther W Brady, with deep gratitude for the
privilege of their superb and caring education
To colleagues and institutions involved in IORT procedures during the last three decades for their
outstanding and generous commitment to excellence in cancer medicine.
Felipe A. Calvo
To my 6 favorite kids, my 2 daughters, 3 nephews and 1 niece: Barbara Harrison, Michella Harrison,
Alan Levy, Ryan Farago, Lance Levy and Sophia Levy. I love all of them and have been lucky to have
them in my life.
Louis B. Harrison
Preface
Intraoperative Irradiation: Techniques and Results, Second Edition is a comprehensive textbook on
intraoperative irradiation therapy (IoRT) that covers topics of interest to those who have intraopera-
tive electron radiation therapy (IoeRT), high-dose-rate brachytherapy (HDR-IoRT) or electronic
brachytherapy/low KV IoRT capabilities. Issues of basic science and physics are covered in addi-
tion to techniques, indications, and results by disease-site. Most disease-site chapters have multina-
tional and multidisciplinary authorship that includes both radiation oncologists and surgeons, which
provides a more balanced presentation of techniques and results by disease-site.
The rationale for using IoRT as a component of treatment is based on the realization that tolerable
doses of external beam radiation therapy (eBRT) are often insufficient to achieve local control of
locally advanced abdominal or pelvic malignancies, even with 3-D conformal or intensity-modulated
radiation techniques (3-D CRT; IMRT). A preferred treatment approach is to deliver preoperative
eBRT of 45–54 Gy in 1.8–2 Gy fractions, often in conjunction with concurrent chemotherapy,
followed by maximal surgical resection and IoRT. The IoRT component of treatment becomes the
optimal conformal technique of irradiation, since dose-limiting organs or structures can either be
surgically displaced (stomach, small intestine, liver, etc.) or protected by surgical placement of lead
shielding or by proper selection of electron energy.
The textbook is again divided into five major sections. The book begins with chapters on the
general rationale for and historical perspectives of IoRT and the radiobiology of IoRT. It then pro-
ceeds to a discussion of methods and techniques of treatment and a presentation of normal tissue
and organ tolerance to IoRT. In the methods and techniques section, a new chapter is included on
“electronic Brachytherapy/Low KV IoRT: Physics and Techniques” which is a possible alternative
IoRT treatment approach. The tolerance chapter is essential reading for any individual or institution
contemplating a program in IoRT; the implications of tolerance are far-reaching both for the
patients who receive IoRT as a component of treatment and the physicians who deliver the IoRT.
The largest section of the text is the presentation of techniques and results by disease-site which
includes outcomes data on disease control, survival, and treatment tolerance. outcomes with non-
IoRT treatment approaches are compared with those using IoRT-containing regimens in many of
the chapters. The closing section is a chapter on conclusions and future possibilities that was written
by the four coeditors of the textbook.
one of the conclusions of the closing chapter is that long-term experience has shown that the use
of IoRT as a component of treatment in conjunction with other modalities (eBRT, concurrent and
maintenance chemotherapy, maximal surgical resection) is feasible and practical if close multidis-
ciplinary cooperation exists. In addition, the IoRT-containing, multimodality regimens appear to
improve local disease control, if not survival, in many disease-sites when compared with non-IoRT
treatment approaches. For patients in whom gross total resection of their cancer is not safely fea-
sible, the ability to achieve central or local control is lessened, thus creating the need for prospective
clinical trials that address the addition of radiation dose modifiers during both eBRT and IoRT.
vii
viii Preface
Patients with locally advanced or locally recurrent cancers who are candidates for IoRT containing
regimens often have high systemic risks as well. Prospective trials that address the addition of
aggressive systemic therapy to the locally aggressive combined treatment are also necessary. The
closing chapter also addresses improvements in technology that make IoRT more feasible in a
larger number of institutions and thus facilitate the conduct of prospective trials in a multi-institu-
tion national or international setting. This technology includes mobile IoeRT equipment (Mobetron,
Novac-7, LIAC), HDR brachytherapy, and electronic brachytherapy/low-KV equipment that can be
used in either an outpatient or operating room setting.
The four coeditors have personally been involved in utilizing IoRT as a component of treatment
in the care of thousands of patients in a multispecialty, multimodality setting. We are therefore
delighted that IoRT is becoming available to more physicians and patients worldwide as a result of
the changes in technology that are discussed in Intraoperative Irradiation: Techniques and Results,
Second Edition.
Scottsdale, AZ, USA Leonard L. Gunderson, M.D., M.S., FASTRo
Durham, NC, USA Christopher G. Willett, M.D.
Madrid, Spain Felipe A. Calvo, M.D.
New York, NY, USA Louis B. Harrison, M.D., FASTRo
Contents
Part I General Rationale and Historical Perspective
1 Rationale and Historical Perspective of Intraoperative Irradiation ............................. 3
Leonard L. Gunderson, Felipe A. Calvo, Christopher G. Willett,
and Louis B. Harrison
2 Biology of Large Dose per Fraction Irradiation ............................................................. 27
Paul okunieff, Srinath Sundararaman, Su Metcalfe, and Yuhchyau Chen
Part II Methods and Techniques of Treatment
3 Intraoperative Electron Beam Irradiation: Physics and Techniques ............................ 51
Peter Biggs, Christopher G. Willett, Harm Rutten, Mario Ciocca,
Leonard L. Gunderson, and Felipe A. Calvo
4 HDR-IORT: Physics and Techniques ............................................................................... 73
eli e. Furhang, Jussi K. Sillanpaa, Kenneth S. Hu, and Louis B. Harrison
5 Electronic Brachytherapy/Low KV-IORT: Physics and Techniques ............................ 85
Uta Kraus-Tiefenbacher, Peter Biggs, Jayant Vaidya, and Dario Francescatti
6 IORT with Electron-Beam, High-Dose-Rate Brachytherapy
or Low-KV/Electronic Brachytherapy: Methodological Comparisons ........................ 99
Subir Nag, Christopher G. Willett, Leonard L. Gunderson, Louis B. Harrison,
Felipe A. Calvo, and Peter Biggs
Part III Normal Tissue Tolerance – IORT
7 Normal-Tissue Tolerance to IOERT, EBRT, or Both: Animal
and Clinical Studies ........................................................................................................... 119
Zeljko Vujaskovic, Christopher G. Willett, Joel e. Tepper, Timothy J. Kinsella,
and Leonard L. Gunderson
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