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TitleIntraoperative Irradiation: Techniques and Results
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Page 2

INTRAOPERATIVE IRRADIATION

Page 279

266 Willett et al.

c
100

80

60
L.,

L---------------------
Preop EBRT + 5-FU (n = 29)

40 Postop EBRT + 5-FU (n = 9)

20 P=0.30

0
% OVERALL SURVIVAL VS TREATMENT SEQUENCE

100 ,..-r-----.

80
-, ----,

60
L,
-----1

40 l-.,

20 P=0.003 ~--------------
0

0 2 3 4 5
Years

D
100 DISEASE-FREE SR VS SITE OF PRIMARY

80
-,

Colon (n 18)

60

40

.. _i
~----.

•----1 Rectum (n = 38)
______ , ______ _

L---~----------------
20 P=0.009

%
0

100 - ----.__t?_VERALL SR VS SITE OF PRIMARY

80

60

40

--i __ .. ____ •

--i ________ ,__. ____ ,

·------------·
20 p =0.10

0
0 2 3 4 5

Years

Fig. 5. (continued)

presumed treatment-related grade 2 (usually pain requiring narcotics) or grade 3 nerve
toxicity, the data suggested a relationship between IOERT dose and the incidence of
grade 2 or 3 neuropathy (:::;12.5 Gy: 1 of29 or 3%; ~15 Gy: 6 of26 or 23%,p = 0.03). The
relative incidence of grade 3 neuropathy by IOERT dose for 57 fields in 55 evaluable
patients was 0 of 29 for :::;12.5 Gy, 1 of 19 (5%) for 15 or 17.5 Gy and 2 of 9 (22%)
for 20 Gy.

The incidence of other treatment -related side effects including ureter is seen in Table 9.
The IOERT boost field encompassed 10 ureters in 9 of the 56 patients (solitary ureter:
8 patients, bilateral ureters: 1 patient). Subsequent ureteral narrowing with hydroneph-
rosis (grade 2) or obstruction requiring a stent (grade 3) occurred in five patients who had
a ureter within IOERT fields (five of nine-56%) and in five patients in whom the ureter
was not included in the field (includes one patient with bilateral ureteral obstruction: one

Page 280

Primary Colorectal EBRT and IOERT 267

Table 7
Primary Colorectal IOERT: Impact of Treatment

and Disease Prognostic Factors on Disease Relapse, Mayo Analysis

Local Relapse
(EBRT) (%) Distant Metastases(%)

#at 3and
Prognostic Factor Risk No.(%) 5 yr pa No.(%) 3 yr 5 yr p

EBRT +1- 5-FU (n = 56)
EBRT+5-FU 39 4 (10) 11 0.54 14 (36) 35 41 0.013
EBRT 17 3 (18) 24 13 (77) 66 83

Treatment sequence (n = 38)
Preop EBRT+5-FUb 29 4 (14) 14 10 (35) 32 39 0.18
Postop EBRT +5-FU 9 0 0 0.37 4 (44) 53 53

Site of Primary (n = 56)
Colon 18 1 (6) 6 0.20 5 (28) 29 29 0.03
Rectum 38 6 (16) 21 22 (58) 53 75

Grade (n = 56)c
1,2 27 2 (7) 4 0.09 15 (56) 43 43 0.83
3,4 29 5 (17) 32 12 (41) 45 45

Nodal status (n =51, unk- 5)
Negative 24 1 (4) 4 0.11 12 (50) 50 62 0.95
Positive 27 5 (19) 23 14 (52) 48 63

Total group 56 7 (13) 16 27 (48) 45 59

a Log rank p value.
b Central failure in IOERT field occurred in only 1 patient (preoperative EBRT + 5-FU, rectal, no resection).
cTime to relapse by grade: grade 2 LFrange 1.0-5.5 yr, DFrange 0.5-5.5 yr, grade 3 allLFby 3 yr, DFby 1.5

yr; grade 4 all LF by 2 yr, DF by 1.5 yrs.
EBRT =external beam irradiation; IOERT intraoperative electron irradiation; LF =local failure in EBRT field;

DF =distant failure, 5-FU = 5-Fluorouracil, unk =unknown. Modified from ref 21.

ureter was within the IOERT field, the other was surgically dissected). Pelvic relapse was
the probable cause of ureteral obstruction in only one patient.

5.4. MD Anderson IOERT Series
In the MD Anderson study, 11 of 38 patients (29%) with primary locally advanced

rectal cancer received IOERT to high-risk regions in the pelvis because of persistent
tumor adherence or residual tumor following preoperative irradiation and infusional
chemotherapy ( 13 ). No local failures were seen in these patients although 7 of 11 patients
developed distant metastases. One patient developed a sensory neuropathy following 20
GyofiOERT.

5.5. Pamplona IOERT Series

In Europe, the Pamplona group has been investigating IOERT in a variety of disease
sites, including rectal cancer (26). From March, 1986 to October, 1993,59 patients with
primary locally rectal cancer received IOERT as a treatment component in multimodal
strategies including surgery and postoperative EBRT (13 patients, group I) or preopera-
tive chemoirradiation followed by planned surgery ( 46 patients, group II). Pelvic recur-
rence has been identified in only one patient (simultaneously with lung and liver

Page 557

550

Trunk sarcoma, see Extremity and trunk soft
tissue sarcomas

Tumor control, see Local tumor control; Metastasis;
specific cancers

Tumor necrosis factor (TNF), expression effects
on radiation sensitivity, 40

u
Ureter, tolerance,

American foxhound tolerance to intraoperative
electron-beam irradiation, 140

beagle studies,
external beam irradiation alone, 153
intraoperative electron-beam irradiation

with or without external beam
irradiation, 153, 154

human tolerance to intraoperative electron-beam
irradiation, 155,266,267,291,433,434

volume effects of intraoperative electron-
beam irradiation, 155, 161, 162

Index

Uterine cancer, see Gynecologic cancer

v
Vascular complications, fractionation effect,

30-32
Vena cava, tolerance,

w

American foxhound tolerance to intraopera-
tive electron-beam irradiation, 138, 139

beagle studies, 148, 149

Wilm's tumor, intraoperative irradiation,
intraoperative electron-beam

irradiation, 461
rationale, 457
surgery, 459
treatment factors, 458, 459

Page 558

ERRATA

INTRAOPERATIVE IRRADIATION: TECHNIQUES AND RESULTS

The following is the corrected portion of the Dedication to this volume. In addition, Christopher G. Willett's name was misspelled
on the cover and title page.

To my wife (Mary Sunday), children (Elizabeth, Julian, and Andrew), and parents (Alice and Bernard)
for their love and support,

To Herman D. Suit, physician, scientist and mentor,
whose wisdom and insight have improved the care of tire cancer patient.

Christopher G. Willett

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