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Tiwari A, Lee SL, MacCabe T, Woyton M, West CT, Micklethwaite R, Yano H, West MA, Mirnezami AH. Intraoperative electron radiotherapy (IOERT) in colorectal cancer: Updated systematic review of techniques, oncological outcomes and complications. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2025; 51:109724. [PMID: 40022886 DOI: 10.1016/j.ejso.2025.109724] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2024] [Revised: 02/11/2025] [Accepted: 02/22/2025] [Indexed: 03/04/2025]
Abstract
BACKGROUND Intra-operative electron radiotherapy (IOERT) directly delivers a large fraction of radiation to at-risk margins during surgery. However, the precise benefit of IOERT in patients with locally advanced and locally recurrent colorectal cancer (LACC/LRCC) is unclear. This study aimed to provide an updated summary of the current evidence available regarding IOERT as part of multi-modality treatment of LACC and LRCC. METHOD This systematic review update was prospectively registered on PROSPERO (CRD42023438184). An electronic literature search was carried out using Ovid (MEDLINE), EMBASE, Web of Science, and the Cochrane Library databases for studies from July 2011 to April 2024. The inclusion criteria were adult patients who received IOERT as part of multi-modal treatment for LACC or LRCC. The primary outcome was overall survival (OS), disease free survival (DFS) and local control (LC) at 5 years. Secondary outcomes included post-operative complications. RESULTS 16 new studies were identified since the previous analysis, and included (study population 1912 patients) of which two were prospective. High heterogeneity prevented meta-analysis of outcomes except for 5-year OS which suggested a non-significant benefit favouring IOERT. Significant methodological concerns were identified making interpretations challenging, however patients with LACC or LRCC with an R1 resection margin showed a favourable 5-year OS (40 % and 18 % respectively) when compared to current evidence. CONCLUSION Although limited by a lack of appropriately conducted randomised evidence, IOERT-containing multi-modality treatment may improve oncological outcomes in LACC and LRCC patients with R1 resections.
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Affiliation(s)
- Abhinav Tiwari
- Academic Surgery, Cancer Sciences, Faculty of Medicine, University of Southampton, Tremona Road, SO16 6YD, Southampton, United Kingdom.
| | - Sheah Lin Lee
- Academic Surgery, Cancer Sciences, Faculty of Medicine, University of Southampton, Tremona Road, SO16 6YD, Southampton, United Kingdom; Southampton Complex Cancer and Exenteration Team, University Hospital Southampton, Tremona Road, SO16 6YD, Southampton, United Kingdom; Centre for Cancer Immunology, Faculty of Medicine, University of Southampton, Tremona Road, SO16 6YD, Southampton, United Kingdom.
| | - Tom MacCabe
- Minimal Access Therapy Training Unit (MATTU), Royal Surrey County Hospital NHS Foundation Trust, Egerton Rd, GU2 7XX, Guildford, United Kingdom; Department of Colorectal Surgery, Royal Surrey County Hospital NHS Foundation Trust, Egerton Rd, GU2 7XX, Guildford, United Kingdom.
| | - Michal Woyton
- Southampton Complex Cancer and Exenteration Team, University Hospital Southampton, Tremona Road, SO16 6YD, Southampton, United Kingdom.
| | - Charles T West
- Academic Surgery, Cancer Sciences, Faculty of Medicine, University of Southampton, Tremona Road, SO16 6YD, Southampton, United Kingdom; Southampton Complex Cancer and Exenteration Team, University Hospital Southampton, Tremona Road, SO16 6YD, Southampton, United Kingdom.
| | - Rohan Micklethwaite
- Academic Surgery, Cancer Sciences, Faculty of Medicine, University of Southampton, Tremona Road, SO16 6YD, Southampton, United Kingdom.
| | - Hideaki Yano
- Southampton Complex Cancer and Exenteration Team, University Hospital Southampton, Tremona Road, SO16 6YD, Southampton, United Kingdom.
| | - Malcolm A West
- Academic Surgery, Cancer Sciences, Faculty of Medicine, University of Southampton, Tremona Road, SO16 6YD, Southampton, United Kingdom; Southampton Complex Cancer and Exenteration Team, University Hospital Southampton, Tremona Road, SO16 6YD, Southampton, United Kingdom; NIHR Southampton Biomedical Research Centre, Perioperative Medicine and Critical Care theme, University Hospital Southampton, Tremona Road, SO16 6YD, Southampton, United Kingdom.
| | - Alex H Mirnezami
- Academic Surgery, Cancer Sciences, Faculty of Medicine, University of Southampton, Tremona Road, SO16 6YD, Southampton, United Kingdom; Southampton Complex Cancer and Exenteration Team, University Hospital Southampton, Tremona Road, SO16 6YD, Southampton, United Kingdom; NIHR Southampton Biomedical Research Centre, Perioperative Medicine and Critical Care theme, University Hospital Southampton, Tremona Road, SO16 6YD, Southampton, United Kingdom.
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Calvo FA, Sole CV, Rutten HJ, Dries WJ, Lozano MA, Cambeiro M, Poortmans P, González-Bayón L. ESTRO/ACROP IORT recommendations for intraoperative radiation therapy in locally recurrent rectal cancer. Clin Transl Radiat Oncol 2020; 24:41-48. [PMID: 32613091 PMCID: PMC7320231 DOI: 10.1016/j.ctro.2020.06.007] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2020] [Accepted: 06/14/2020] [Indexed: 12/28/2022] Open
Abstract
Multimodal strategies have been implemented for locally recurrent rectal cancer scheduled for complete surgical resection. Irradiation and systemic therapy have been added to improve the oncological outcome, as surgery alone was associated with a poor prognosis. Intraoperative irradiation (IORT) is a component of irradiation intensification. Long-term cancer control and a higher survival rate were consistently reported in patients who had IORT as a component of their multidisciplinary treatment. The experience reported by expert IORT groups is reviewed and recommendations to guide clinical practice are explained in detail.
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Affiliation(s)
- Felipe A. Calvo
- Department of Oncology, Clínica Universidad de Navarra, Universidad de Navarra, Madrid, Spain
- School of Medicine, Complutense University, Madrid, Spain
- Institute for Sanitary Research, Hospital General Universitario Gregorio Marañón, Madrid, Spain
- Corresponding author at: Department of Oncology, Clínica Universidad de Navarra, Madrid, Spain.
| | - Claudio V. Sole
- Department of Radiation Oncology, Instituto de Radiomedicina, Santiago, Chile
- Institute for Sanitary Research, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Harm J. Rutten
- Department of Surgery, Catharina Hospital, Eindhoven, the Netherlands
- GROW: School of Oncology and Developmental Biology, University of Maastricht, Maastricht, the Netherlands
| | - Wim J. Dries
- Departments of Medical Physics and Radiotherapy, Catharina Hospital, Eindhoven, the Netherlands
| | - Miguel A. Lozano
- Department of Radiation Oncology, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Mauricio Cambeiro
- Department of Oncology, Clínica Universidad de Navarra, Universidad de Navarra, Madrid, Spain
| | - Philip Poortmans
- Department of Radiation Oncology, Institut Curie, Paris, France
- Paris Sciences & Lettres - PSL University, Paris, France
| | - Luis González-Bayón
- Institute for Sanitary Research, Hospital General Universitario Gregorio Marañón, Madrid, Spain
- Department of General Surgery, Hospital General Universitario Gregorio Marañón, Madrid, Spain
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Ma L, Qiang J, Yin H, Lin L, Jiao Y, Ma C, Li X, Dong L, Cui J, Wei D, Sharma AM, Schwartz DL, Gu W, Chen H. Low-kilovolt x-ray intraoperative radiotherapy for pT3 locally advanced colon cancer: a single-institution retrospective analysis. World J Surg Oncol 2020; 18:132. [PMID: 32552838 PMCID: PMC7301558 DOI: 10.1186/s12957-020-01903-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2020] [Accepted: 06/02/2020] [Indexed: 11/10/2022] Open
Abstract
Background Patients with locally advanced colon cancer (LACC) treated with surgery had a high risk of local recurrence. The outcomes can vary significantly among patients with pT3 disease. This study was undertaken to assess whether low-kilovolt (kV) x-ray intraoperative radiotherapy (IORT) can achieve promising results compared with electron beam IORT (IOERT) and whether specific subgroups of patients with pT3 colon cancer may benefit from low-kV x-ray IORT. Methods We retrospectively reviewed 44 patients with pT3 LACC treated with low-kV x-ray IORT. Clinicopathologic characteristics were analyzed to identify patients that could potentially benefit from low-kV x-ray IORT. The Kaplan-Meier survival analysis was used to assess overall survival (OS) and progression-free survival (PFS). Correlation analysis was used to discover the association of multiple factors to the results of treatment represented by the values of OS and PFS. Results The median follow-up of patients was 20.5 months (range, 6.1–38.8 months). At the time of analysis, 38 (86%) were alive and 6 (14%) had died of their disease. The 3-year Kaplan-Meier of PFS and OS for the entire cohort was 82.8% and 82.1%, respectively. At median follow-up, no in-field failure within the low-kV x-ray IORT field had occurred. Locoregional and distant failure had occurred in 2 (5%) patients each. The rate of perioperative 30-day mortality was 0%, and the morbidity rate was 11%. Five patients experienced 7 complications, including 4 early complications (30 days) and three late complications (> 30 days) leading early and late morbidity rates of 9% and 7%, respectively. Conclusion Patients with LACC who had undergone an additional low-kV x-ray IORT can achieve encouraging locoregional control, PFS, OS, and distant control without an increase in short-term or long-term complications. Low-kV x-ray IORT can be considered as part of management in pT3 LACC.
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Affiliation(s)
- Li Ma
- Center of Integrative Research, The First Hospital of Qiqihar, 30 Gongyuan Road, Longsha District, Qiqihar, 161005, Heilongjiang, People's Republic of China.,Affiliated Qiqihar Hospital, Southern Medical University, 30 Gongyuan Road, Longsha District, Qiqihar, 161005, Heilongjiang, People's Republic of China.,Department of Orthopedic Surgery and BME-Campbell Clinic, University of Tennessee Health Science Center, 956 Court Avenue, Memphis, TN, 38163, USA
| | - Junhao Qiang
- Center of Integrative Research, The First Hospital of Qiqihar, 30 Gongyuan Road, Longsha District, Qiqihar, 161005, Heilongjiang, People's Republic of China.,Affiliated Qiqihar Hospital, Southern Medical University, 30 Gongyuan Road, Longsha District, Qiqihar, 161005, Heilongjiang, People's Republic of China
| | - Heliang Yin
- Center of Integrative Research, The First Hospital of Qiqihar, 30 Gongyuan Road, Longsha District, Qiqihar, 161005, Heilongjiang, People's Republic of China.,Affiliated Qiqihar Hospital, Southern Medical University, 30 Gongyuan Road, Longsha District, Qiqihar, 161005, Heilongjiang, People's Republic of China.,Department of Orthopedic Surgery and BME-Campbell Clinic, University of Tennessee Health Science Center, 956 Court Avenue, Memphis, TN, 38163, USA
| | - Lin Lin
- Center of Integrative Research, The First Hospital of Qiqihar, 30 Gongyuan Road, Longsha District, Qiqihar, 161005, Heilongjiang, People's Republic of China.,Affiliated Qiqihar Hospital, Southern Medical University, 30 Gongyuan Road, Longsha District, Qiqihar, 161005, Heilongjiang, People's Republic of China.,Department of Orthopedic Surgery and BME-Campbell Clinic, University of Tennessee Health Science Center, 956 Court Avenue, Memphis, TN, 38163, USA
| | - Yan Jiao
- Department of Orthopedic Surgery and BME-Campbell Clinic, University of Tennessee Health Science Center, 956 Court Avenue, Memphis, TN, 38163, USA
| | - Changying Ma
- Center of Integrative Research, The First Hospital of Qiqihar, 30 Gongyuan Road, Longsha District, Qiqihar, 161005, Heilongjiang, People's Republic of China.,Affiliated Qiqihar Hospital, Southern Medical University, 30 Gongyuan Road, Longsha District, Qiqihar, 161005, Heilongjiang, People's Republic of China
| | - Xinwei Li
- Center of Integrative Research, The First Hospital of Qiqihar, 30 Gongyuan Road, Longsha District, Qiqihar, 161005, Heilongjiang, People's Republic of China.,Affiliated Qiqihar Hospital, Southern Medical University, 30 Gongyuan Road, Longsha District, Qiqihar, 161005, Heilongjiang, People's Republic of China
| | - Li Dong
- Center of Integrative Research, The First Hospital of Qiqihar, 30 Gongyuan Road, Longsha District, Qiqihar, 161005, Heilongjiang, People's Republic of China.,Affiliated Qiqihar Hospital, Southern Medical University, 30 Gongyuan Road, Longsha District, Qiqihar, 161005, Heilongjiang, People's Republic of China
| | - Jinglin Cui
- Center of Integrative Research, The First Hospital of Qiqihar, 30 Gongyuan Road, Longsha District, Qiqihar, 161005, Heilongjiang, People's Republic of China.,Affiliated Qiqihar Hospital, Southern Medical University, 30 Gongyuan Road, Longsha District, Qiqihar, 161005, Heilongjiang, People's Republic of China
| | - Dongmei Wei
- Center of Integrative Research, The First Hospital of Qiqihar, 30 Gongyuan Road, Longsha District, Qiqihar, 161005, Heilongjiang, People's Republic of China.,Affiliated Qiqihar Hospital, Southern Medical University, 30 Gongyuan Road, Longsha District, Qiqihar, 161005, Heilongjiang, People's Republic of China
| | - Ankur M Sharma
- Department of Radiation Oncology, University of Tennessee Health Science Center, 920 Madison Avenue, Memphis, TN, 38163, USA
| | - David L Schwartz
- Department of Radiation Oncology, University of Tennessee Health Science Center, 920 Madison Avenue, Memphis, TN, 38163, USA
| | - Weikuan Gu
- Department of Orthopedic Surgery and BME-Campbell Clinic, University of Tennessee Health Science Center, 956 Court Avenue, Memphis, TN, 38163, USA. .,Research Service 151, VA Medical Center, 1030 Jefferson Avenue, Memphis, TN, 38104, USA.
| | - Hong Chen
- Center of Integrative Research, The First Hospital of Qiqihar, 30 Gongyuan Road, Longsha District, Qiqihar, 161005, Heilongjiang, People's Republic of China. .,Affiliated Qiqihar Hospital, Southern Medical University, 30 Gongyuan Road, Longsha District, Qiqihar, 161005, Heilongjiang, People's Republic of China.
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