We know that R0 resection is clearly desirable in preventing local recurrences, but in the setting of large resections, e.g. extended or trisegmentectomy, with potential R1 resection due to positive margins, has anyone had experience with IORT to supplement margins? The use of IORT in rectal cancer and breast cancer have been demonstrated, but little reports for primary intrahepatic cholangiocarcinoma or HCC.
We havent used IORT at our center. We have used pre-op stereotactic radiation in a few cases withe recurrent HCC after ltx beforelocal resection of the tumour. Presently the interest for stereot irrad at Karolinskafor HCC is quite low ( personal reasons )
Best Regards
We use IORT in rectal, gastric, pancreatic cáncer and Sarcomas. The problem un liver is hepatitis by radiation. I think is not a Good indication. Other options are MICROESPHERES, TACE, HIFU....
We have looked at IORT/SBRT vs Transarterial radiotherapy, really no difference in radiation induced liver injury. We do use IORT to provide an effective zone of treatment to 5-7 mm , probably a bit deeper than for thermal device treated margins, e.g. Aquamantys. There is little literature about IORT, I was hoping to get a measure of those centers that are using this to perhaps pool data.
I believe that IORT is not a good indication for obtain R0 resection in liver tumor. R0 resection is not achieved when tumor is near hepatic hilo with vascular involvement or near Cava vein. R0 liver resection may be obtained by surgery after portal embolization or portal ligation when residual parenchyma is small. Hepatitis, biliary fistula, may be the risk of IORT therapy
We usually use IORT in sarcoma, rectal cancer, local recurrece of gynecologic cancer, ..., but we´ve never used IORT in liver resecction. We work a lot in liver resection for HCC, cholangiocarcinoma and liver metastasis, but we don´t have any data to share on IORT in the liver. It could be interesting to participate in a multicentric trial.
If one thinks about "additive" IORT in HCC, predicting or knowing that R0 cannot be achieved, radiotherapy as the primary therapy should be taken into account. Some data on SBRT, Proton beam therapy and CT- guided brachytherapy already exists with promising data. Reasons: less morbidity/mortality/costs, and an equal effectivity to R1 can be easily assumed.
IORT to the liver is well tolerated in an experimental study we have performed at the UMCG in de eighties! see for details publications listed below:
1. Liver tissue tolerance for irradiation: experimental and clinical investigations. Cromheecke M, Konings AW, Szabo BG, Hoekstra HJ. Hepatogastroenterology. 2000 Nov-Dec;47(36):1732-40. Review.
2. Tissue damage after single high-dose intraoperative irradiation of the canine liver: evaluation in time by means of radionuclide imaging and light microscopy. Cromheecke M, Piers BA, Beekhuis H, ter Veen H, Sluiter WJ, Grond AK, Hoekstra HJ. Radiat Res. 2000 Nov;154(5):537-46.
3. Short- and long-term histopathological changes in the canine liver following single high-dose intraoperative radiation therapy (IORT). Cromheecke M, Grond AJ, Szabo BG, Hoekstra HJ. Int J Radiat Biol. 1999 Nov;75(11):1437-48.
4.Beagle model used in a tissue tolerance study of the response of normal and surgically manipulated liver to single high-dose intraoperative radiotherapy. Cromheecke M, Meijer D, Hietkamp J, Vermeij J, van Ginkel RJ, Hoekstra HJ. Lab Anim Sci. 1996 Dec;46(6):640-7.
5.Tissue tolerance of normal and surgically manipulated canine liver to intraoperative radiation therapy (IORT). Cromheecke M, Vermeij J, Grond AJ, Konings AW, Oldhoff J, Hoekstra HJ. Int J Radiat Oncol Biol Phys. 1993 Dec 1;27(5):1141-6.
We have no experience in IORT. One of the reasons why we did not pursue this idea was the question of the tumor biology. HCC as well as intrahepatic CCa are rather multifocal in the liver, hence the intrahepatic recurrence aside of resection margins. The question we asked was, if it helps to treat resection margins rather than the whole liver. What do other think?
Maybe a better question to ask is: do you use Stereotactic body radiotherapy (SBRT) aka Cyberknife, for treatment of any liver tumors? There has been a wealth of experience from Asia that SBRT is as effective and less toxicity than TACE or RFA.
In Egypt, (IORT) in liver resection for primary liver cancer is not used.
HCC is multifocal in the cirrhotic liver, Resection for cholangiocarcinoma is R0 or only palliative surgery due to dismal prognosis.
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