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Intraoperative Irradiation
Second edition
Current Clinical OncologyMaurie Markman, MD, Series Editor
For other titles published in this series, go tohttp://www.springer.com/series/7631
Leonard L. Gunderson • Christopher G. Willett Felipe A. Calvo • Louis B. Harrisoneditors
Intraoperative Irradiation
Techniques and Results
Second edition
EditorsLeonard L. Gunderson, M.D., M.S., FASTRoDepartment of Radiation oncology Mayo Clinic College of Medicine and Mayo Clinic Arizona, Scottsdale, AZ USAllg.scottsdale@cox.net
Christopher G. Willett, M.D. Department of Radiation oncology Duke University Medical Center Durham, NC USAchristopher.willett@duke.edu
Felipe A. Calvo, M.D. Department of oncology Hospital Gregorio Maranón Madrid, Spainfcalvo.hgugm@salud.madrid.org
Louis B. Harrison, M.D., FASTRo Department of Radiation oncologyContinuum Cancer Centers of New York Beth Israel Medical Center, St Luke’s and Roosevelt Hospitals, Albert einstein College of Medicine, New York, NY USAlharriso@chpnet.org
ISBN 978-1-61779-014-0 e-ISBN 978-1-61779-015-7DoI 10.1007/978-1-61779-015-7Springer New York Dordrecht Heidelberg London
Library of Congress Control Number: 2011924474
© Springer Science+Business Media, LLC 2011All rights reserved. This work may not be translated or copied in whole or in part without the written permission of the publisher (Humana Press, c/o Springer Science+Business Media, LLC, 233 Spring Street, New York, NY 10013, USA), except for brief excerpts in connection with reviews or scholarly analysis. Use in connection with any form of information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed is forbidden.The use in this publication of trade names, trademarks, service marks, and similar terms, even if they are not identified as such, is not to be taken as an expression of opinion as to whether or not they are subject to proprietary rights.While the advice and information in this book are believed to be true and accurate at the date of going to press, neither the authors nor the editors nor the publisher can accept any legal responsibility for any errors or omissions that may be made. The publisher makes no warranty, express or implied, with respect to the material contained herein.
Printed on acid-free paper
Humana Press is part of Springer Science+Business Media (www.springer.com)
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
vii
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.
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., FASTRoDurham, NC, USA Christopher G. Willett, M.D.Madrid, Spain Felipe A. Calvo, M.D.New York, NY, USA Louis B. Harrison, M.D., FASTRo
ix
Contents
Part I General Rationale and Historical Perspective
1 Rationale and Historical Perspective of Intraoperative Irradiation ............................. 3Leonard L. Gunderson, Felipe A. Calvo, Christopher G. Willett, and Louis B. Harrison
2 Biology of Large Dose per Fraction Irradiation ............................................................. 27Paul okunieff, Srinath Sundararaman, Su Metcalfe, and Yuhchyau Chen
Part II Methods and Techniques of Treatment
3 Intraoperative Electron Beam Irradiation: Physics and Techniques ............................ 51Peter Biggs, Christopher G. Willett, Harm Rutten, Mario Ciocca, Leonard L. Gunderson, and Felipe A. Calvo
4 HDR-IORT: Physics and Techniques ............................................................................... 73eli e. Furhang, Jussi K. Sillanpaa, Kenneth S. Hu, and Louis B. Harrison
5 Electronic Brachytherapy/Low KV-IORT: Physics and Techniques ............................ 85Uta 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 ........................ 99Subir 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 ........................................................................................................... 119Zeljko Vujaskovic, Christopher G. Willett, Joel e. Tepper, Timothy J. Kinsella, and Leonard L. Gunderson
x Contents
Part IV Results of IORT Alone or Plus EBRT by Disease Site
8 Central Nervous System Tumors .................................................................................... 141David ortiz de Urbina, Patrick Schueller, Normann Willich, Kintomo Takakura, osami Kubo, and Felipe A. Calvo
9 Head and Neck Cancer .................................................................................................... 163Kenneth S. Hu, Sue Yom, Michael J. Kaplan, Rafael Martinez-Monge, and Louis B. Harrison
10 Breast Cancer ................................................................................................................... 189Felix Sedlmayer, Jean-Bernard DuBois, Roland Reitsamer, Gerd Fastner, David olilla, and Roberto orecchia
11 Lung Cancer ..................................................................................................................... 201Javier Aristu, Felipe A. Calvo, Marta Moreno, Rafael Martínez, Jesús Herreros, Maria esperanze Rodriguez, Jean-Bernard DuBois, and Scott Fisher
12 Gastric Cancer ................................................................................................................. 223Rafael Martinez-Monge, Miren Gaztañaga, Javier Álvarez-Cienfuegos, Robert C. Miller, and Felipe A. Calvo
13 Pancreas Cancer .............................................................................................................. 249Robert C. Miller, Vincenzo Valentini, Adyr Moss, Giuseppe R. D’Agostino, Matthew D. Callister, Theodore S. Hong, Christopher G. Willett, and Leonard L. Gunderson
14 Bile Duct and Gallbladder Cancer ................................................................................. 273Takeshi Todoroki, Gernot M. Kaiser, Wolfgang Sauerwein, and Leonard L. Gunderson
15 Primary Colorectal Cancer ............................................................................................. 297Nils D. Arvold, Theodore S. Hong, Christopher G. Willett, Paul C. Shellito, Michael G. Haddock, Harm Rutten, Vincenzo Valentini, Felipe A. Calvo, Brian Czito, and Leonard L. Gunderson
16 Recurrent Colorectal Cancer .......................................................................................... 323Michael G. Haddock, Heidi Nelson, Vincenzo Valentini, Leonard L. Gunderson, Christopher G. Willett, Harm Rutten, Felipe A. Calvo, Louis B. Harrison, Warren enker, and J.L. Garcia-Sabrido
17 Retroperitoneal Sarcomas ............................................................................................... 353Brian Czito, John Donohue, Christopher G. Willett, Doug Tyler, Ivy A. Petersen, Robert Krempien, Kenneth S. Hu, Felipe A. Calvo, Matthew D. Callister, Kaled M. Alektiar, Michael eble, and Ana Alvarez
18 Extremity and Trunk Soft-Tissue Sarcomas ................................................................. 387Ivy A. Petersen, Robert Krempien, Christopher Beauchamp, Michael eble, Felipe A. Calvo, Ignacio Azinovic, Matthew D. Callister, and Ana Alvarez
xiContents
19 Bone Sarcomas ................................................................................................................. 407Felipe A. Calvo, Luis Sierrasesumaga, Ana Patiño, Carmen González, Manuel González, Carlos Ferrer, Normann Willich, and José Cañadell
20 Gynecologic Malignancies ............................................................................................... 431Kaled M. Alektiar, Michael G. Haddock, Dennis Chi, Felipe A. Calvo, and Ivy A. Petersen
21 Genitourinary Cancer ..................................................................................................... 459Marco Krengli, Felipe A. Calvo, Carlo Terrone, Michael G. Haddock, Jean-Michel Hannoun-Levi, Juliette Thariat, Jean-Pierre Gerard, and Roberto orecchia
22 Pediatric Malignancies .................................................................................................... 481Nadia N. Issa Laack, Paula J. Schomberg, Suzanne Wolden, and Jesus Vazquez
Part V Conclusions and Future Possibilities
23 Conclusions and Future Possibilities: IORT ................................................................. 503Leonard L. Gunderson, Christopher G. Willett, Felipe A. Calvo, and Louis B. Harrison
Index .......................................................................................................................................... 519
xiii
Contributors
Kaled M. Alektiar, M.D. Department of Radiation oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
Ana Alvarez, M.D. Department of oncology, University Hospital Gregorio Maranón, Madrid, Spain
Javier Álvarez-Cienfuegos, M.D. Department of Surgery, Navarra University Clinic, Pamplona, Spain
Javier Aristu, M.D. Department of Radiation oncology, Navarra University Clinic, Pamplona, Spain
Nils D. Arvold, M.D. Department of Radiation oncology, Massachusetts General Hospital, Boston, MA, USA
Ignacio Azinovic, M.D. Department of Radiation oncology, Navarra University Clinic, Pamplona, Spain
Christopher Beauchamp, M.D. Department of orthopedic oncology, Mayo Clinic, Scottsdale, AZ, USA
Peter Biggs, Ph.D. Department of Physics, Massachusetts General Hospital, Boston, MA, USA
Matthew D. Callister, M.D. Department of Radiation oncology, Mayo Clinic Arizona, Scottsdale, AZ, USA
Felipe A. Calvo, M.D. Department of oncology, Hospital Gregorio Maranón, Madrid, Spain
José Cañadell, M.D, Ph.D. emaritus Professor, Department of orthopedic Surgery, Clinica Universitaria de Navarra, Pamplona, Spain
Yuhchyau Chen, M.D., Ph.D. Department of Radiation oncology, University of Rochester School of Medicine and Dentistry, Rochester, NY, USA
Dennis Chi, M.D. Department of Gynecologic oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
xiv Contributors
David Ortiz de Urbina, M.D. Department of Radiation oncology, Institutu onkologikoa of Guipuzcoa, San Sebastian, Spain
Mario Ciocca, Ph.D. Division of Medical Physics, european Institute of oncology, Milan, Italy
Brian Czito, M.D. Department of Radiation oncology, Duke University Medical Center, Durham, NC, USA
Giuseppe R. D’Agostino, M.D. Department of Radiotherapy, Universita Cattolica del Sacro Cuore, Rome, Italy
John Donohue, M.D. Department of General Surgery, Mayo Clinic, Rochester, MN, USA
Jean-Bernard DuBois, M.D. Department of Radiotherapy, Centre Regional de Lutte Contre Le Cancer (CRLC), Montpellier, France
Michael Eble, M.D. Department of Radiation oncology, Aachen University, Aachen, Germany
Warren Enker, M.D. Surgical oncology, Beth Israel, New York, NY, USA
Gerd Fastner, M.D. Department of Radiotherapy and Radio-oncology, Paracelsus Medical University Clinics, Salzburg, Austria
Carlos Ferrer, M.D. Institute of oncology, Hospital Provincial de Castellón, Castellón, Spain
Scott Fisher, M.D. Department of Radiation oncology, Thomas Jefferson University Hospital, Philadelphia, PA, USA
Dario Francescatti, M.D., J.D. Department of Surgery, Rush Medical Center, Chicago, IL, USA
Eli E. Furhang, Ph.D. Department of Radiation oncology, Continuum Cancer Centers of New York, Beth Israel Medical Center, St Luke’s and Roosevelt Hospitals, Albert einstein College of Medicine, New York, NY, USA
J.L. Garcia-Sabrido, M.D. Surgical oncology, Hospital Gregorio Maranón, Madrid, Spain
Miren Gaztañaga, M.D. Department of Radiation oncology, University of Navarra, Avda Pío XII, Pamplona, Spain
Jean-Pierre Gerard, M.D. Department of Radiation oncology, Centre Antoine Lacassagne, Nice, France
Carmen González, M.D. Department of Radiation oncology, Hospital Gregorio Maranón, Madrid, Spain
Manuel González, M.D. Department of Radiation oncology, Hospital Gregorio Maranón, Madrid, Spain
xvContributors
Leonard L. Gunderson, M.D., M.S. Department of Radiation oncology, Mayo Clinic College of Medicine and Mayo Clinic Arizona, Scottsdale, AZ, USA
Michael G. Haddock, M.D. Department of Radiation oncology, Mayo Clinic, Rochester, MN, USA
Jean-Michel Hannoun-Levi, M.D. Department of Radiation oncology, Centre Antoine Lacassagne, Nice, France
Louis B. Harrison, M.D. Department of Radiation oncology, Continuum Cancer Centers of New York, Beth Israel Medical Center, St Luke’s and Roosevelt Hospitals, Albert einstein College of Medicine, New York, NY, USA
Jesús Herreros, M.D. Department of Cardiovascular Surgery, Clínica Universitaria de Navarra, Pamplona, Spain
Theodore S. Hong, M.D. Department of Radiation oncology, Massachusetts General Hospital, Boston, MA, USA
Kenneth S. Hu, Ph.D. Department of Radiation oncology, Continuum Cancer Centers of New York, Beth Israel Medical Center, St Luke’s and Roosevelt Hospitals, Albert einstein College of Medicine, New York, NY, USA
Gernot M. Kaiser, M.D. Department of General, Visceral and Transplantation Surgery, University Hospital essen, essen, Germany
Michael J. Kaplan, M.D. Department of otolaryngology, Head and Neck Surgery, Stanford University School of Medicine, Stanford, CA, USA
Timothy J. Kinsella, M.D., M.S. Department of Radiation oncology, Warren Alpert Medical School of Brown University, Rhode Island Hospital, Providence, RI, USA
Uta Kraus-Tiefenbacher, M.D. Department of Radiation oncology, University Medical Center Mannheim, University of Heidelberg, Mannheim, Germany
Robert Krempien, M.D. Department of Radiation oncology, University of Heidelberg, Heidelberg, Germany
Marco Krengli, M.D. Department of Radiotherapy, University of Piemonte orientale, Novara, Italy
Osami Kubo, M.D. Department of Neurosurgery, Tokyo Women’s Medical University, Tokyo, Japan
Nadia N. Issa Laack, M.D., M.S. Department of Radiation oncology, Mayo Clinic, Rochester, MN, USA
Rafael Martinez-Monge, M.D. Department of Radiation oncology, Navarra University Clinic, Pamplona, Spain
xvi Contributors
Su Metcalfe, M.D, M.P.H Department of Radiation oncology, University of Rochester School of Medicine and Dentistry, Rochester, NY, USA
Robert C. Miller, M.D. Department of Radiation oncology, Mayo Clinic, Rochester, MN, USA
Marta Moreno, M.D. Department of Radiation oncology, Navarra University Clinic, Pamplona, Spain
Adyr Moss, M.D. Division of General Surgery Mayo Clinic in Arizona, Scottsdale, AZ, USA
Subir Nag, M.D. Department of Radiation oncology, Northern California Kaiser Permanente, Santa Clara, CA, USA
Heidi Nelson, M.D. Department of Colorectal Surgery, Mayo Clinic, Rochester, MN, USA
Paul Okunieff, M.D. Department of Radiation oncology, University of Florida, Gainesville, FL, USA
David Olilla, M.D. Department of Surgery, Division of Surgical oncology and endocrine Surgery, University of North Carolina, USA
Roberto Orecchia, M.D. Department of Radiotherapy, european Institute of oncology, Milan, Italy
Ana Patiño, M.D. Department of Pediatrics, Clínica Universitaria de Navarra, Pamplona, Spain
Ivy A. Petersen, M.D. Department of Radiation oncology, Mayo Clinic, Rochester, MN, USA
Roland Reitsamer, M.D. Department of Special Gynecology/Breast Unit, General Hospital, Paracelsus Medical University Clinics, Salzburg, Austria
Maria Esperanza Rodriguez, M.D. Department of Radiation oncology, Navarra University Clinic, Pamplona, Spain
Harm Rutten, M.D. Department of Surgery, Catharina Hospital, eindhoven, The Netherlands
Wolfgang Sauerwein, M.D. Department of Radiation oncology, University Hospital essen, essen, Germany
Paula J. Schomberg, M.D. Department of Radiation oncology, Mayo Clinic, Rochester, MN, USA
Patrick Schueller, M.D. Competence Center for oncology of the Medical Service of the German Health Insurances, Duesseldorf, Germany
Felix Sedlmayer, M.D. Department of Radiotherapy and Radio-oncology, Paracelsus Medical University Clinics, Salzburg, Austria
xviiContributors
Paul C. Shellito, M.D. Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
Luis Sierrasesumaga, M.D. Department of Pediatrics, Clínica Universitaria de Navarra, Pamplona, Spain
Jussi K. Sillanpaa, Ph.D. Department of Radiation oncology, Continuum Cancer Centers of New York, Beth Israel Medical Center, St Luke’s and Rooseuelt Hospital, Albert einstein College of Medicine, New York, NY, USA
Srinath Sundararaman, M.D. Radiation oncology Branch, National Cancer Institute, Hollywood, FL, USA
Kintomo Takakura, M.D. Department of Neurosurgery, Tokyo Women’s Medical University, Tokyo, Japan
Joel E. Tepper, M.D. Department of Radiation oncology, University of North Carolina School of Medicine, Chapel Hill, NC, USA
Carlo Terrone, M.D. Department of Urology, University of Piemonte orientale, Novara, Italy
Juliette Thariat, M.D. Department of Radiation oncology, Centre Antoine Lacassagne, Nice, France
Takeshi Todoroki, M.D. Department of Surgery, Kita-ibaraki Municipal General Hospital, Kita-Ibaraki, Japan
Doug Tyler, M.D. Division of General Surgery, Duke University Medical Center, Durham, NC, USA
Jayant Vaidya, M.D. Research Department of Surgery, Division of Surgery and Interventional Science, University College London, London, UK
Vincenzo Valentini, M.D. Radiation oncology, Polyclinico Universitario A. Gemelli, Rome, Italy
Jesus Vazquez, M.D. Department of Pediatric Surgery, Hospital General Universitario Gregorio Marañon, Madrid, Spain
Zeljko Vujaskovic, M.D., Ph.D. Department of Radiation oncology, Duke University Medical Center, Durham, NC, USA
Christopher G. Willett, M.D. Radiation oncology, Duke University, Durham, NC, USA
Normann Willich, M.D. Department of Radiation oncology, University Hospital Muenster, Muenster, Germany
Suzanne Wolden, M.D. Department of Radiation oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
Sue Yom, M.D. Department of Radiation oncology, University of California, San Francisco, CA, USA
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