• CRS-HIPEC
• IORT
• LARC
• LRRC
• colorectal neoplasms
• cytoreduction
• intro operative radiotherapy
• locally advanced rectal cancer
• locally recurrent rectal cancer
• peritoneal metastases
• surgical procedures

• Humans
• Rectal Neoplasms/radiotherapy
• Rectal Neoplasms/surgery
• Rectal Neoplasms/pathology
• Rectal Neoplasms/mortality
• Brachytherapy/methods
• Male
• Neoplasm Recurrence, Local
• Female
• Aged
• Middle Aged
• Electrons/therapeutic use
• Intraoperative Care
• Radiotherapy Dosage
• Retrospective Studies
• Intraoperative Period
• Margins of Excision
• Aged, 80 and over
• Disease-Free Survival
• Adult
• Treatment Outcome

• Adverse effects
• Brachytherapy
• Neoadjuvant therapy
• Patient selection
• Radiation oncology
• Rectal neoplasms

In recent years, intraoperative radiotherapy (IORT) has been increasingly used for the treatment of rectal cancer. However, the efficacy and safety of IORT for the treatment of rectal cancer are still controversial.

To evaluate the value of IORT for patients with rectal cancer.

We searched PubMed, Embase, Cochrane Library, Web of Science databases, and conference abstracts and included randomized controlled trials and observational studies on IORT vs non-IORT for rectal cancer. Dichotomous variables were evaluated by odds ratio (OR) and 95% confidence interval (CI), hazard ratio (HR) and 95%CI was used as a summary statistic of survival outcomes. Statistical analyses were performed using Stata V.15.0 and Review Manager 5.3 software.

In this study, 3 randomized controlled studies and 12 observational studies were included with a total of 1460 patients, who are mainly residents of Europe, the United States, and Asia. Our results did not show significant differences in 5-year overall survival (HR = 0.80, 95%CI = 0.60-1.06; P = 0.126); 5-year disease-free survival (HR = 0.94, 95%CI = 0.73-1.22; P = 0.650); abscess (OR = 1.10, 95%CI = 0.67-1.80; P = 0.713), fistulae (OR = 0.79, 95%CI = 0.33-1.89; P = 0.600); wound complication (OR = 1.21, 95%CI = 0.62-2.36; P = 0.575); anastomotic leakage (OR = 1.09, 95%CI = 0.59-2.02; P = 0.775); and neurogenic bladder dysfunction (OR = 0.69, 95%CI = 0.31-1.55; P = 0.369). However, the meta-analysis of 5-year local control was significantly different (OR = 3.07, 95%CI = 1.66-5.66; P = 0.000).

The advantage of IORT is mainly reflected in 5-year local control, but it is not statistically significant for 5-year overall survival, 5-year disease-free survival, and complications.

• Intraoperative radiotherapy
• Rectal cancer
• Systematic review
• External beam radiation therapy
• Randomized controlled trials
• Meta-analysis

Die intraoperative Radiotherapie (IORT) kann bei lokal weit fortgeschrittenen Tumoren und zu erwartender bzw. nicht vermeidbarer R1-Situation ergänzend zur chirurgischen Resektion eingesetzt werden. Ziel ist eine verbesserte lokale Tumorkontrolle und damit ein besseres Langzeitüberleben. Indikationen sind sowohl primäre intraabdominelle und retroperitoneale Tumoren als auch Rezidivtumoren. Im Rahmen der vorliegenden Arbeit werden die eigenen Erfahrungen mit der Durchführung einer IORT bei viszeralchirurgischen Resektionen zusammengefasst.

Patienten, die von Januar 2008 bis Dezember 2018 eine IORT kombiniert mit abdomineller Tumorresektion in der Klinik für Allgemein- und Viszeralchirurgie des Universitätsklinikums Freiburgs erhalten hatten, wurden in diese Arbeit eingeschlossen und hinsichtlich Kurz- und Langzeitergebnisse evaluiert.

Die häufigste Indikation zur Durchführung einer IORT stellten Sarkome gefolgt von Rektum- und Analkarzinomen dar. Die mediane angewandte Strahlendosis der IORT betrug 15 Gy (8–19 Gy). Bei einem medianen „comprehensive complication index“ (CCI) von 11,9 traten bei 24 % der Patienten Komplikationen (Dindo-Clavien ≥ °III) auf. Die 90-Tage-Mortalität betrug 0 %. Besonders für Analkarzinomrezidive war die lokale Kontrolle nach einem Jahr trotz R0-Resektion unzureichend.

In unserem Patientenkollektiv war die IORT mit vertretbarer Morbidität einsetzbar. Dennoch sind Indikationsstellung und Patientenselektion kritische Punkte für die Durchführung der Behandlung. Der Effekt der IORT zur Verbesserung der lokalen Kontrolle und damit auch des Langzeitüberlebens sollte in weiteren Studien evaluiert werden.

• Anal carcinoma
• Intraoperative radiotherapy
• Local tumor recurrence
• Rectal carcinoma
• Sarcoma

Pelvic exenteration (PE) may be associated with prolonged overall survival (OS) in selected patients with advanced or recurrent cervical cancer. However, the factors related to improved survival following PE are not clearly defined. The aim of this study was to perform a retrospective analysis of OS rates in a group of patients undergoing PE in order to identify the factors related to improved long-term outcomes.

Our study group consisted of 44 patients, including 21 squamous cell cancer (SCC) patients, 22 patients with adenocarcinomas (AC) of the cervix, and one patient with undifferentiated cervical carcinoma. The patients were categorized according to the type of surgery, namely, primary surgery (12 patients) or surgery due to cancer recurrence (32 patients).

In the group of patients with recurrent cervical cancer, we found that improved OS correlated with the SCC histological type and the presence of vaginal fistula. The need for reoperation within 30 days and the presence of severe adverse events significantly worsened the prognosis. We found a non significant trend toward improved survival in those patients with tumor-free margins. Lymph node metastases, the initial stage of the disease, the time to recurrence, and a history of hysterectomy had no impact on patients’ OS. In the group of patients undergoing primary PE, we observed a trend toward improved survival among those diagnosed with vaginal fistula.

Pelvic exenteration seemed to improve the long-term outcomes for patients with SCC cancer recurrence and vaginal fistula whose surgery was unrelated to severe adverse events.

• Cancer recurrence
• Cervical cancer
• Pelvic exenteration
• Vaginal fistula

Even with the augmentative application of anal-preservation surgery in low rectal cancer, the role and indications of laparoscopic intersphincteric resection (Lap ISR) are still under debate, especially for T3 or node-positive (T3N0M0, T1–3N+M0) cancer, mainly due to the oncological safety and functional outcomes. INTRABEAM (Carl Zeiss, Germany) intraoperative radiotherapy (IORT) using low-energy X-rays features in accurate irradiation, less exposure, and reduced complications. Taking advantages of Lap ISR and INTRABEAM IORT, this innovative approach aims to increase the probability of the anal preservation with acceptable postoperative outcomes.

From December 2015 to August 2019, we retrospectively analyzed the short-term outcomes of 12 patients evaluated preoperatively with T3 or node-positive (T3N0M0, T1–3N+M0) primary locally advanced low rectal cancer. They all had received Lap ISR and INTRABEAM IORT with a dose of 16–18 Gy applied by an applicator through the anus (natural orifice). Then, with no pre- or postoperative radiotherapy given, the patients were suggested to receive 6–8 cycles of the XELOX chemotherapy regimen (oxaliplatin, 130 mg/m² and capecitabine, 1000 mg/m²).

All patients achieved R0 resection. The median radiation time was 27 min and 15 s, and the mean radiative dose was 17.3 Gy (range 16–18 Gy). The median follow-up time was 18.5 months (range 3–45 months). Two patients experienced local recurrence. Two male patients experienced anastomotic stenosis. Furthermore, one of them experienced perianal abscess and the other one experienced pulmonary metastasis after refusing to receive chemotherapy. One female patient with internal anal sphincter invasion experienced distant metastases to the liver and gluteus maximus muscle 35 months after IORT. No acute radiation injuries or symptoms were observed. Although they experienced a reduction in anal function, every patient was satisfied with the postoperative outcomes.

For patients evaluated preoperatively with T3 or node-positive (T3N0M0, T1–3N+M0) primary locally advanced low rectal cancer, Lap ISR with INTRABEAM IORT may be a safe and feasible approach for anal preservation without compromising oncological outcomes.

• IORT
• Lap ISR
• Low rectal cancer
• Low-energy X-rays
• T1–3N+M0
• T3N0M0

• External beam radiotherapy
• Intraoperative radiotherapy
• Rectal cancer

• Aged
• Aged, 80 and over
• Cause of Death
• Cohort Studies
• Databases, Factual
• Disease-Free Survival
• Female
• Humans
• Kaplan-Meier Estimate
• Middle Aged
• Neoplasm Invasiveness/pathology
• Neoplasm Recurrence, Local/mortality
• Neoplasm Recurrence, Local/pathology
• Neoplasm Recurrence, Local/surgery
• Neoplasm Staging
• Pelvic Exenteration/methods
• Pelvic Exenteration/mortality
• Pelvic Neoplasms/mortality
• Pelvic Neoplasms/pathology
• Pelvic Neoplasms/surgery
• Prognosis
• Proportional Hazards Models
• Retrospective Studies
• Risk Assessment
• Survival Analysis
• Tertiary Care Centers

The present study aimed to examine whether the combination of neoadjuvant volumetric modulated arc radiotherapy (VMAT) using simultaneous integrated boost (SIB-VMAT) techniques and chemotherapy with capecitabine is associated with better clinical and dosimetric outcomes compared to the standard treatment.

The study included 59 patients with cT2–T4 rectal cancer. In the standard arm, patients (n = 37) were treated preoperatively with image-guided VMAT plus capecitabine. In the SIB arm, patients (n = 22) were treated with the SIB-VMAT technique plus capecitabine. All patients underwent radical surgical resection after neoadjuvant radiochemotherapy.

In the standard arm, cT0N0 was reached in 12 patients (32.4%), primary tumor clinical downstaging was observed in 22 patients (59.5%), and disease stability was achieved in 3 patients (8.1%). In the SIB arm, cT0N0 was reached in 15 patients (68.2%), primary tumor clinical downstaging was observed in 6 patients (27.3%), and disease stability was achieved in 1 patient (4.5%) (P = 0.028). Complete pathological response was observed in 11 patients (29.7%) in the standard arm and in 13 patients (59.1%) in the SIB arm (P = 0.026). In the SIB arm mild diarrhea appeared in 59.1%, moderate in 40.9%, and severe in 0% of the cases. In the standard arm mild, moderate, and severe diarrhea rates were in 54.1%, 43.2%, and 2.7%, respectively. In the SIB arm mild, moderate, and severe cystitis appeared in 63.6%, 22.7%, and 13.6%, while in the standard group mild cystitis developed in 67.6%, moderate in 24.3%, and severe in 8.1%. Mild, moderate, and severe radiation dermatitis rates were 45.5%, 45.5%, and 9.1% in the SIB group and 40.5%, 48.6%, and 10.8% in the standard group, respectively.

The SIB-VMAT technique is effective and safe for irradiating locally advanced rectal cancer. Its effectiveness is expressed in higher clinical and pathological complete response rates and safety with the same rates of acute toxicity.

• Rectal cancer
• chemoradiotherapy
• neoadjuvant
• boost

• HDR-IORT
• Rectal cancer
• brachytherapy
• intra-operative radiation therapy
• sarcoma

• Elderly
• Locally advanced rectal cancer
• Locally recurrent rectal cancer
• Total pelvic exenteration

Intraoperative radiotherapy (IORT) is a technique that involves precise delivery of a large dose of ionising radiation to the tumour or tumour bed during surgery. Direct visualisation of the tumour bed and ability to space out the normal tissues from the tumour bed allows maximisation of the dose to the tumour while minimising the dose to normal tissues. This results in an improved therapeutic ratio with IORT. Although it was introduced in the 1960s, it has seen a resurgence of popularity with the introduction of self-shielding mobile linear accelerators and low-kV IORT devices, which by eliminating the logistical issues of transport of the patient during surgery for radiotherapy or building a shielded operating room, has enabled its wider use in the community.

Electrons, low-kV X-rays and HDR brachytherapy are all different methods of IORT in current clinical use. Each method has its own unique set of advantages and disadvantages, its own set of indications where one may be better suited than the other, and each requires a specific kind of expertise.

IORT has demonstrated its efficacy in a wide variety of intra-abdominal tumours, recurrent colorectal cancers, recurrent gynaecological cancers, and soft-tissue tumours. Recently, it has emerged as an attractive treatment option for selected, early-stage breast cancer, owing to the ability to complete the entire course of radiotherapy during surgery. IORT has been used in a multitude of roles across these sites, for dose escalation (retroperitoneal sarcoma), EBRT dose de-escalation (paediatric tumours), as sole radiation modality (early breast cancers) and as a re-irradiation modality (recurrent rectal and gynaecological cancers).

This article aims to provide a review of the rationale, techniques, and outcomes for IORT across different sites relevant to current clinical practice.

• IORT
• complications
• indications
• outcomes
• techniques

• colorectal cancer
• high dose rate brachytherapy
• radiation therapy
• rectal cancer
• sarcoma

• Cancer
• Colorectal
• Radiation

• T4 rectal cancer
• intraoperative irradiation
• pooled results
• re-irradiation

• colorectal cancer
• intraoperative radiotherapy
• recurrence
• surgery
• survival

• Humans
• Intraoperative Care/methods
• Neoplasm Recurrence, Local
• Rectal Neoplasms/mortality
• Rectal Neoplasms/pathology
• Rectal Neoplasms/radiotherapy
• Rectal Neoplasms/surgery
• Survival Analysis
• Treatment Outcome

• Humans
• Colorectal Neoplasms/pathology
• Colorectal Neoplasms/radiotherapy
• Colorectal Neoplasms/surgery
• Combined Modality Therapy
• Intraoperative Care
• Neoplasm Recurrence, Local/pathology
• Neoplasm Recurrence, Local/radiotherapy
• Neoplasm Recurrence, Local/surgery
• Radiotherapy Dosage
• Treatment Outcome

• K07 CA133187 NCI NIH HHS
• C28503/A10013 Cancer Research UK
• K07-CA1333187 NCI NIH HHS

• Primary locally advanced rectal cancer
• radiotherapy
• recurrent rectal cancer
• surgery

Complete resection is the most important prognostic factor in surgery for pelvic tumors. In locally advanced and recurrent pelvic malignancies, radical margins are sometimes difficult to obtain because of close relation to or growth in adjacent organs/structures. Total pelvic exenteration (TPE) is an exenterative operation for these advanced tumors and involves en bloc resection of the rectum, bladder, and internal genital organs (prostate/seminal vesicles or uterus, ovaries and/or vagina).

Between 1994 and 2008, a TPE was performed in 69 patients with pelvic cancer; 48 with rectal cancer (32 primary and 16 recurrent), 14 with cervical cancer (1 primary and 13 recurrent), 5 with sarcoma (3 primary and 2 recurrent), 1 with primary vaginal, and 1 with recurrent endometrial carcinoma. Ten patients were treated with neoadjuvant chemotherapy and 66 patients with preoperative radiotherapy to induce down-staging. Eighteen patients received IORT because of an incomplete or marginal complete resection.

The median follow-up was 43 (range, 1–196) months. Median duration of surgery was 448 (range, 300–670) minutes, median blood loss was 6,300 (range, 750–21,000) ml, and hospitalization was 17 (range, 4–65) days. Overall major and minor complication rates were 34% and 57%, respectively. The in-hospital mortality rate was 1%. A complete resection was possible in 75% of all patients, a microscopically incomplete resection (R1) in 16%, and a macroscopically incomplete resection (R2) in 9%. Five-year local control for primary locally advanced rectal cancer, recurrent rectal cancer, and cervical cancer was 89%, 38%, and 64%, respectively. Overall survival after 5 years for primary locally advanced rectal cancer, recurrent rectal cancer, and cervical cancer was 66%, 8%, and 45%.

Total pelvic exenteration is accompanied with considerable morbidity, but good local control and acceptable overall survival justifies the use of this extensive surgical technique in most patients, especially patients with primary locally advanced rectal cancer and recurrent cervical cancer.

• tme
• local recurrence
• rectal cancer
• carcinoma
• radiotherapy
• cea

• Rectal cancer
• adjuvant
• chemotherapy
• radiation
• review

• Anal Canal
• Combined Modality Therapy
• Humans
• Neoadjuvant Therapy
• Preoperative Care
• Randomized Controlled Trials as Topic
• Rectal Neoplasms/drug therapy
• Rectal Neoplasms/pathology
• Rectal Neoplasms/radiotherapy

• Adult
• Aged
• Combined Modality Therapy
• Female
• Humans
• Male
• Middle Aged
• Neoplasm Recurrence, Local/radiotherapy
• Neoplasm Recurrence, Local/surgery
• Neoplasm Staging
• Pelvic Exenteration/methods
• Postoperative Complications
• Prognosis
• Proportional Hazards Models
• Rectal Neoplasms/pathology
• Rectal Neoplasms/radiotherapy
• Rectal Neoplasms/surgery
• Survival Rate
• Treatment Outcome