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International Journal of Cancer Research & erapy
Volume 2 | Issue 2 | 1 of 3
Int J Cancer Res er, 2017
Intraoperative Radiotherapy promoting early Breast Cancer Detection: An observational
Review
Research Article
Maha Abdel Hadi*, Lina Abu Arida, Amal Khalifa and Hiyam Al Haddad
Abstract
Aim: The lack of structured breast cancer awareness programs (BCAP) in developing countries coupled by the
scarcity of radiation oncology centers limit the available surgical options. The aim of this study is to Probe the use
Intraoperative radiotherapy (IORT) treatment as a stem to initiate positive impact on early disease detection and
propagate breast conserving surgery (BCS).
Materials and Methods: This observational review was undertaken at King Fahd hospital of the university, AL
Khobar, Eastern province of Saudi Arabia between 2012- 2016. All patients diagnosed with breast cancer were
reviewed. Strict recruitment criteria were adopted for patients to receive IORT. Selected candidates where only
those who were eligible and consented to undergo BCS and IORT. Special emphasis was placed on demographic
data, tumor size at the initial presentation, post Neo-adjuvant chemotherapy response, post–pathology cavity size
and applicator size used.
Results: The total number of patients diagnosed with breast cancer were 330 out of which 69 (20%) patient were
eligible for IORT. Age ranged from31-75years with the Median age 50 years. Applicator sizes used ranged from
2.0-5.0. Tumor size ranged between 0.6-4.0 centimeters. 1 (1%) was post pathology case with excision performed
two weeks prior to presentation. 0-1 in 8(11%), 1.1-2 in 22(31%), 2.1-3 in 24(34%), and 3.1- 4.0 in 15 (21%)
patients. 7(10%) patients received Neo-adjuvant chemotherapy with positive response and were included. The
applicator sizes available ranged between 1.5-5.0 centimeters. Applicator sizes were size 2.0 in 2 (3%), size 2.5
in 10 (14%), size 3.0 in 18(26%), size 3.5 in 16 (23%), size 4.0 in 10 (14%), size 4.5 in 6 cases (9%) and size 5.0 in
7 cases (10%). Smaller applicator sizes 2.0-3.5 centimeter in diameter were used in 46 (66%) of cases suggesting
that smaller lesions are currently been diagnosed.
Conclusion: The introduction of Intraoperative radiotherapy (IORT) intended as boost therapy is a break through
treatment of early breast cancer. While developing countries remain disadvantaged by the lack of adequate
radiotherapy centers to cover its population needs, IORT can offer an alternative solution for a selected subset of
women with early breast cancer as an exclusive or boost therapy. Its positive impact on the early detection is well
illustrated in this observational study. In addition, its use supported the promotion of BCS in early breast cancer
thus, it braced a positive impact on early detection strategies.
Breast Division, Department of Surgery, Imam Abdulrahman
Alfaisal University Kingdom of Saudi Arabia.
*Corresponding author
Maha Abdel Hadi, Professor/Consultant General & Breast surgeon,
King Fahd hospital of the University, P.O.Box 40293 Al-Khobar
31952, Kingdom of Saudi Arabia, E-mail: mhadi@uod.edu.sa
Submitted: 11 Feb 2017; Accepted: 04 Mar 2017; Published: 15 Sep 2017
Keywords: IORT, Intrabeam, Applicators, Early detection.
Introduction
The fast pace of urbanization in many developing countries
coupled with the imposed changes in life style has resulted in many
alterations in disease patterns. Breast cancer has shown increasing
incidence over the last decades with young age and advanced
disease at the initial presentations [1]. The unpopular Breast Cancer
Awareness programs (BCAP) are focused on didactic educational
lectures with repetitive information. These programs usually dish
out basic knowledge on breast cancer, early detection methods,
and risk factors, however; they generally fail to fully disseminate
information or disclose treatment options [2]. Radiotherapy as
an integral treatment modality in cancer therapy that dictates
its demand. In developing countries and countries with limited
resources these facilities are scarce. They are expensive to establish,
upgrade, and maintain. Stringent plans are needed to estimate the
disease burden to be able to appreciate the cost that may be incurred
by advanced disease [3]. The increase prevalence of breast cancer
in our communities in recent years coupled by cultural stigma and
the limited surgical options of liberal adoption of mastectomies
alienate women from presenting with early disease [4]. In culturally
ISSN: 2476-2377
Volume 2 | Issue 2 | 2 of 3Int J Cancer Res er, 2017
driven communities introducing IORT as boost or exclusive therapy
has nally caught women’s attention. IORT information circulated
through health education programs initiated interest in promoting
breast conserving surgery BCS for early breast cancer.
Materials and Methods
This observational review was undertaken at King Fahd hospital
of the university, AL Khobar, Eastern province of Saudi Arabia
between 2012- 2016. All patients diagnosed with breast cancer
were reviewed. Strict recruitment criteria were adopted for patients
to receive IORT. Selected candidates where only those who
were eligible and consented to undergo BCS and IORT. Special
emphasis was placed on demographic data, tumor size at the initial
presentation. Those with post Neo-adjuvant chemotherapy treatment
and post pathology excision were included. Emphasis was placed
on the cavity size and applicator size used. The applicator sizes
available ranged between 1.5-5.0 centimeters. Wide local excision
with 1-2cm gross margin was adopted in all surgical procedures.
Cavity size is measured and the corresponding applicator size was
chosen. Intraoperative ultrasound was used to conrm the contact of
the target tissue with the applicator. ZIESS INTRABEAM PRS 500
with XRS4 delivering uniformly 20 Gy. to the target tissue.
Results
The total number of patients diagnosed with breast cancer were 330
out of which 69 (20%) patients fullled the strict criteria and were
eligible for IORT. Age ranged from 31-75years with the Median age
50 years. 1 (1%) was post pathology case with excision performed
two weeks prior to presentation. Tumor size reported uniformly by
ultrasound was between 0.6-4.0 centimeters 0-1 in 8(11%), 1.1-2
in 22(31%), 2.1-3 in 24(34%), and 3.1- 4.0 in 15 (21%) patients.
Figure I 7(10%) patients received Neo-adjuvant chemotherapy with
positive response and were included.
Applicator sizes available ranged from 1.5-5.0 centimeter in diameter.
(Figure II) (a,b) Applicator used were size 2.0 in 2 (3%), size 2.5
in 10 (14%), size 3.0 in 18(26%), size 3.5 in 16 (23%), size 4.0 in
10 (14%), size 4.5 in 6 cases (9%) and size 5.0 in 7cases (10%). To
our surprise smaller applicator sizes 2.0-3.5 centimeter in diameter
accounted for 46 (66%) of cases conrming that smaller lesions are
currently been diagnosed. (Figure III) (a,b).
Figure I: Applicators and the Radiation source.
Figure II (a,b): Tumor Size.
Figure III (a,b): Applicator Sizes used.
Discussion
Breast cancer continues to be ranked rst among females worldwide
[5]. It is estimated annual number of cases diagnosed globally with
breast cancer exceeds 1 million and this number is expected to
increase to 1.5 million by the end of the decade because of the major
increase in the number of diagnosed cases in countries with limited
resources [6]. Due to the suboptimal early detection strategies in
developing countries the average tumor size at the time of the initial
presentation is reported as more than 4 centimeters in diameter [7].
Therefore, it is understandable that mastectomy is still advocated
as the rst treatment option by many surgeons and oncologists in
developing countries. The cultural inuence of body image stigma
inicted by the liberal adoption of mastectomies further distant
women from seeking early treatment, hence delayed presentations.
Wide local excision is infrequent, it is practiced cautiously with
major reservations.
While radiotherapy remains an integral adjuvant component in
the treatment of segmental breast resections, yet, the scarcity
of the radiotherapy centers in many developing countries limits
the surgical options offered. Concerns over the global increase
of cancer burden have been voiced by the International Atomic
Energy Agency (IAEA). As the cancer burden increase, the long
term high cost incurred by the treatment of advanced disease and
palliative care reciprocally increase. The least prepared developing
countries take the brunt and the consequences. As the economy
dictates, the number of Radiation Oncology centers worldwide is
scarce and mainly clustered in developed countries [8].
Emerging alarming reports indicate that 57% of cancer cases
occur in low and middle income countries with 50% - 90% of
underprivileged patients requiring radiotherapy are deprived
from access to radiation facilities [9]. The late presentation of
the young women in the reproductive age is both disturbing and
disruptive. Partial treatment contributes to advanced disease and
high mortality for a potentially treatable cases [10].
Tumor size No. of Patients
0-1 8
1.1-2 22
2.1-3 24
3.1-4 15
Applicator size No. of Patients
1.5 0
2.0 2
2.5 10
3.0 18
3.5 16
4.0 10
4.5 6
5.0 7
Volume 2 | Issue 2 | 3 of 3
Int J Cancer Res er, 2017
Extensive efforts have been probed in an attempt to improve
breast cancer management options in developing countries thereby
encouraging women to present early. Sporadic and individual efforts
are commendable yet, they function in a limited scale that do not
signicantly contribute to reality.
The introduction of the modern modality of IORT as targeted
treatment for early breast cancer appears as a breakthrough. It
expected to provide a practical, convenient and efcient method of
treatment both as an exclusive or boost therapy suitable for healthcare
facilities in countries with limited resources. The encouraging results
from this observational study of IORT have prompted women who
would normally shy away with breast masses, resist disclosure and
refuse treatment to present early.
Despite the lack of structured awareness programs in our communities
in this encouraging study the tumors size at the initial presentation
ranged between impalpable masses of 0.6-4 centimeters in largest
diameter. Women were more willing to receive neo-adjuvant
chemotherapy in order to be able to undergo BCS. The applicator
sizes used were smaller in 46 (66%) of cases than the predicted
sizes for treatment. Further, the easy handling of IORT equipment in
the conventional operating rooms shattered all known barriers and
concerns to radiation exposure and safety.
IORT is an efcient, convenient, cost effective, sparing or shortening
the patients the long sessions of external beam radiation while
providing equally effective outcomes [11,12].
Conclusion
While developing countries remain by the lack of adequate
radiotherapy centers to cover its population needs, IORT can offer
an alternative solution for a selected subset of women with early
breast cancer as an exclusive or boost therapy. Its positive impact
on the early detection is well illustrated in this observational study.
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Copyright: ©2017 Maha Abdel Hadi, et al. is is an open-access article
distributed under the terms of the Creative Commons Attribution License,
which permits unrestricted use, distribution, and reproduction in any
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