Results: recurrence. The median follow up period was 18

Results: The median age of patients was 60 year (range 50-71).They were four males and two females. The type of cancer was 3 pancreaticcancer, two ampullary cancer and one duodenal cancer. Five patients hadcomplete surgical resection combined with IORT. One patient was found to haveunresectable tumor. Bypass operation in the form of choledochojejunostomy and gastrojejunostomywas done combined with IORT. The median operative time was 4.

5 hours (range 4-6 hours). The histopathological results were demonstrated in (Table. 3).The average postoperative hospital stay was 13.5 days (range 10– 17 days).

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Allpatient tolerated the procedure without in-hospital morbidity or mortality. Nopatient received neoadjuvant chemotherapy. Only 4 patients receivedpostoperative chemotherapy. All patients had regular follow up. Follow up wasdone every 3 months for the first 2 years then every 6 months for the next 2years then annually. The follow up entails physical examination, completelaboratory tests with tumor markers and imaging by CT scan. During the followup period of the current study, 2 patients died. Both patients were diagnosed to have pancreatic cancer.

 Their management was surgical resectioncombined with IORT and they both received postoperative chemotherapy. The firstpatient who had unresectable tumor died after 14 months from disease progressionand liver metastases. The second patient died after 17 months. This patient hadrecurrent parathyroid cancer that was operated before. He developed lungmetastases which was proved by biopsy to be metastases from the parathyroidcancer.

This patient received postoperative chemotherapy. The remaining4 patients are still surviving with overall free survival rate 66.6%.

They comeregularly for follow up. They have no recurrence. The median follow up period was18 months (range 6-41). Discussion:IORT was applied since more than 4 decades. It wasdiscovered in Japan. Since then, IORT was applied in patients with non-metastasizing,resectable or partially resectable tumors  (10). The idea is to allow the radiation beam to pass fromthe radiation machine to the affected area with tumor residual after incompleteresection or tumor bed after complete tumor resection.

This beam will have accessto the targeted area directly in a focused concentrated beam. This willguarantee the administration of a big dose of radiation to the affected areaswhich increases the chance of destroying the tumor cells remaining aftersurgical resection. The unaffected organs and tissues can be shielded or takenaway in order to decrease the risk of radiation complications on these organs (11). Many studiesevaluated the effect of the application IORT on the patients with locallyadvanced diseases or who have residual diseases concluded that it is of great effecton the residual tumor and also increases the period taken for tumor recurrence (12, 13). Theseresults also can applied also for patients with resectable pancreatic andperiampullary adenocarcinoma. In cases of locally advanced tumors which arebeyond complete surgical resection, IORT still has the advantages of destroyingthe disease locally which  decreases itslocal complications and decreasing the tumor pain resulting from theinfiltration of the neural plexus (14).

The studies that recorded the effect of IORT application forthe patients who have pancreatic or periampullary cancer and who had complete surgicalresection are mainly retrospective (15-18). Also many studieshave recorded the results in patients who have complete resection combined withIORT and who had complete resection without IORT application (4).  They concludedthat the application of IORT reduces the incidence of disease recurrence. (4). Zerbi et al.

(15)  studied theeffect of the application of IORT on patients after complete tumor resection andcompared them with patients who had complete tumor resection without IORT applicationand they found that IORT application will not add for postoperative patient’smorbidity and mortality. Also, they found that the incidence of tumor recurrencewas only 26% in the group of patients who received the IORT compared with 56% tumorrecurrence in the group who had complete resection without IORT application. Anotherstudy was conducted on 2 groups of patients.

The first included 127 patientswho had complete resection of the tumor with the application of IORT and thesecond included 76 patients who had complete tumor resection without IORTapplication. The results showed that the application of IORT did not affectboth the post-operative complications and operative related mortality. They alsofound that the application of IORT delayed the local recurrence significantly inthe first group especially in patients who have their tumor in its early stages(16). More recentstudies came in accordance with these result (17, 18).

 After the review of the histopathology of ourpatients with pancreatic and periampullary cancer and the affection of the localizedtissues and lymph nodes and also after the review of the related literature, westarted to apply IORT as part of our protocol in the treatment of pancreaticand periampullary cancers. Our initial results from our center prove the benefitof the application of IORT as a part of the management of theses tumors. Conclusion: Application of IORT is a very safe and feasibleprocedure.

The patient can tolerate it well. It did not affect thepostoperative course regarding postoperative complications and operativerelated mortalities. Our preliminary results are favorable. In order to have arigid recommendation for the application of IORT, the study needs larger numberof patients with long period of follow up.