Textbook

Foreword

Targeted intraoperative radiotherapy was developed more than a decade ago so that radiation was applied during operation targeted to the peri-tumoral tissues. The technique was designed at University College London for breast cancer and has through a randomized controlled trial disseminated all over the world.

The targeted intraoperative radiotherapy in oncology is the first reference textbook in this field, edited by the pioneers of this technology. A panel of multidisciplinary experts who have been involved with the TARGIT technology for many years contributed to this book. It covers the scientific background of this technology, including radiobiology, mechanism of action and radiation safety aspects. It also provides a well-illustrated practical guidance to clinicians from various disciplines involved in management in cancer. It comprehensively covers the quality assurance and commissioning of the equipments and also provides detailed information on how to use the system in the operating room. The book also provides the latest updates on the results of randomised controlled trials and all the literatures related to this technology. The quality of life and health economics and cosmesis is also covered, along with training requirements to introduce this innovative technology into the health care system. Although the emphasis has been on breast cancer, applications in other cancers including rectal, brain, head and neck and cervical cancers as well as its use in bone metastasis is discussed.

We congratulate the editorial team with an excellent review on this topic, which will alter the management of patients with many solid tumors, especially breast cancer, in the coming years.

Cornelis J.H. van de Velde            
Professor of Surgery
President European CanCer Organization (ECCO)

Professor David Azria
Coordonnateur du pôle de Radiothérapie Oncologique
Président de la CME ICM Montpellier
 

Preface

Over the past few decades, the major change in the management of early breast cancer has been the shift towards less invasive approaches. These include breast conservation surgery and sentinel lymph node biopsy. Postoperative radiotherapy is regarded as an essential adjunct to BCS and cannot be safely omitted. There is overwhelming evidence that this approach decreases the risk of local recurrence and improves survival. The aim of radiotherapy is to selectively kill any residual tumour cells without damaging normal cells.

It is important to remember that whole breast radiotherapy is not without risks. Although treatment regimens have become safer with careful planning using computed tomography and treatment delivery using tangential fields, healthy tissues such as the heart, ribs and lungs do receive a small but significant dose of radiation.

Although the recurrence rate in breast cancer is low, the results of many clinical trials and observational studies have demonstrated that around 90 % of local recurrences after BCS occur within the same quadrant of the breast that harboured the primary tumour (index quadrant). This observation raises the question of whether whole breast radiotherapy is necessary in all patients and whether radiotherapy to the index quadrant of the breast alone would be sufficient. This has led to growing interest in accelerated partial breast irradiation (APBI), which aims to decrease the volume of breast treated and increase the daily fraction size of radiation.

A Photon Radiosurgery System (PRS) was first introduced at the London Royal Free Hospital in 1995 to assess its role in the treatment of solitary brain metastases. The tip of the probe was placed into the tumour, using standard
stereotactic techniques, allowing for the delivery of a prescribed therapeutic radiation dose directly into the centre of the metastasis. Subsequently, the system was trialed for the first time in treatment of primary breast cancer at the University College London after the design and development of polymer applicators of various diameters to insert into the tumour cavity after resection.

In March 2000, an international, phase 3 randomised controlled trial in early breast cancer was launched as a non-inferiority trial and enrolled over 3,400 patients from 33 centres in eleven countries. The trial results indicate that the TARGIT technique using IntrabeamTM  is safe and the efficacy falls within the pre-specified non-inferiority margin of 2.5 % for local recurrence as compared to external beam radiotherapy. Subsequently this technique was used for other solid tumours which is at various stages of development.

TARGIT Academy was subsequently established in 2010 to ensure appropriate introduction of this new technology into routine clinical practice. The focus of the Academy is on quality assurance and high standards in clinical education and training. It runs regular training courses in London and Mannheim and offers high-quality training and provides a networking platform which enables interaction and cooperation between surgeons, radiation oncologists, medical physicists and the extended multidisciplinary team.

This book is prepared by a panel of multidisciplinary experts who have been involved with the TARGIT technology from the outset. The purpose of this book is to provide a practical guide to clinicians from various disciplines who treat cancer patients. Although the emphasis is on breast cancer, however we have included the experience in brain tumours, rectal cancer and spinal metastases. We have presented case histories to enhance the learning points. We hope that you find this book a useful adjunct to your day-to-day practice.

  • London, UK Mohammed Keshtgar
  • London, UK Katharine Pigott
  • Mannheim, Germany Frederik Wenz