Using the New INTRABEAM Mobile Intraoperative Radiotherapy System During Surgery for Pancreatic Cancer

A Case Report

Xiaodong Song; Zili Shao; Huihong Liang

Disclosures

J Med Case Reports. 2019;13(23) 

In This Article

Case Presentation

A 56-year-old Chinese man was hospitalized 2 months after the discovery of a pancreatic mass and a 1-month history of abdominal pain. He had taken no medication before hospitalization.

A physical examination after the hospitalization did not reveal any obvious abnormalities. He had a body temperature of 36.6 °C, heart rate of 99 beats per minute, blood pressure of 141/83 mmHg, respiratory rate of 20 breaths per minute, and oxygen saturation of 100%. His neurological status was normal. His family history was noncontributory. He smoked cigarettes for 20 years, but it is unknown how many cigarettes he smoked per day. He never consumed alcohol. Occupationally, he worked as an office manager.

Laboratory test results are shown in Table 1. Blood tests revealed a high level of the CA19-9 tumor marker (1525.84 U/mL). An abdominal computed tomography scan with enhancement and vascular reconstruction revealed a space-occupying lesion in the pancreatic head and neck; the findings suggested the presence of pancreatic cancer with invasion of the hepatic artery, splenic artery, mesenteric vein, and origin of the portal vein (Figure 1). Pathological examination of a specimen from an endoscopic ultrasound puncture biopsy revealed abnormal cells, with a morphology consistent with that of adenocarcinoma. Positron emission tomography-computed tomography revealed abnormally high fluorodeoxyglucose metabolism that was limited to the space-occupying lesion, suggesting a malignant pancreatic lesion, with atrophy of the pancreatic tail and many small nodules in the space surrounding the pancreas. He was diagnosed as having a T4N2M0 local advanced pancreatic cancer.

Figure 1.

Representative computed tomography scan images. The white circle represents the location of the tumor

Six days after admission, he underwent distal pancreatectomy and splenectomy as well as intraoperative radiotherapy (described below) under general anesthesia with tracheal intubation. A subcostal incision was made to expose his abdominal cavity, and the Kocher maneuver was subsequently performed to dissect the gastrocolic ligament and duodenal lateral peritoneum, which exposed the pancreatic tumor. The lesion was approximately 8 cm × 5 cm and had a hard texture and the tumor activity is poor (Figure 2). Dissection and pancreatic isolation (starting from the tail and moving to the right) revealed that the tumor had invaded the superior mesenteric vein, middle colic artery, and celiac trunk artery. After isolating his spleen, the pancreatic retroperitoneum was opened, and his spleen and pancreatic tail were turned upward and isolated left to right from the posterior aspect to the superior mesenteric artery. A harmonic scalpel was used at this site to sever his pancreas, and the pancreatic duct was closed using a 4–0 Dexon suture. Local tumor remnants were observed in the posterior pancreas. The upper boundary of the remaining tumor bed reached the trunk of his abdominal cavity, the lower boundary reached his middle colic artery starting from the superior mesenteric artery, and the right boundary reached his superior mesenteric artery.

Figure 2.

The resected gross specimen of the pancreatic cancer and spleen

The INTRABEAM system was moved into the surgical field, and a 6-cm flatbed source applicator was selected based on the appearance of the tumor bed (Figure 3). After applying an aseptic protective cover, the source applicator was placed close to the tumor bed, and our patient's surrounding bowel and organs were protectively insulated using two layers of surgical gauze (approximate thickness 2 cm). After all personnel had left the operating room, radiotherapy was started using the following parameters: a radiotherapy dose of 10 Gy, an irradiation time of 27.4 minutes, an acceleration voltage of 50 kV, and an acceleration current of 40 μA. A drainage tube was subsequently placed at the cut edge of his pancreas, and his abdominal cavity was closed after confirming that there was no bleeding or pancreatic leakage. The total intraoperative blood loss was 200 mL.

Figure 3.

Intraoperative radiation therapy using the INTRABEAM radiation system

He passed gas on postoperative day 2, and the gastric feeding tube was subsequently removed. On postoperative day 8, < 30 mL of fluid (amylase 21 U/L) had been lost via the abdominal drainage tube, which was removed before our patient was discharged on postoperative day 9. No surgery-related complications were observed, his postoperative CA19-9 level was 924.73 U/L, and his abdominal pain completely disappeared based on the numerical rating scale for cancer pain.[11] He has been followed for 6 months after surgery, and no obvious tumor recurrence has been observed.

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