Intraoperative Radiation Therapy - IORT

For selected women with early breast cancer, the whole course of radiation can be given in the operating room, in the twenty minutes after the tumor comes out. One dose. No return visits.

Intraoperative radiation therapy, or IORT, delivers a single dose of radiation to the bed of a tumor while the patient is still under anesthesia, through an applicator placed into the wound. The TARGIT-A trial randomized 2,298 women aged 45 and over with small breast cancers to a single intraoperative dose or to three to six weeks of external radiation, and found local recurrence at five years of 2.11 percent against 0.95 percent, inside the margin the trial had set for equivalence, with no difference in survival from breast cancer over a median of 8.6 years (Vaidya and colleagues, BMJ, 2020). Around one woman in five needed external radiation added when the pathology showed higher risk. This page explains who qualifies, what the two large trials found and where they disagree, what happens in the operating room, the side effects, the other cancers treated this way, and how patients from abroad arrange it at Biruni Hospital in Istanbul.

What IORT is

Radiation after breast-conserving surgery exists to kill the cancer cells that may remain in the tissue around the cavity. Nine out of ten recurrences in the breast happen within a few centimeters of where the tumor was. IORT takes that observation literally. Once the surgeon has removed the tumor and checked the margins, an applicator the size of the cavity is placed into it, the tissue is gathered around it, and a dose that would take three to five weeks to deliver from outside is given in a single exposure lasting twenty to thirty minutes. The staff leave the room. The anesthesia continues. Then the applicator comes out and the wound is closed as usual.

Two ways to deliver it

One system generates low-energy X-rays at the tip of a probe inside a spherical applicator. The dose peaks at the surface of the cavity and falls away within a centimeter, which spares the skin, the ribs, the lung and the heart almost entirely. The other uses a mobile linear accelerator wheeled into the operating room to deliver electrons through a cylinder placed against the tumor bed, reaching a little deeper and treating a wider area in a few minutes. The trials below tested one of each. Which system the hospital uses for a given patient depends on the size and depth of the tumor bed, and the case review will say.

Who qualifies

A minority of women with breast cancer. The right minority.

1. Age. Forty-five and over in the TARGIT-A trial, 48 to 75 in ELIOT. Younger women have a higher rate of recurrence and are treated with whole breast radiation.
2. Size. A single tumor of 3.5 centimeters or less on imaging, and in practice under 2.5 centimeters, of the ordinary ductal type.
3. Lymph nodes. Clinically clear before surgery, confirmed by a sentinel node biopsy at the operation.
4. Receptors. Estrogen receptor positive and HER2 negative disease carries the lowest risk of recurrence and gains the most.
5. Margins. Clear on the frozen section at surgery, and confirmed on the final pathology.

The risk-adapted approach

What the trials show

Two large randomized trials. They agree on survival and disagree on recurrence, and the reason for the disagreement is the lesson.

• ELIOT gave the single dose to every woman randomized to it, whatever the final pathology showed, and its recurrence rate was more than four times that of whole breast radiation, although survival was identical (Orecchia and colleagues, Lancet Oncology, 2021).
• TARGIT-A added external radiation when the pathology showed risk, and its recurrence rate stayed within a percentage point.
• Both trial groups reached the same conclusion in their own words, that ELIOT should be offered to selected patients at low risk of recurrence and that TARGIT-IORT should be discussed with eligible patients when breast-conserving surgery is planned.

Reading the numbers as a patient

A recurrence in the breast after IORT is treated, usually by a second operation and external radiation, and it did not shorten life in either trial. What a patient weighs, then, is a small extra risk of a second local treatment against the certainty of avoiding three to five weeks of daily visits, the skin reaction, the tiredness and the exposure of the heart and lung. For a woman of 70 with a small hormone-sensitive tumor, the trade is easy. For a woman of 46 with a grade 3 tumor, it is a trade the criteria exist to prevent.

The operation day

The same operation as any breast-conserving surgery, made longer by about forty minutes.

If the frozen section says no

Recovery and side effects

Fewer than after external radiation, and different in timing.

What the trials did not measure

Beyond the breast

The randomized evidence lives in breast cancer. The technique itself predates it by decades, and specialist centers use it wherever a tumor lies against a structure that cannot be given a full dose from outside, because the surgeon can lift the bowel, the ureter or the nerve out of the field with a retractor and the dose can go where no external beam could safely reach.

• Locally advanced and recurrent rectal cancer, where a single electron dose to the pelvic sidewall after removal of the tumor raises local control in patients whose margins are close.
• Pancreatic cancer, where the dose goes to the bed of the tumor after resection or, in unresectable disease, to the tumor itself for pain control.
• Soft tissue sarcoma of the limb or retroperitoneum, where IORT to the tumor bed reduces the external dose needed and protects the nerves and bowel nearby.
• Recurrent gynecologic and head and neck cancers in previously irradiated tissue, where no further external dose is possible.

What it does not replace

Chemotherapy, hormone therapy and surgery itself. IORT changes how radiation is given. Nothing on this page changes whether radiation is needed.

Deciding, and coming from abroad

IORT rewards planning. Imaging and biopsy settle the decision before surgery, the frozen section confirms it during, and a patient who arrives with the right studies can have the operation within days of the consultation. What the team needs is the mammogram and ultrasound as images, the biopsy report with receptor status and grade, an MRI if one was done, the surgical plan proposed at home, and the list of medicines. Two things shorten the process more than anything else. A biopsy report that states the receptor status, the HER2 result and the grade, since without those three the case cannot be assessed and the biopsy would have to be repeated, and imaging sent as files rather than as a written report, because the radiologist here will measure the tumor again and look for a second focus that would rule IORT out. A patient who has already been told at home that she needs a mastectomy, or that her tumor is too large for IORT, should still send the file, because the criteria vary between centers and the answer is sometimes different.

TARGIT-IORT should be discussed with eligible patients when breast conserving surgery is planned (Vaidya and colleagues, 2020).

One coordinator from the international patients office handles arrangements from the first message through discharge and answers the same WhatsApp number once you are back home. The office works in English, Arabic, French, Russian, Serbian, Romanian and Spanish and books interpreters for other languages. It arranges the visa invitation letter, airport transfers, daily transport and accommodation near the hospital. The kitchen prepares halal, vegetarian and diabetic meals, a prayer room is on site, and a request for a female surgeon is met wherever the rota allows. Patients are fit to fly after the wound check.

Cost

An estimate follows the file review and covers the surgery, anesthesia, the intraoperative dose with the physicist's time, the applicator, pathology and the hospital night. Hospitals in this market quote breast-conserving surgery with IORT as one package, with any external radiation that the pathology later requires priced as a separate course.

Two questions. What the figure includes, and what the added course would cost if the pathology calls for it.