Intraoperative Irradiation. Techniques and Results

INTRAOPERATIVE IRRADIATION. TECHNIQUES AND RESULTS. Edited by Leonard L. Gunderson, Christopher G. Willet, Louis B. Harrison and Felipe A. Calvo. 550 pp. Illust. Humana Press, Totowa, NJ. 1999.US$195.ISBN0-896-03523-9

This comprehensive review by internationally recognized radiation oncologists, surgeons and scientists likely represents the definitive text on intraoperative irradiation and allied techniques. The 4 editors and 75 contributors are from the United States and Europe; none are Canadian.

The book contains 29 chapters divided into 5 parts: general rationale, techniques and methods, normal tissue tolerances, disease site, and organspecific results and conclusions. The text is extremely well referenced, with numerous diagrams and tables. Given the complex nature of the material I would have appreciated some editorial comment at the end of each chapter.

The reader needs to appreciate that across Canada there is no single intraoperative radiotherapy system. Although the resource-intensive nature of an intraoperative radiation source is certainly a contributing factor, in large part the reason for the absence of a single system is the lack of randomized controlled data (comparing standardized therapies with intraoperative irradiation), which, if positive, would mandate the acquisition of intraoperative irradiation machines as the standard of care for various malignant conditions. Despite this, the book remains a useful reference for the dedicated multidisciplinary oncology team, wishing to have a comprehensive review of these techniques (and current results), which are available in only a very few selected North American and European centres.

In addition, it is important for the reader to appreciate the differences between intraoperative radiotherapy and brachytherapy techniques. In the latter, which is almost universally available in Canadian radiation oncology centres, hollow needles can be placed in various sites such as the esophagus, prostate, retroperitoneum, head and neck and limb, after which the radiation source is introduced into the affected area. Patients then receive a measured radiation dose for a period ranging from a few hours to a few days, providing a greater dose intensity than is possible by standard external beam techniques. With the intraoperative irradiation technique, high-dose radiation is applied in the operating room directly to the tumour bed once the tumour has been removed, generally in a one-time dose rather than in multiple doses as with external beam radiotherapy. Thus, very high doses of radiation can be applied to a small area with a much reduced risk of damaging surrounding tissues. The biophysics of a single high dose versus multiple small doses is well covered in the text.

This book left me with a sense of rivalry between the major United States centres providing this service with often very encouraging, but presumably biased, results.