In a groundbreaking procedure, the East Hospital employs intraoperative radiation therapy during a complex pelvic tumor surgery

For the first time, the Riga East Clinical University Hospital (East Hospital) used intraoperative radiation device during a high-complexity sarcoma surgery. Following a thorough evaluation of the most effective and least invasive treatment options in a multidisciplinary preoperative council review, and by carefully planning each stage of the surgery, the team succeeded in facilitating the patient’s recovery from a profoundly serious and seemingly hopeless condition.

The patient is a young woman who underwent successful tumor removal surgery 12 years ago. Initially, she attended regular follow-up consultations to monitor her health, but eventually discontinued these visits and fell out of medical observation. “Sadly, oncology patients sometimes display this kind of defense mechanism, choosing to deny their diagnosis rather than come to terms with it. Consequently, they avoid follow-up appointments, fearing that “something” may be discovered, and this particular patient was no exception. When her illness became impossible to ignore, she returned to seek medical assistance. It was a considerable challenge to prepare her for surgery and to plan the most effective treatment,” pointed out Associate Professor Armands Sīviņš, Head of the Oncology Surgery Clinic of the Latvian Oncology Centre inpatient facility at the Riga East University Hospital.

First stage of surgery: surgical removal of sarcoma

By the time the patient arrived at the East Hospital, her health was in a critical state due to the massive size of the tumor. She presented high fever that would not drop for an extended period of time. It was evident that the greatest challenge would be the surgical removal of the massive tumor.

“The sarcoma presented as a local recurrence, which most commonly spreads to the lungs. The tumor was lodged in the small pelvis, fused with the uterus and uterine appendages. One of the patient’s ureters was compressed, causing functional issues, and it was necessary to relieve it first to save kidney function. We were prepared to remove all pelvic organs, including the bladder, uterine appendages, and the rectum, but we ultimately managed to preserve the bladder, which is still functioning. However, the tumor had to be removed along with the rectum, uterus, and uterine appendages. Since the tumor had invaded the pelvic walls, some nerves also had to be excised. There was a high risk of local recurrence. As the tumor grew, it pressed into the bone. We removed the tumor, but we cannot be certain if any microscopic cancer cells remain,” explained Associate Professor A. Sīviņš, describing the course of the surgery.

Second stage of surgery: radiation using the intraoperative radiation device directly in the operating room

This was the first time the intraoperative radiation therapy was employed to irradiate the tumor bed in the abdominal cavity (pelvis). This procedure took place during surgery, immediately following the surgical removal of the tumor by Associate Professor A. Sīviņš’ team. The intraoperative radiation procedure itself takes just under two minutes, though substantial planning and preparation are necessary beforehand.

“The planning of radiation therapy primarily relies on radiological examinations. We examined the areas where the tumor was most closely attached, as these would be the most likely targets for radiation. Unlike breast tumors, where we have used intraoperative radiotherapy for some time, this case was more complex and challenging. The tumor was very large, but the pelvic cavity is a confined space from a radiotherapy perspective. In this particular case, it was initially difficult to predict which areas would be exposed during surgery and where additional radiation would be necessary,” explained Gints Rausis, Radiation Oncologist in the Clinical Department of Radiotherapy at the Latvian Oncology Centre inpatient facility at the East Hospital.

Hands-on training played a crucial role in the successful outcome, involving the entire team of radiation oncologists, radiographers, and medical physicists, who initially worked out the equipment setup and arranged the necessary tools for the radiation procedure.  This was followed by a personalized radiation therapy plan for the patient, outlining the specifics of the radiation process. The plan specified the angle and size of the tube, the radiation dose, and the intensity required to irradiate the tumor bed and surrounding tissues. The radiation therapy plan underwent multiple checks to ensure the affected tissues were precisely targeted while healthy tissues were protected as much as possible.

Conclusion of the surgery and findings

“With the successful implementation of intraoperative radiation therapy device at the East Hospital, the patient was able to avoid postoperative radiation therapy, leading to a gentler treatment approach and significantly decreasing the overall treatment time,” summarizes G. Rausis.

The surgery was challenging, yet due to careful planning, it extended for eight hours.  The patient experienced sensory disorders during the postoperative period, but she is now able to walk and move on her own without a wheelchair.

“We can certainly say that the implementation of intraoperative radiation therapy rendered this surgery safer, which underscores the importance and benefit of innovative technologies. During the surgery, the safest scenario is when surgeons are able see what they are doing or what needs to be done. If visibility is compromised, it leads to stress. For added safety, we successfully employ a new surgical technique through multidisciplinary cooperation. Radiation oncologists and surgeons will investigate and validate the advantages, as our current working philosophy in tumor surgery is – all or nothing! I must express my deep satisfaction in being able to assist the patient, while also showcasing our collaboration, professionalism, and the use of innovative technologies,” highlights Associate Professor A. Sīviņš.

The surgery was performed by the medical team of the Latvian Oncology Centre inpatient facility at the East Hospital: 

• Head of the Oncology Surgery Clinic, Associate Professor Armands Sīviņš
• Surgeon Kārlis Tapiņš
• Gynaecological oncologist Zanda Barinska
• 5th year surgical resident Marika Juško
• Anaesthesiologist-intensivist Aļona Antonova from the Anaesthesiology and Intensive Care Unit
• Nurse anaesthetists Zita Zalivska and Ksenija Aleksejeviča from the Anaesthesiology and Intensive Care Unit
• Surgical nurse Kristīne Daubare
• Nurse assistant Jūlija Ižika
• Radiation oncologist Gints Rausis from the Clinical Department of Radiotherapy
• Medical physicists Džeina Platace, Sanda Kronberga, Inga Balode, and Gaļina Boka from the Department of Clinical Medical Physics and Dosimetry
• Radiation oncologist Anastasija Trofimoviča-Krasnorucka from the Clinical Department of Radiotherapy
• Radiographer Kristaps Reinis from the Department of Clinical Medical Physics and Dosimetry

About the East Hospital 

Riga East Clinical University Hospital is the largest and strategically significant multi-profile hospital in the country. The hospital consists of five inpatient facilities – Gaiļezers, Latvian Oncology Centre, Biķernieki, Tuberculosis and Lung Disease Centre, and Latvian Infectious Diseases Centre, along with various specialised centres and clinics. The hospital provides highly specialised inpatient and secondary outpatient healthcare, offering multidisciplinary tertiary-level treatment and care in line with modern technology and medical knowledge. Approximately 80% of all cancer patients in Latvia are treated at the hospital. It serves as a practical training base for both Latvian educational institutions and foreign students, providing further education and knowledge transfer to healthcare specialists within and beyond the country. The hospital engages in scientific research and develops innovative methods for patient treatment. As the third-largest employer in the country, the hospital employs around 5000 staff members.