The first intraoperative radiotherapy procedure has been performed in a breast cancer patient at the East Hospital

Riga East University Hospital (Riga East Hospital) has performed the first intraoperative radiotherapy procedure on a 68-year-old woman diagnosed with an early tumour of the left breast. Intraoperative radiotherapy is applied to irradiate the tumour bed during surgery immediately after tumour removal, and it allows certain groups of patients to forgo postoperative – adjuvant – radiotherapy. Due to the successful use of intraoperative radiotherapy device, breast cancer treatment at the East Hospital has become even more sparing for certain groups of patients, while significantly shortening the treatment time.

The intraoperative radiotherapy equipment is currently the only one in the Baltic States whose effectiveness has been confirmed in clinical trials and can be successfully used in breast cancer surgery.

“It is important to emphasize that intraoperative radiotherapy is not a complete substitute for postoperative or adjuvant radiotherapy and should be used in a specially selected group of patients. For elderly patients with an early diagnosis of unifocal, low-grade breast cancer, especially patients with comorbidities, using a course of intraoperative radiotherapy, we can perform a more breast-conserving surgery, thus improving the quality of life of our patients and significantly reducing the need for further treatment and lengthy hospital stays. Another indication for intraoperative therapy in breast cancer patients is to reduce the duration of adjuvant radiotherapy,” explains Krista Arcimoviča, surgeon of the Department of Breast Surgery at the Oncology Centre of Latvia of the East Hospital.

The first patient treated with intraoperative radiotherapy was a 68-year-old woman diagnosed with an early tumour of the left breast. The patient was initially diagnosed with a suspected breast tumour during a screening mammography examination. An early unifocal breast tumour, a subtype of low-grade breast cancer, was diagnosed after further examinations at the Oncology Centre of Latvia. Although the woman’s general health was good, she had a chronic, progressive neurological comorbidity.

Kristaps Eglītis, surgeon of the Department of Breast Surgery, emphasizes:  “The size of the tumour in this patient was small in relation to the size of the breast gland. According to the recommendations, in cases where the tumour is removed while preserving the breast, it is necessary to prescribe postoperative – adjuvant – radiotherapy to reduce the chance of tumour relapse in the breast. Adjuvant radiotherapy can last up to four weeks. Especially difficult are situations where the patient lives in remote regions of Latvia and is unable to travel to undergo radiotherapy as an outpatient service, which was also the case for this patient. Although the patient could theoretically receive outpatient radiootherapy, she has to stay in an inpatient department for the entire duration of the treatment. In addition, considering that the patient in question is contraindicated for post-operative radiotherapy due to neurological comorbidities, her only treatment tactic to date would have been removal of the breast gland or mastectomy. Undoubtedly, it would be a more extensive surgery, with consequent cosmetic and physical defects that would impair future quality of life. However, due to the availability of intraoperative radiotherapy, the multidisciplinary team recommended to start the treatment with surgery using intraoperative radiotherapy for the first time, thus making breast-conserving surgery possible.”

“We are pleased that the surgery went very smoothly and successfully. We simulated the operation beforehand and trained with the device. The whole multidisciplinary team was emotionally and mentally involved in planning the surgery. The radiographers had done their job, the layout of the surgical block had been planned, and all radiation safety precautions had been followed. We underwent a radiation safety training course. The medical physicists had done their job – calibrating and measuring the devices. The surgery lasted just under two hours due to very careful preparation. We started the surgery with a biopsy of the lymph node to make sure there were no tumour metastases in the sentinel node. We then removed the tumour, making sure that it was removed completely and with sufficient margins,” concludes K. Arcimoviča.

Gints Rausis, radiation therapist of the Clinical Unit of Radiotherapy, informs: “We then started placing additional intraoperative radiotherapy devices in the breast. Under sterile conditions, in collaboration with radiographers, we inserted intraoperative radiotherapy devices into the breast according to the localisation of the removed tumour. We performed repeated fine-tuning measurements to tailor the required radiotherapy to the patient’s exact tissues. After monitoring the patient’s vital signs, the medical team left the operating theatre to perform the radiation treatment, which lasted only 1–1.5 minutes. The intraoperative radiotherapy device was then gradually disconnected and the surgeons could complete the surgery.”

The patient felt well in the post-operative period, the wound healed primarily, without any complications, and she went home after the drain was removed.

Due to the use of intraoperative radiotherapy, it is expected that this particular patient will receive only hormone therapy as further treatment in a local medical facility. This has provided the patient received a successful cancer treatment that is not only highly effective and well tolerated, but also significantly reduces the need to stay in hospital.

The intraoperative radiotherapy device has the potential to be used not only for breast tumours, but also for tumours in other locations, but it is up to the multidisciplinary team to assess which treatment method is recommended and in what order for specific tumour of each patient. The newly introduced treatment technology can be applied to a selected group of patients strictly according to medical indications.

There are several types of intraoperative radiotherapy equipment available worldwide. The East Hospital has an electron particle irradiation equipment, which has been shown to be highly effective in localised therapy according to the scientific literature. This equipment can be used due to a multidisciplinary approach and teamwork between surgeons, radiotherapists, anaesthetists, medical physicists, radiographers, radiologists, pathologists, scrub nurses and anaesthetic nurses.

“Sharing our successful treatment experience, I encourage women to respond to mammography screening and to be vigilant after screening age – if any changes are found in the breast, you should undergo additional examinations at a specialised centre. The earlier we detect changes in the breast, the more successfully these issues can be tackled, especially due to additional use of the new technologies available to us. Early breast cancer is a curable disease!” K. Eglītis encourages.

The multidisciplinary team that performed the first intraoperative radiotherapy surgery in Latvia:

• Krista Arcimoviča, surgeon, Department of Breast Surgery
• Kristaps Eglītis, surgeon, Department of Breast Surgery
• Gints Rausis, radiation therapist, Clinical Unit of Radiotherapy
• Ilana Šapiro, anaesthesiologist, intensivist, Department of Anaesthesiology and Intensive Care
• Anastasija Trofimoviča-Krasnorucka, radiation therapist, Clinical Unit of Radiotherapy
• Kristaps Reinis, Radiographer, Unit of Clinical Medical Physics and Dosimetry
• Zita Zeļevska, Medical assistant/nurse, Department of Anaesthesiology and Intensive Care
• Jeļena Gučeka, General nurse, Department of Anaesthesiology and Intensive Care
• Nataļja Dementjeva, Assistant Nurse, Surgical Block
• Prof. Jānis Eglītis, head of the Department of Breast Surgery
• Arturs Šorubalko, head of the Clinic of Therapeutic Radiology and Medical Physics
• Tatjana Verhoustinska, senior nurse, Surgical Block
• Gaļina Boka, senior medical physicist, Unit of Clinical Medical Physics and Dosimetry
• Inga Balode, medical physicist, Unit of Clinical Medical Physics and Dosimetry
• Džeina Platace, medical physicist, Unit of Clinical Medical Physics and Dosimetry
• Sanda Kronberga, medical physicist, Unit of Clinical Medical Physics and Dosimetry

About the East Hospital 

Riga East University Hospital is the largest and most strategically important multi-profile hospital in the country. The hospital consists of five clinical centres: Clinical Centre of Emergency Medicine Gailezers, Oncology Centre of Latvia, Clinical Centre Biķernieki, Centre of Tuberculosis and Lung Diseases and Latvian Centre of Infectious Diseases with centres and clinics of different profiles. The hospital provides highly specialised inpatient and secondary outpatient healthcare, providing multidisciplinary tertiary-level treatment and care in line with modern technologies and medical knowledge. The hospital provides treatment for about 80% of all cancer patients in Latvia. The hospital provides a practical training base for both Latvian and foreign students and provides continued professional development and knowledge transfer for health professionals in our country and abroad. The hospital carries out scientific research and develops innovative methods for treating patients. The hospital is the third largest employer in the country, with around 5,000 employees.