MEDICAL POLICY

POLICY
RELATED POLICIES
POLICY GUIDELINES
DESCRIPTION
SCOPE
BENEFIT APPLICATION
RATIONALE
REFERENCES
CODING
APPENDIX
HISTORY

Intraoperative Radiation Therapy (IORT)

Number 8.01.528

Effective Date July 8, 2013

Revision Date(s) N/A

Replaces 8.01.08

Policy

Intraoperative radiation therapy may be considered medically necessary in the following situation:

  • Rectal cancer with positive or close margins with T4 lesions or recurrent disease.

(See Policy Guidelines for a description of tumor grades)

Intraoperative radiation therapy is considered investigational when used for all other oncologic applications, including but not limited to:

  • Breast cancer
  • Fibromatosis
  • Gastric cancer
  • Glioma
  • Gynecologic cancers
  • Head and neck cancers
  • Neuroblastoma
  • Pancreatic cancer
  • Renal cell cancer
  • Soft tissue sarcoma

Related Policies

6.01.10

Stereotactic Radiosurgery and Stereotactic Body Radiation Therapy

7.01.95

Radiofrequency Ablation of Miscellaneous Solid Tumors Excluding Liver Tumors

8.01.45

Intercavitary Balloon Catheter Brain Brachytherapy for Malignant Gliomas or Metastasis to the Brain

8.01.521

Radioembolization for Primary and Metastatic Tumors of the Liver

11.01.503

Clinical Trials

Policy Guidelines

Tumor grades

TNM stands for Tumor, Node, Metastases. This staging system describes the size of a primary tumor (T), whether any lymph nodes contain cancer cells (N), and whether the cancer has spread to another part of the body (M).

There are 4 stages of tumor size in bowel cancer

T1 means the tumor is only in the inner layer of the bowel

T2 means the tumor has grown into the muscle layer of the bowel wall

T3 means the tumor has grown into the outer lining of the bowel wall or into organs or body structures next to the bowel

T4 means the tumor has grown into other parts of the bowel, other organs or body structures near to the bowel (such as the liver or small bowel), or the tumor has broken through the membrane covering the outside of the bowel (the peritoneum)

A T4 tumor is an advanced tumor that invades surrounding structures like pelvic wall, vagina, prostate, bladder or seminal vesicles. These patients require a long course of chemoradiation and extensive surgery.

Coding

CPT

77424

Intraoperative radiation treatment delivery, x-ray, single treatment session

77425

Intraoperative radiation treatment delivery, electrons, single treatment session

77469

Intraoperative radiation treatment management

Description

Radiation therapy delivered directly to exposed tissues during surgery is called intraoperative radiation therapy (IORT). IORT can be delivered by electron beams produced by linear accelerators, also called IOERT or high-dose rate radiation brachytherapy, also called HDR-IORT.

IORT is designed to increase the intensity of radiation directly delivered to tumors. The tumor and associated tissues at risk for micrometastatic spread are directly visualized at the time of surgery. IORT is delivered directly to the tumor bed of the surgical site, and normal or uninvolved tissues are not exposed to radiation because they are removed or shielded from the treatment field. Radiation can be either by using IOERT, or HDR-IORT. Most reported clinical practice involves IOERT. (1)

IORT is performed with applicators and cones that attach to the treatment head of the high-energy medical linear accelerator that are designed to direct radiation to defined surface structures. Most patients are subsequently treated with external beam photon irradiation (EBRT).

Regulatory Status

Intraoperative radiation therapy (IORT) for breast cancer is a procedure and, therefore, not subject to FDA regulation. However, any medical devices, drugs, or tests used as part of this procedure may be subject to FDA regulation. Radiation delivery systems and devices are regulated by the FDA as Class II devices.

The INTRABEAM® system was approved by the U.S. Food and Drug Administration (FDA) for intracranial tumors in 1999 and subsequently approved for whole body use in 2005. The INTRABEAM® spherical applicators are indicated for use with the INTRABEAM® system to deliver a prescribed dose of radiation to the treatment margin or tumor bed during intracavity or intraoperative radiotherapy treatments.

The Mobetron mobile election beam accelerator designed for use in the operating room received 510(k) marketing clearance in 1998.

Another form of intraoperative radiotherapy using electrons is called ELIOT (2), the related RCT NCT01849133 has completed and initial results are pending. Another IORT modality being researched under clinical trial NCT01644669 is the Xoft® Axxent® eBx™ system.

One device can provide either intraoperative or intracavity treatments. The FDA has required a black box warning on each stating that “The safety and effectiveness of the … [device] as a replacement for whole breast irradiation in the treatment of breast cancer has not been established.”

Scope

Medical policies are systematically developed guidelines that serve as a resource for Company staff when determining coverage for specific medical procedures, drugs or devices. Coverage for medical services is subject to the limits and conditions of the member benefit plan. Members and their providers should consult the member benefit booklet or contact a customer service representative to determine whether there are any benefit limitations applicable to this service or supply.

Benefit Application

Note: In 2013 two local facilities, Virginia Mason Medical Center, and Oregon Health Sciences University are conducting clinical trials on the use of IORT in early stage breast cancer. Individuals may be eligible for coverage of participation in these trials, under the Clinical Trials medical policy (see Related Policies), as well as Oregon and Washington State law.

Rationale

Literature Review

The most recent MEDLINE review is through May 2013. The literature consists mainly of retrospective reports of small case series with historic controls from single institutions; systematic reviews and early phase trials have also been published. Evaluation of the effectiveness of intraoperative radiation therapy (IORT) is limited by the absence of randomized controlled trials (RCTs).

Colorectal Cancer

Cantero-Muñoz and colleagues conducted a systematic review on the efficacy and safety of IORT in colorectal cancer. (3) The scientific literature published between January 2000 and October 2009 was reviewed; study inclusion criteria included any study design, a minimum of 30 patients treated with IORT, adults diagnosed with any stage disease and a median follow-up period of greater than 3 months. Fifteen studies met the inclusion criteria and included one systematic review (1); the majority of studies were case series, except for 3, which had a comparative design. The median follow-up was over 3 years in only 6 studies and 5 years in 2 studies. Sample size was more than 100 patients in the majority of studies and more than 200 patients in 2 studies. Study quality was judged to be low given the heterogeneous patient populations, lack of comparison groups, heterogeneous delivery of IORT doses, and the concomitant heterogeneous delivery of other treatments. Five-to-six-year local control was greater than 80% and 5-year overall survival was close to 65%. For recurrences, the 5-year overall survival was 30%. The main acute complications were gastrointestinal. The authors concluded that it was difficult to draw conclusions and to separate the attributing effects of IORT given the complexity of surgery, patient heterogeneity and because IORT was delivered as part of combined treatment, but that adding IORT to conventional treatment approaches appeared to reduce the incidence of local recurrence within the radiation area by more than 10%.

The Skandarajah systematic review included large series (>100 patients) of IORT for locally advanced or recurrent colorectal cancer from the Mayo clinic and Massachusetts General Hospital. (1) In the Massachusetts General study of IORT for locally advanced colorectal cancer, for example, patients with negative tumor margins (R0) had local control of 89% and disease-free survival at 5 years of 69%. (4) Local control and disease-free survival for patients with an R1 (microscopic involvement) margin were 68% and 40%, respectively, and for R2 (macroscopic involvement), 57% and 14%, also respectively. These results were reported to be better than those for historical controls. In all of the studies, disease-free survival was associated with complete surgical resection. Complete resection was also the most important prognostic factor in patients with recurrent rectal cancer for whom prior operation complicates surgery and extended resections may be required. Some, but not all, studies of multimodality treatment with IORT and preoperative external-beam radiotherapy (EBRT) demonstrate improvement in local control in patients who received IORT. The authors note that the most extensive experience with IORT for recurrent rectal cancer is reported by the Mayo Clinic. (5) Of 304 patients who underwent resection, 131 received IORT, 52% with palliative intent and 33% with curative intent. The Mayo Clinic reported 5-year survivals of 21% for the palliative group and 27% in the patients for whom the treatment was intended to be curative. The possibility of selection bias prevents firm conclusions; good local control rates and good overall results suggest that combined therapy might be applied in selected patients.

Investigators at the Mayo Clinic describe a large series of patients treated from April 1981 through January 2008. (6) Six hundred seven patients with recurrent colorectal cancer received IOERT (delivered by electron beams produced by linear accelerators) as a component of treatment. IOERT was preceded or followed by external radiation in 583 patients (96%). Resection was classified as R0 (negative margins) in 227 (37%) and R1 (residual microscopic disease) in 224 (37%). Median overall survival was 36 months. Five- and 10-year survival rates were 30% and 16%, respectively. Survival estimates at 5 years were 46% and 27% for R0 and R1 resection, respectively. Multivariate analysis revealed that R0 resection, no prior chemotherapy, and more recent treatment (in the second half of the series) were associated with improved survival. The 3-year cumulative incidence of central (within the IOERT field), local, and distant relapse was 12%, 23%, and 49%, respectively. Toxicity Grade 3 or higher partially attributable to IOERT was observed in 66 patients (11%). The authors conclude that continued evaluation of curative-intent, combined-modality therapy is warranted for this high-risk population.

Gastric Cancer

Skandarajah et al. observe that few studies of IORT for gastric cancer have been published in the last decade, suggesting that there is minimal efficacy for this indication and that is achieved only with potential toxicity to other organs. (1) Three RCTs and case series with historic controls were reviewed; all demonstrate only a small survival benefit at any cancer stage and with high complications rates in the IORT-treated patients. Evaluation of IORT for pancreatic cancer is hampered by the small number of patients eligible for resection. In the single RCT reviewed by Skandarajah et al. (12 patients and 12 controls), IORT decreased local recurrence rates (33% vs. 100% in the control group) but had no impact on overall survival.

Soft Tissue Sarcomas

Regarding soft tissue sarcomas, the systematic review by Skandarajah et al. highlights the potential value of IORT in the multimodal treatment of retroperitoneal sarcoma because these tumors are often close to dose-limiting structures but notes that it is not without complications. (1) One randomized study compared IORT combined with postoperative external beam radiation therapy (EBRT) with EBRT alone. The local recurrence rate was 40% in the combined therapy group versus 80% in patients who received EBRT only, but there was no difference in overall survival. Patients who received IORT had fewer radiation enteritis events but more disabling peripheral neuropathies. In a nonrandomized study of 251 patients, 92 of whom received IORT, IORT patients had more surgical complications and significantly more infectious complications; however, the IORT-treated patients had a 40% lower rate of local recurrence. IORT has demonstrated effective tumor control in osteosarcoma, but fracture of irradiated bone can be significant.

Investigators in Japan reported on a series of 28 patients who received IORT after resection of large (median size 9.75 cm) retroperitoneal sarcomas; resection of tumor and adjacent organs was performed to obtain a disease-free anterior margin and IORT was delivered to any close posterior margin. (7) Margins were positive for disease in 15 patients, usually posterior. After median follow-up of 33 months, 2 patients with primary disease and 3 patients with recurrent disease experienced local recurrence. The authors conclude that IORT may deliver sufficient radiation dose to the posterior margin to control microscopic residual disease, especially in patients with primary disease. A retrospective analysis of a series of 38 patients treated at a German center with IORT and EBRT for soft tissue sarcoma found a local recurrence in 10 of 36 patients, lymph node metastases in 2 of 35 patients, and distant metastases in 6 of 35 patients at mean follow-up of 2.3 years. (8) Actuarial local control was 63% and overall survival rate was 57% at 5 years. Complications, though not severe, were frequent.

Gynecologic Cancers

A Phase 2 trial examined the use of radical surgery with intraoperative high-dose radiotherapy after chemotherapy in extra cervical locally advanced cervical cancer patients. (9) Between 2000 and 2007, 42 locally advanced cervical cancer (stage IIA bulky-IVA) patients were treated. External-beam radiation was administered to the whole pelvic region in combination with chemotherapy, and then radical surgery with IORT was performed 6-8 weeks after the end of the external-beam radiation and chemotherapy treatment. After external-beam radiation and chemotherapy, 35/42 patients (83%) underwent radical surgery and IORT treatment. At pathologic examination 8/35 (23%) patients showed complete response, while the rest (27/35) had residual disease, either microscopic (17/27) or gross (10/27). The 5-year disease free survival (DFS) and the 5-year overall survival (OS) were 46% and 49% respectively. There were significantly better DFS and OS when residual tumor was absent or limited to the cervix, respectively 78% versus 16% and 81% versus 20% (p<0.001). At the time of the analysis, 17/35 (48%) of patients were alive but developed a relapse with a median of 22 months, and 15/35 (43%) of patients died of disease with a median of 33 months. Three of 35 (9%) patients were alive and free of disease. The authors concluded that external-beam radiation and chemotherapy followed by surgery and IORT in locally advanced cervical cancer patients was active in a subgroup of patients with pathological complete response to treatment or partial response with residual tumor limited to the cervix.

No systematic reviews of IORT for gynecologic cancers were identified in the literature search. Reports of single institution case series published in the past 10 years are summarized here. A case series of 67 patients with locally advanced (n=31) and recurrent cervical cancer (n=36) treated with IORT at a Spanish center was reported by Martinez-Monge et al. (10) Previously unirradiated patients received preoperative chemoradiation. The 10-year control rate within the area treated with IORT was 69.4% for the entire group, 98.2% for the primary group, and 46.4% for the recurrent group. Control in the treated area correlated to margin status, amount of residual disease, and pelvic lymph node involvement. The overall incidence of toxic events attributable to IORT was 13.9%. The 10-year survival rate for the entire group was 34%, 58% for patients with primary disease, and 14% for those with recurrent disease The authors conclude that IORT is a valuable boosting technique particularly in the management of advanced but resectable cervical cancer. Patients, especially those with recurrent disease, with positive lymph nodes, parametrial involvement, and/or incomplete resection have poor local control despite IORT at the doses used in the study.

Gemignani et al. report on 17 patients with recurrent gynecologic cancers treated with radical resection and high-dose intraoperative radiation therapy (HDR-IORT) at the Sloan-Kettering Cancer Center. (11) The site of the primary tumor was the cervix in 9, the uterus in 7, and the vagina in 1 patient. In patients with complete gross resection (n=13), the 3-year local control rate was 83% versus 25% in patients with gross residual disease. The overall 3-year survival rate was 54%.The overall distant metastasis-free rate was also 54%; 7 patients, all of whom had microscopic residual disease, developed distant metastases. The authors conclude that radical surgical resection with IORT appears to provide a reasonable local-control rate in patients who have failed prior surgery and/or definitive radiation; however, only patients with complete gross resection at completion of surgery appear to benefit. Two of the authors state in a later review that for most patients with recurrent cervical cancer, pelvic exenteration is the only therapeutic option that offers the possibility of long-term survival, and patients for exenteration are those with central local recurrences that have not extended to the pelvic sidewalls. (12) They suggest that HDR-IORT combined with radical resection makes this option available to more patients, and those with recurrences that extend close to the pelvic sidewalls should be referred to centers where HDR-IORT is available. Dowdy and colleagues report on a series of 25 patients who received radical resection and IORT for recurrent endometrial cancer at the Mayo Clinic; 56% received radiation and 48% had either secondary surgery or chemotherapy before referral. (13) Seven patients required exenteration with resection of the pelvic sidewall. Overall 5-year survival was 47% versus 71% for those with a gross total resection but close margins. The most common complications were peripheral neuropathy, functional ureteral obstruction, and fistula formation. EBRT, tumor size after resection, grade, and patient age were associated with improved survival.

A retrospective study by Gao and colleagues evaluated clinical outcomes and the toxicity of intraoperative, whole pelvic electron-beam radiation therapy in advanced and recurrent ovarian carcinoma. (14) Forty-five women with epithelial ovarian carcinoma were treated with IOERT; 25 had primary disease without distant metastasis at IOERT, and 20 patients had an isolated local recurrence after surgery. All 45 patients in this series underwent optimal cytoreductive surgery. Thirty-three patients received postoperative intraperitoneal chemotherapy, while 7 received intravenous chemotherapy. Five patients refused concurrent chemotherapy. Overall survival rates were analyzed using the Kaplan-Meier method. Tumor recurrence and metastasis were observed in 16 patients (35.6%). Of those, 14 patients (31.1%) relapsed and 2 patients (4.4%) had distant metastasis alone. Eight of 25 (32%) local failures were observed in the primary disease group, as compared to 6/20 (30%) in the isolated local recurrence group (p=0.885). Actuarial local control at 5-year follow-up was 31/45 (68.9%). Seventeen of the total 45 (37.8%) patients died; 9 of 25 (36%) in the primary disease group, and 8 of 20 (40%) in the isolated local recurrence group. The 5-year OS and DFS rates were 28/45 (62.2%) and 25/45 (55.6%), respectively. In the primary disease group, the 5-year OS and DFS rates were 16/25 (64%) and 14/25 (56%) (p>0.05, vs. the isolated local recurrence group at 12/20 and 11/20, respectively). The OS and DFS in the IOERT plus intraperitoneal group were 25/33 (75.8%) and 23/33 (69.7%), respectively, which were superior to the rates achieved with IOERT plus intraoperative chemotherapy (p<0.05). The major complication of IOERT was neuropathy. Five (11.1%) patients developed peripheral neurotoxicity.

Head and Neck Cancers

Zeidan and colleagues reported on 2 case series of head and neck cancers. In the first publication, they reported on the use of IORT for patients with advanced cervical metastasis. (15) For this series, between August 1982 and July 2007, 231 patients underwent neck dissections as part of initial therapy or as salvage treatment for advanced cervical node metastases resulting from head and neck malignancies. IORT was administered as a single fraction to a dose of 15 Gy or 20 Gy in most patients. Overall survival at 1, 3, and 5 years after surgery and IORT was 58%, 34%, and 26%, respectively. Recurrence-free survival (RFS) at 1, 3, and 5 years was 66%, 55%, and 49%, respectively. Disease recurrence was documented in 83 (42.8%) patients. The recurrences were regional in 38 patients, local in 20 patients, and distant failures in 25 patients. The authors concluded that IORT results in effective local disease control at acceptable levels of toxicity. The authors indicate that these results support the initiation of a Phase III trial comparing outcomes for patients with cervical metastasis treated with or without IORT. The second publication reviewed the authors’ experience with the use of IORT for primary or recurrent cancer of the parotid gland. (16) For this study, conducted between 1982 and 2007, 96 patients were treated with gross total resection and IORT for primary or recurrent cancer of the parotid gland. Of the 96 patients, 33 had previously undergone external-beam radiotherapy as a component of definitive therapy. Also, 34 patients had positive margins after surgery, and 40 had perineural invasion. IORT was administered as a single fraction of 15 or 20 Gy. The median follow-up period was 5.6 years. In this series, 1 patient experienced local recurrence, 19 developed regional recurrence, and 12, distant recurrence. The RFS rate at 1, 3, and 5 years was 82%, 69%, and 65%, respectively. The 1-, 3-, and 5-year overall survival rate after surgery and IORT was 88%, 66%, and 56%, respectively. Complications developed in 26 patients. The authors concluded that IORT results in local disease control at acceptable levels of toxicity and should be considered for patients with primary or recurrent cancer of the parotid gland.

Thirty-four patients with recurrent head and neck cancer received IORT at another U.S. center. (17) At median follow-up of 23 months (range, 6-54 months), 8 patients were alive and without evidence of disease. The 1- and 2-year estimates for in-field local progression-free survival rates were 66% and 56%, respectively, with 13 (34%) in-field recurrences. One- and 2-year distant metastases-free survival rates were 81% and 62%, respectively, with 10 patients (29%) developing distant failure. One- and 2-year overall survival rates were 73% and 55%, respectively, with median time to overall survival of 24 months.

Pancreatic Cancer

Zygogianni and colleagues conducted a systematic review of the literature on the effectiveness and safety of IORT in pancreatic cancer. (18) The review assessed the potential impact of IORT on local control, quality of life, and overall survival. PubMed was searched from 1980 until 2010, and the search was restricted to articles published in English. Thirteen studies were included. The authors concluded that the results of their review found no clear evidence to indicate that IORT was more effective than other therapies in treating pancreatic cancer.

A 2008 systematic review of the literature from 1995 to 2007 by Ruano-Ravina and colleagues assessed the efficacy and safety of IORT in pancreatic cancer. (19) Study inclusion criteria included a minimum of 30 patients and survival results based on a minimum 3-month follow-up. Fourteen papers were included, one was an IORT technology assessment report, 5 were cohort studies, and 8 were case series studies, 2 of which belonged to the same series. There were no published studies that assessed quality of life.

The authors concluded that, in general, the studies showed that IORT could slightly increase survival among patients with pancreatic cancer in localized stages. However, there was no clear evidence to indicate that IORT was more effective than other therapies in treating pancreatic cancer in locally advanced and metastatic stages.

Reports of 3 series of patients treated with IORT for pancreatic cancer were identified in the recent literature; in 2, IORT appeared to provide local control. The largest series, a retrospective analysis of results in 201 patients treated with IORT after resection of pancreatic cancer (R0 [negative margins]:147 patients; R1 [residual microscopic disease]: 63 patients), was performed by investigators in Japan. (20) Fifty-four patients also had postoperative EBRT, and 114 patients had chemotherapy. Median follow-up of the surviving 62 patients was 26.3 months (range, 2.7-90.5 months). Fifteen percent of patients had positive margins, usually posterior. Median follow-up of surviving patients was 26.3 months (range, 2.7-90.5 months). At the time of analysis, 150 patients had disease recurrences, local failure was seen in 31 patients, and the 2- year local control rate was 83.7%. The median survival time and the 2-year actuarial overall survival in all 210 patients were 19.1 months and 42%, respectively. The authors concluded that IORT yields an excellent local control rate with infrequent severe late toxicity and that IORT combined with chemotherapy confers a survival benefit compared with IORT alone. Comparisons to other current management approaches are not made. A U.S. center reports a retrospective review of 23 patients treated between 1990 and 2001. (21) Most tumors (83%) were located in the head of the pancreas. Most patients (83%) had IORT at the time of definitive surgery. Three patients had preoperative chemoradiation. Median and mean follow-up were 6.5 and 21 months, respectively. Kaplan-Meier 2-year infield control, locoregional control, distant metastasis-free survival, and overall survival were 83%, 61%, 26%, and 27%, respectively. Investigators at another U.S. center found that IORT did not improve locoregional control and did not alter survival in 37 patients who underwent pancreaticoduodenectomy for periampullary tumors including pancreatic cancers. (22)

Renal Cell Cancer

Hallemeier and colleagues reported outcomes of a multimodality therapy combining maximal surgical resection and IOERT for patients with locoregionally (LR) recurrent renal cell carcinoma (RCC) after radical nephrectomy or LR advanced primary RCC. (23) From 1989 through 2005, a total of 22 patients with LR recurrent (n=19) or LR advanced primary (n= 3) RCC were treated with this multimodality approach. Twenty-one patients (95%) received perioperative external-beam radiotherapy (EBRT) with a median dose of 45 Gy (range, 41.4-55). Surgical resection was R0 (negative margins) in 5 patients (23%) and R1 (residual microscopic disease) in 17 patients (77%). The median IOERT dose delivered was 12.5 Gy (range, 10-20). The overall survival and disease-free survival at 1, 5, and 10 years were 91%, 40%, and 35% and 64%, 31%, and 31%, respectively. Central recurrence (within the IOERT field), LR relapse (tumor bed or regional lymph nodes), and distant metastases at 5 years were 9%, 27%, and 64%, respectively. The authors concluded that in patients with LR recurrent or LR advanced primary RCC, a multimodality approach of perioperative EBRT, maximal surgical resection, and IOERT yielded encouraging results, and this approach warrants further study.

Glioma

Nemoto et al. reported results or treatment with IORT for 32 patients with previously untreated malignant gliomas over a 10-year period. (24) Patients also had postoperative radiation therapy. Eleven patients had histological diagnoses of anaplastic astrocytoma (AA), and 21 had glioblastoma (GBM). Median survival time was 24.7 months in the AA group versus 33.6 months for matched historical controls. Differences in 1-, 2-, and 5-year survival between IORT-treated patients and historical controls were also not significant. In the GBM group, median survival was 13.3 months in the IORT-treated patients versus 14.6 months in the matched controls. Data on 1-, 2-, and 5-year survival were also not significantly different between groups.

The literature search also found recent reports of single institution case series of patients treated with IORT for head and neck tumors; however, comparisons with conventional treatment were not found. A large case series of patients was reported by Chen et al. (25) between 1991 and 2004; 137 patients underwent gross total resection and IORT for recurrence or persistence of locoregional cancer of the head and neck. Eighty-three percent of them had previously received EBRT. Surgical margins were microscopically positive in 56 patients. Median follow-up among surviving patients was 41 months (range, 3–122 months). One-, 2-, and 3-year estimates of in-field control after surgery and IORT were 70%, 64%, and 61%, respectively, and positive margins at the time of IORT predicted in-field failure. Three-year rates of locoregional control, distant metastasis-free survival, and overall survival were 51%, 46%, and 36%, respectively. A series of Phase 2 clinical trials of 3 multimodal intensification regimens consisting of perioperative cisplatin chemoradiotherapy, surgical resection with intraoperative radiotherapy, and postoperative paclitaxel and cisplatin chemoradiotherapy for advanced, resectable, previously untreated squamous cell cancer of the oral cavity, oropharynx, or hypopharynx were conducted at Ohio State University, (26) and 123 patients were treated. Compliance (patients receiving full doses of chemotherapy and radiation within the prescribed time without delay or dose reduction and receiving all courses of treatment in the protocol) was 61%. Overall 5-year survival by Kaplan-Meier analysis was 57% (46% in the first regimen, 56% in the second, and 68% in the third). Overall disease-specific 5-year survival was 73%, with 60% for the first regimen, 78% for the second and 80% for the third. The overall locoregional disease control rate was 91%, and the rate of distant metastases was 13.8%. The precise contribution of IORT cannot be established from these data.

Neuroblastoma

Rich and colleagues reported their experience using IORT after re-resection in patients with locally recurrent or persistent high-risk neuroblastomas. (27) They retrospectively reviewed 44 consecutive patients who received IORT at one institution between April 2000 and September 2009 after gross total resection of recurrent/persistent tumor. Median follow-up after IORT was 10.5 months. Each patient received prior chemotherapy and surgery, and 94.5% had previous EBRT. There was a 50.4% probability of local control. Median overall survival was 18.7 months (95% confidence interval [CI]: 11.7-25.6 months). The authors concluded that intraoperative radiation therapy after re-resection of locally recurrent/persistent neuroblastoma results in a reasonable rate of local control with acceptable morbidity and survival and that this approach should be considered in this high-risk population.

Fibromatosis

Roeder et al. reviewed outcomes of 30 patients (31 lesions) with aggressive fibromatosis. (28) Treatment with IORT was undertaken to avoid mutilating surgical procedures when complete surgical removal seemed to be unlikely or impossible. Median age was 31 years (range, 13-59 years). Resection status was close margin in 6 lesions, microscopically positive in 13, and macroscopically positive in 12. Median tumor size was 9 cm. Twenty-five patients received additional EBRT. After a median follow-up of 32 months (range, 3-139 months), no disease-related deaths occurred. A total of 5 local recurrences were seen, resulting in actuarial 3-year local control rates of 82% overall and 91% inside the IOERT areas. Trends to improved local control were seen for older age (>31 years) and negative margins, but none of these factors reached significance. Perioperative complications were found in 6 patients, in particular as wound healing disturbances in 5 patients and venous thrombosis in 1 patient. Late toxicity was seen in 5 patients.

Breast Cancer

Radiation therapy is the standard care for patients with breast cancer undergoing breast-conserving surgery (BCS), as it reduces recurrences and lengthens survival. The conventional radiation therapy regimen consists of approximately 25 treatments of 2 Gray (Gy; a measure of absorbed radiation dose) delivered over 5 to 6 weeks. However, not all patients undergo radiation therapy following BCS; the duration and logistics of treatment may be barriers for some women. A number of reviews and editorials discussed the preliminary results of the TARGIT-A trial. (29-33). Potential benefits reported for the use of intraoperative radiotherapy, include convenience, “excellent delineation of the tumour bed under visual control, very good dose homogeneity, and high sparing of normal tissue” (29), but a number of concerns have been expressed as well (33). They include the following:

  • If intraoperative radiation therapy (IORT) is performed during the surgery to excise the tumor, the definitive pathology is not available when the radiotherapy is performed. Therefore, a subset of patients must also undergo whole-breast external-beam radiotherapy following surgery. The article reports that 14% of patients in the IORT arm also received whole-breast external-beam radiotherapy. When only those who received IORT during initial surgery are considered, 21% received whole-breast external-beam radiotherapy. There are limited data suggesting that breast symptoms and pain following treatment may be greater for patients receiving both IORT and whole-breast external radiotherapy compared with IORT alone and that patients’ satisfaction is greater for whole-breast external radiotherapy or IORT alone compared to the combined treatment. (30) Therefore, IORT may result in harm for a subset of patients who receive both IORT and whole-breast external radiotherapy.
  • Whether the radiation dose and type is actually equivalent to the standard radiation therapy regimen. Of particular concern is the rapid drop in dose with distance from the applicator and whether any residual disease will be eradiated. Some argue that the TARGIT-A trial alleviates this concern, while others do not.
  • The length of follow-up is insufficient to determine long-term toxicity and efficacy, particularly since only 19% of the participants in the TARGIT-A trial completed 4 years of follow-up. The median follow-up is not reported but appears to be around 2 years.

Clinical Trials

Thirty-six studies were found at clinicaltrials.gov using the basic search criteria of “IORT”. Only 1 current phase 3 study was found at the time this policy was developed in 2013.

Summary

The evidence suggests that IORT, as part of multimodal treatment of solid tumors, provides a benefit in local recurrence rates for many tumors. However, the impact of its use on survival rates (and the development of distant disease) is less clear and, for some tumors, is achieved at the price of significant treatment-related morbidity. In addition, the impact of this modality compared with some of the newer radiation therapy techniques (that allow better targeting of tumor) and chemotherapy regimens is not known. Finally, since standard radiation therapy is often administered following IORT, it is more difficult to determine the incremental value of IORT. Given the available evidence, the strength of the evidence, IORT may be considered as a medically necessary treatment option in patients with rectal cancer with very close or positive margins after resection. All other uses are considered investigational given the limited evidence, especially the lack of comparative data, regarding the impact on net health outcome. A number of large randomized, controlled trials are underway that will provide additional clinical outcome data for future consideration.

Practice Guidelines and Position Statements

National Comprehensive Cancer Network Guidelines

Breast cancer NCCN guidelines (v3.2013) – state that preliminary studies of accelerated partial breast irradiation suggest rates of local control in select patients with early-stage breast cancer may be comparable to those treated with standard whole breast radiation therapy. However, follow up is limited and studies are ongoing. Patients are encouraged to participate in clinical trials. http://www.nccn.org/professionals/physician_gls/pdf/breast.pdf. Last accessed June 21, 2013.

Colon cancer NCCN guidelines (v3.2013) -- state that intraoperative radiotherapy (IORT) should be considered for patients with T4 or recurrent cancers as an additional boost. (Category 2A)

http://www.nccn.org/professionals/physician_gls/pdf/colon.pdf . Last accessed June 21, 2013.

Gynecological cancers NCCN guidelines indicate that IORT is an option for patients with:

Pancreatic cancer NCCN guidelines (v1.201) – state that “ideally, patients should be treated in clinical trials when available” and “that sometimes IORT is used for resectable cases and may be best used when resection may result in close or involved margins.” http://www.nccn.org/professionals/physician_gls/pdf/pancreatic.pdf . Last accessed June 21, 2013.

Rectal cancer NCCN guidelines (v4.2013) – indicate that “IORT, if available, should be considered for very close or positive margins after resection, as an additional boost, especially for patients with T4 or recurrent cancers.” (Category 2A) http://www.nccn.org/professionals/physician_gls/pdf/rectal.pdf . Last accessed June 21, 2013.

Soft Tissue Sarcomas NCCN guidelines (v3.2012) – indicate that IORT is a postoperative treatment option following surgery for soft tissue sarcomas.

http://www.nccn.org/professionals/physician_gls/pdf/sarcoma.pdf . Last accessed June 21, 2013.

References

  1. Skandarajah, AR, Lynch AC, Mackay JR et al. The role of intraoperative radiotherapy in solid tumors. Ann Surg Oncol 2009; 16(3):735-44.
  2. Veronesi U, Orecchia R, Luini A et al. Intraoperative radiotherapy during breast conserving surgery: A study on 1,822 cases treated with electrons. Breast Cancer Res Treat 2010; 124(1):141-51.
  3. Cantero-Munoz P, Urien MA, Ruano-Ravina A. Efficacy and safety of intraoperative radiotherapy in colorectal cancer: a systematic review. Cancer Lett 2011; 306(2):121-33.
  4. Willett CG, Shellito PC, Tepper JE et al. Intraoperative electron beam radiation therapy for primary locally advanced rectal and rectosigmoid carcinoma. J Clin Oncol 1991; 9(5):843-9.
  5. Hahnloser D, Haddock MG, Nelson H. Intraoperative radiotherapy in the multimodality approach to colorectal cancer. Surg Oncol Clin N Am 2003; 12(4):993-1013, ix.
  6. Haddock MG, Miller RC, Nelson H et al. Combined modality therapy including intraoperative electron irradiation for locally recurrent colorectal cancer. Int J Radiat Oncol Biol Phys 2011; 79(1):143-50.
  7. Yoon SS, Chen YL, Kirsch DG et al. Proton-beam, intensity-modulated, and/or intraoperative electron radiation therapy combined with aggressive anterior surgical resection for retroperitoneal sarcomas. Ann Surg Oncol 2010; 17(6):1515-29.
  8. Niewald M, Fleckenstein J, Licht N et al. Intraoperative radiotherapy (IORT) combined with external beam radiotherapy (EBRT) for soft-tissue sarcomas--a retrospective evaluation of the Homburg experience in the years 1995-2007. Radiat Oncol 2009; 4:32.
  9. Giorda G, Boz G, Gadducci A et al. Multimodality approach in extra cervical locally advanced cervical cancer: chemoradiation, surgery and intra-operative radiation therapy. A phase II trial. Eur J Surg Oncol 2011; 37(5):442-7.
  10. Martinez-Monge R, Jurado M, Aristu JJ et al. Intraoperative electron beam radiotherapy during radical surgery for locally advanced and recurrent cervical cancer. Gynecol Oncol 2001; 82(3):538-43.
  11. Gemignani ML, Alektiar KM, Leitao MM Jr. et al. Radical surgical resection and high-dose intraoperative radiation therapy (HDR-IORT) in patients with recurrent gynecologic cancers. Int J Radiat Oncol Phys 2001; 50(3):687-94.
  12. Leitao MM Jr., Chi DS. Recurrent cervical cancer. Current Treat Options Oncol 2002; 3(2):105-11.
  13. Dowdy SC, Mariani A, Cliby WA et al. Radical pelvic resection and intraoperative radiation therapy for recurrent endometrial cancer: technique and analysis of outcomes. Gynecol Oncol 2006; 101(2):280-6.
  14. Gao Y, Liu Z, Chen X et al. Intraoperative radiotherapy electron boost in advanced and recurrent epithelial ovarian carcinoma: a retrospective study. BMC Cancer 2011; 11:439.
  15. Zeidan YH, Yeh A, Weed D et al. Intraoperative radiation therapy for advanced cervical metastasis: a single institution experience. Radiat Oncol 2011; 6:72.
  16. Zeidan YH, Shiue K, Weed D et al. Intraoperative radiotherapy for parotid cancer: a single-institution experience. Int J Radiat Oncol Biol Phys 2012; 82(5):1831-6.
  17. Perry DJ, Chan K, Wolden S et al. High-dose-rate intraoperative radiation therapy for recurrent head-and-neck cancer. Int J Radiat Oncol Biol Phys 2010; 76(4):1140-6.
  18. Zygogianni GA, Kyrgias G, Kouvaris J et al. Intraoperative radiation therapy on pancreatic cancer patients: a review of the literature. Minerva Chir 2011; 66(4):361-9.
  19. Ruano-Ravina A, Almazan Ortega R, Guedea F. Intraoperative radiotherapy in pancreatic cancer: a systematic review. Radiother Oncol 2008; 87(3):318-25.
  20. Ogawa K, Karasawa K, Ito Y et al. Intraoperative radiotherapy for resected pancreatic cancer: a multi-institutional retrospective analysis of 210 patients. Int J Radiat Oncol Biol Phys 2010; 77(3):734-42.
  21. Bachireddy P, Tseng D, Horoschak M et al. Orthovoltage intraoperative radiation therapy for pancreatic adenocarcinoma. Radiat Oncol 2010; 5:105.
  22. Showalter TN, Rao AS, Rani Anne P et al. Does intraoperative radiation therapy improve local tumor control in patients undergoing pancreaticoduodenectomy for pancreatic adenocarcinoma? A propensity score analysis. Ann Surg Oncol 2009; 16(8):2116-22.
  23. Hallemeier CL, Choo R, Davis BJ et al. Long-term outcomes after maximal surgical resection and intraoperative electron radiotherapy for locoregionally recurrent or locoregionally advanced primary renal cell carcinoma. Int J Radiat Oncol Biol Phys 2012; 82(5):1938-43.
  24. Nemoto K, Ogawa Y, Matsushita H et al. Intraoperative radiation therapy (IORT) for previously untreated malignant gliomas. BMC cancer 2002; 2:1.
  25. Chen AM, Bucci MK, Singer MI et al. Intraoperative radiation therapy for recurrent head-and-neck cancer: the UCSF experience. Int J Radiat Oncol Biol Phys 2007; 67(1):122-9.
  26. Schuller DE, Ozer E, Agrawal A et al. Multimodal intensification regimens for advanced, resectable, previously untreated squamous cell cancer of the oral cavity, oropharynx, or hypopharynx: a 12-year experience. Arch Otolaryngol Head Neck Surg 2007; 133(4):320-6.
  27. Rich BS, McEvoy MP, LaQuaglia MP et al. Local control, survival, and operative morbidity and mortality after re-resection, and intraoperative radiation therapy for recurrent or persistent primary high-risk neuroblastoma. J Pediatr Surg 2011; 46(1):97-102.
  28. Roeder F, Timke C, Oertel S et al. Intraoperative electron radiotherapy for the management of aggressive fibromatosis. Int J Radiat Oncol Biol Phys 2010; 76(4):1154-60.
  29. Azria D, Bourgier C. Partial breast irradiation: new standard for selected patients. Lancet 2010; 376(9735):71-2.
  30. Wetzel G, Hofmann F, Blank E et al. Health-related quality of life after breast-conserving surgery and intraoperative radiotherapy for breast cancer using low-kilovoltage x-rays. Ann Surg Oncol 2010; 17(Suppl 3):S359-67.
  31. Khan AJ, Dale RG, Arthur DW et al. Ultrashort courses of adjuvant breast radiotherapy: wave of the future or fool’s errand? Cancer 2012; 118(8):1962-70.
  32. Orecchia R, Leonardo MC. Intraoperative radiation therapy: Is it a standard now? Breast 2011; 20 (Suppl 3):S111-5.
  33. Sautter-Bihl M-L, Sedlmayer F, Budach W et al. Intraoperative radiotherapy as accelerated partial breast irradiation for early breast cancer: Beware of one-stop shops? Strahlenther Onkol 2010; 186(12):651-7.
  34. Blue Cross and Blue Shield Association Technology Evaluation Center (TEC). Accelerated Radiotherapy after Breast-Conserving Surgery for Early Stage Breast Cancer. TEC Assessments 2013, In press. Update of Volume 24, No. 9. Found at URL address: http://www.bcbs.com/blueresources/tec/vols/27/accelerated-radiotherapy.html. Last accessed June 21, 2013.
  35. BlueCross BlueShield Association Medical Policy Reference Manual, Intraoperative Radiation Therapy. Medical Policy Reference Manual, Policy No. 8.01.08, 2012.

Coding

Codes

Number

Description

CPT

77424

Intraoperative radiation treatment delivery, x-ray, single treatment session

 

77425

Intraoperative radiation treatment delivery, electrons, single treatment session

 

77469

Intraoperative radiation treatment management

ICD-9 Procedure

92.41

Intraoperative electron radiation therapy

ICD-9 Diagnosis

154.1

Malignant neoplasm of rectum

 

171.5

Malignant neoplasm of connective and other soft tissue; abdomen (includes intra-abdominal soft tissue sarcoma)

 

171.8

Malignant neoplasm of connective and other soft tissue; other specified sites (includes extremity soft tissue sarcoma)

 

174.0 - 175.9

Malignant neoplasm of breast

     
     
     

HCPCS

S8049

Intraoperative radiation therapy (single administration) deleted 04/01/12

ICD-10-CM
(effective 10/01/14)

C20

Malignant neoplasm of rectum

 

C49.4

Malignant neoplasm of connective and soft tissue of abdomen

 

C49.8

Malignant neoplasm of overlapping sites of connective and soft tissue 

ICD-10-PCS
(effective 10/01/14)

DD073Z0

Radiation oncology, gastrointestinal system, beam radiation, rectum, electrons, intraoperative

Type of Service

Therapy/
Radiation

 

Place of Service

Inpatient

 

Appendix

N/A

History

Date

Reason

07/08/13

New Policy. PR policy created to include information about IORT as an investigational treatment for breast cancer. The BC policy does not include information about breast cancer. Rationale section includes information about clinical trials using IORT for breast cancer. Benefit application section includes information about regional IORT clinical trials. BC policy 8.01.08 is deleted.

03/11/14

Coding Update. Code 99.88 was removed per ICD-10 mapping project; this code is not utilized for adjudication of policy.


Disclaimer: This medical policy is a guide in evaluating the medical necessity of a particular service or treatment. The Company adopts policies after careful review of published peer-reviewed scientific literature, national guidelines and local standards of practice. Since medical technology is constantly changing, the Company reserves the right to review and update policies as appropriate. Member contracts differ in their benefits. Always consult the member benefit booklet or contact a member service representative to determine coverage for a specific medical service or supply. CPT codes, descriptions and materials are copyrighted by the American Medical Association (AMA).
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