Can Advances in Artificial Intelligence Strengthen the Role of Intraoperative Radiotherapy in the Treatment of Cancer?

Intraoperative radiotherapy (IORT) is a radiation technique that allows for the delivery of a high radiation dose to the target while preserving the surrounding structures, which can be displaced during the surgical procedure. An important limitation of this technique is the lack of real-time image guidance, which is one of the main achievements of modern radiation therapy because it allows for treatment optimization. IORT can be delivered by low-energy X-rays or by accelerated electrons. The present review describes the most relevant clinical applications for IORT and discusses the potential advantages of using artificial intelligence (AI) to overcome some of the current limitations of IORT. In recent decades, IORT has proven to be an effective treatment in several cancer types. In breast cancer, IORT can be used to deliver a single dose of radiation (partial breast irradiation) or as a boost in high-risk patients. In locally advanced rectal cancer, a single dose to the tumor bed can improve local control and prevent pelvic relapse in primary and recurrent tumors. In sarcomas, IORT enables the delivery of high doses, achieving good functional outcomes with low toxicity in tumors located in the retroperitoneum and extremities. In pancreatic cancer, IORT shows promising results in borderline resectable and unresectable cases. Ongoing technological advances are addressing current challenges in imaging and radiation planning, paving the way for personalized, image-guided IORT. Recent innovations such as CT- and MRI-equipped hybrid operating theaters allow for real-time imaging, which could be used for AI-assisted segmentation and planning. Moreover, the implementation of AI in terms of machine learning, deep learning, and radiomics can improve the interpretation of imaging, predict treatment outcomes, and optimize workflow efficiency.