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Does selective pleural irradiation of malignant pleural mesothelioma allow radiation dose escalation?

A planning study

Erlaubt die selektive pleurale Bestrahlung maligner Pleuramesotheliome eine Dosiseskalation?

Eine Planungsstudie

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Abstract

Background

After lung-sparing radiotherapy for malignant pleural mesothelioma (MPM), local failure at sites of previous gross disease represents the dominant form of failure. Our aim is to investigate if selective irradiation of the gross pleural disease only can allow dose escalation.

Materials and methods

In all, 12 consecutive stage I–IV MPM patients (6 left-sided and 6 right-sided) were retrospectively identified and included. A magnetic resonance imaging-based pleural gross tumor volume (GTV) was contoured. Two sets of planning target volumes (PTV) were generated for each patient: (1) a “selective” PTV (S-PTV), originating from a 5-mm isotropic expansion from the GTV and (2) an “elective” PTV (E-PTV), originating from a 5-mm isotropic expansion from the whole ipsilateral pleural space. Two sets of volumetric modulated arc therapy (VMAT) treatment plans were generated: a “selective” pleural irradiation plan (SPI plan) and an “elective” pleural irradiation plan (EPI plan, planned with a simultaneous integrated boost technique [SIB]).

Results

In the SPI plans, the average median dose to the S‑PTV was 53.6 Gy (range 41–63.6 Gy). In 4 of 12 patients, it was possible to escalate the dose to the S‑PTV to >58 Gy. In the EPI plans, the average median doses to the E‑PTV and to the S‑PTV were 48.6 Gy (range 38.5–58.7) and 49 Gy (range 38.6–59.5 Gy), respectively. No significant dose escalation was achievable.

Conclusion

The omission of the elective irradiation of the whole ipsilateral pleural space allowed dose escalation from 49 Gy to more than 58 Gy in 4 of 12 chemonaive MPM patients. This strategy may form the basis for nonsurgical radical combined modality treatment of MPM.

Zusammenfassung

Hintergrund

Beim malignen Pleuramesotheliom (MPM) ist nach lungenschonender Radiotherapie das lokale Scheitern an Stellen eines früheren, sichtbaren Tumors die dominierende Form des Scheiterns. Unser Ziel ist es, zu untersuchen, ob die selektive Bestrahlung nur des sichtbaren Pleuratumors eine Dosiseskalation ermöglicht.

Material und Methoden

Es wurden 12 konsekutive MPM-Patienten in Phase I–IV (6 links- und 6 rechtshändig) retrospektiv identifiziert und inkludiert. Ein MRT-basiertes makroskopisches Tumorvolumen (GTV) der Pleura wurde umrandet. Für jeden Patienten wurden zwei Typen von Planungszielvolumen (PTV) erzeugt: (1) ein „selektives“ PTV (S-PTV), das einer isotropen Expansion von 5 mm vom GTV entstammt, und (2) ein „elektives“ PTV (E-PTV), das einer isotropen Expansion von 5 mm von der ganzen ipsilateralen Pleurahöhle entstammt. Zwei verschiedene Behandlungspläne mit volumetrisch modulierter Bogentherapie (VMAT) wurden erstellt: ein „selektiver“ pleuraler Bestrahlungsplan (SPI-Plan) und ein „elektiver“ pleuraler Bestrahlungsplan (EPI-Plan; geplant mit simultan integrierter Boost-Technik [SIB]).

Ergebnisse

In den SPI-Plänen betrug die durchschnittliche mittlere Dosis beim S‑PTV 53,6 Gy (Spanne 41–63,6 Gy). Bei 4 von 12 Patienten ließ sich die Dosis beim S‑PTV auf >58 Gy eskalieren. In den EPI-Plänen betrugen die durchschnittlichen mittleren Dosen beim E‑PTV und beim S‑PTV 48,6 Gy (Spanne 38,5–58,7 Gy) bzw. 49 Gy (Spanne 38,6–59,5 Gy). Eine signifikante Dosiseskalation war nicht möglich.

Schlussfolgerung

Das Weglassen der elektiven Bestrahlung der ganzen ipsilateralen Pleurahöhle ermöglichte bei 4 von 12 chemonaiven MPM-Patienten eine Dosiseskalation von 49 Gy bis über 58 Gy. Diese Strategie kann die Basis für eine nichtchirurgische, radikal kombinierte Modalitätsbehandlung von MPM bilden.

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Acknowledgements

A. B. is supported by a grant from the Stichting tegen kanker/Fondation contre le cancer (CA/2014/354) and by Kom op Tegen Kanker (Stand up to Cancer, The Flemish Cancer Society).

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Correspondence to A. Botticella MD.

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A. Botticella, G. Defraene, K. Nackaerts, C. Deroose, J. Coolen, P. Nafteux, B. Vanstraelen, S. Joosten, L.A.W. Michiels, S. Peeters, and D. DeRuysscher declare that they have no competing interests.

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This article does not contain any studies with human participants or animals performed by any of the authors.

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Botticella, A., Defraene, G., Nackaerts, K. et al. Does selective pleural irradiation of malignant pleural mesothelioma allow radiation dose escalation?. Strahlenther Onkol 193, 285–294 (2017). https://doi.org/10.1007/s00066-017-1108-y

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