Outcomes After Extrapleural Pneumonectomy and Intensity-Modulated Radiation Therapy for Malignant Pleural Mesothelioma

doi:10.1016/j.athoracsur.2007.04.076

The Annals of Thoracic Surgery

Volume 84, Issue 5, November 2007, Pages 1685-1693

Presented at the Fifty-third Annual Meeting of the Southern Thoracic Surgical Association, Tucson, AZ, Nov 8–11, 2006.

https://doi.org/10.1016/j.athoracsur.2007.04.076 Get rights and content

Background

Malignant pleural mesothelioma is a locally aggressive tumor that is usually fatal. Extrapleural pneumonectomy (EPP) followed by hemithoracic irradiation has shown promise, but local failure remains a significant problem. To improve local control, we have used intensity-modulated radiation therapy (IMRT) as it allows better dose distribution to regions at risk of recurrence as well as reduced radiation to surrounding organs.

Methods

One hundred consecutive patients underwent EPP. At a median interval of 2.5 months from surgery, 63 patients received IMRT (median dose 45 Gy) with curative intent. Chemotherapy was not routinely administered.

Results

Tumors were right sided in 66 patients (66%) and nonepithelioid in 33 (33%). American Joint Committee on Cancer pathology stage was I in 6 patients (6%), II in 7 (7%), III in 72 (72%), and IV (T4) in 15 (15%). Fifty-four patients (54%) had ipsilateral nodal metastases. Perioperative mortality was 8%. Median overall survival (n = 100) was 10.2 months. For patients who received IMRT (n = 63), median overall and 3-year survival was 14.2 months and 20%. Of these, node-negative patients with epithelioid histology (n = 18) had median and 3-year survival of 28 months and 41%. Distant recurrences occurred in 33 of 61 evaluable patients (54%). Eight patients (13%) had local or regional recurrence, 5 of whom also recurred distally. Only 3 patients (5%) had recurrence within the irradiated field.

Conclusions

Intensity-modulated radiation therapy after EPP results in excellent local control for malignant pleural mesothelioma; however, distant metastases remain a significant problem and limit survival. This provides a strong rationale for combining aggressive local regimens with systemic therapy.

Section snippets

Material and Methods

The study was approved by the Institutional Review Board at the University of Texas M. D. Anderson Cancer Center and waiver of individual informed consent was granted. We included all patients who had a diagnosis of malignant pleural mesothelioma and who were treated with extrapleural pneumonectomy between October 1999 and July 2005 at the University of Texas M. D. Anderson Cancer Center. Patients were radiographically staged with computed tomography (CT [n = 100]) and positron emission

Demographics

From October 1999 through July 2005, 100 consecutive patients underwent EPP. There were 14 women (14%), and the mean age at the time of surgery was 60 years (range, 37 to 80). Tumors were right-sided in 66 patients (66%) and were epithelioid in 67 (67%), biphasic in 24 (24%), and sarcomatoid in 9 (9%), as shown in Table 1. Postsurgical (or pathologic) stage was Ib in 6 patients (6%), II in 7 (7%), III in 72 (72%), and IV in 15 (15%). With the exception of a single patient who was found to have

Comment

Local failure remains a significant problem after EPP despite adjuvant radiation. Baldini and colleagues [4] reported patterns of failure in 35 patients who underwent trimodality treatment with EPP, chemotherapy, and radiation therapy (median dose 30.6 Gy). Local recurrence occurred in 31% of patients and did not appear to be influenced by histology, nodal, or margin status. Subsequently, Rusch and coworkers [18] prospectively evaluated the use of higher dose (54 Gy) adjuvant radiation after

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Our study showed that V5 and V20 were independent predictors for grade ≥ 2 RP in NSCLC patients receiving radiotherapy after pneumonectomy. Grade 3 RP did not occur whenV5 < 30%, V20 < 13% and MLD < 751.2cGy, respectively. In addition, patient underwent right pneumonectomy may have a lower tolerance to radiation compared to left pneumonectomy.
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Un total de 22(26,8 %) patients ont souffert de pneumopathie radique de grade 2 et cinq (6,1 %) de grade 3. L’analyse unifactorielle a démontré que les V5, V10, V20, V30 (Vx: volume recevant X Gy), la MLD (mean lung dose), le PTV (volume cible prévisionnel) et le ratio PTV/TLV (total lung volume) étaient associés à la survenue de pneumopathie radique de grade ≥ 2, alors qu’aucun des facteurs cliniques n’était significatif; le V5 (OR [odds ratio]: 1,213; IC à 95 % [intervalle de confiance à 95 %]: 1,099–1,339; p < 0,001) et le V20 (OR: 1,435; IC à 95 %, 1,166–1,765; p = 0,001) étaient les prédicteurs significatifs indépendants dans l’analyse multifactorielle et ont été inclus dans le nomogramme. L’analyse ROC pour les valeurs seuils pour prédire un grade ≥ 2 de pneumopathie radique était un V5 de plus de 23 % (ASC [aire sous la courbe] = 0,819, sensibilité: 0,701, spécificité: 0,832) et un V20 de plus de 8 % (ASC = 0,812, sensibilité: 0,683, spécificité: 0,811). De plus, la pneumpathie radique de grade ≥ 3 ne s’est pas produite lorsque le V5 était de moins de30 %, le V20 de moins de13 % et la MLD de moins de 751,2c Gy.
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Original articleGeneral thoracicOutcomes After Extrapleural Pneumonectomy and Intensity-Modulated Radiation Therapy for Malignant Pleural Mesothelioma

Background

Methods

Results

Conclusions

Section snippets

Material and Methods

Demographics

Comment

Ann Thorac Surg

J Thorac Cardiovasc Surg

J Radiat Oncol Biol Phys

Int J Radiat Oncol Biol Phys

Radiother Oncol

Int J Radiat Oncol Biol Phys

Int J Radiat Oncol Biol Phys

Int J Radiat Oncol Biol Phys

Int J Radiat Oncol Biol Phys

J Thorac Cardiovasc Surg

Ann Thorac Surg

J Thorac Cardiovasc Surg

Phase III study of pemetrexed in combination with cisplatin versus cisplatin alone in patients with malignant pleural mesothelioma

Int J Radiat Oncol Biol Phys

Original article
General thoracic
Outcomes After Extrapleural Pneumonectomy and Intensity-Modulated Radiation Therapy for Malignant Pleural Mesothelioma