ReviewRadiotherapy for the treatment of pain in malignant pleural mesothelioma: A systematic review
Introduction
In 2009, over 2500 patients were diagnosed with MPM in the UK. The global incidence is not known but has been estimated at 14,200 per year [1]. The most common symptoms in MPM are pain and breathlessness though the reported incidence of pain varies from 25% to 90% [2], [3], [4], [5].
The cause of the pain in MPM is often multifactorial. It may be caused by infiltration of the intercostal nerves by tumour and/or due to surgical procedures (pleural biopsy, thoracotomy etc.) [6]. Furthermore, mesothelioma may also invade bone causing significant pain. Therefore, the pathophysiology of pain in MPM is generally mixed: a combination of bone and neuropathic pain. As a result, patients are often on multiple analgesics such as non steroidal anti inflammatory drugs (NSAIDs), opioids, paracetamol, adjuvant analgesics for neuropathic pain as well as topical agents such as lidocaine patches [7]. Cordotomy is occasionally performed for these patients, however this is not widely available [6], [8]. There is an urgency for patients with MPM to receive optimal pain control.
In terms of oncological interventions for treating pain in MPM, the armamentarium is limited. Surgery, chemotherapy and radiotherapy have all been studied in this disease. Surgical studies have tended to focus on long term tumour control rather than symptom improvement. Chemotherapy studies have generally been disappointing though two studies have shown a survival advantage [9], [10].
Radiotherapy is effective at palliating many symptoms in cancer patients, especially cancer related bone pain [11]. Although precise data on the utilisation of radiotherapy in treating pain in MPM is unknown, it is frequently used for this purpose. However, the evidence supporting its use has not been clearly established [7].
This systematic review examines the evidence supporting the use of radiotherapy in treating pain in patients with MPM.
Section snippets
Materials and methods
Ethical approval was not required for this systematic review. The following databases were searched electronically: Medline (1946–2013), Embase (1974–2013) and CENTRAL (The Cochrane Library Issue 9, 2012). The keywords and search strategy are outlined in Appendix 1. The date of the last literature search was 5th February 2013.
Results
The following number of articles was retrieved: 462 (Medline), 1007 (EMBASE) and 11 (Central). The literature search results are shown in Fig. 1. Following the appraisal process described, eight articles were eligible.
Articles which met the eligibility criteria are shown in Table 1. Key aspects of each study are detailed. It is noted that no patients in any of the studies received pemetrexed based chemotherapy.
Excluded articles are shown in supplementary Table 1; [30], [31], [32], [33], [34],
Discussion
Based on the studies presented in this review, the evidence for radiotherapy in treating pain in mesothelioma ranges from Level 2 to 3 [17]. Therefore, firm recommendations on the role of radiotherapy in the relief of pain in MPM cannot be made. Due to a combination of poor study design and small numbers of patients, none of the studies fully examine the role of radiotherapy in the treatment of pain in MPM. Indeed, in four of the eight studies, assessment of pain response was retrospective and
Conflict of interest statement
No conflict of interest declared.
Acknowledgements
The authors would like to acknowledge grants received from the June Hancock Mesothelioma Research Fund and the Beatson Oncology Centre Fund as well as the work from Ms. K Coltart who helped conduct the literature review.
References (39)
- et al.
Re-evaluating the role of palliative radiotherapy in malignant pleural mesothelioma
Eur J Cancer
(2011) - et al.
Active symptom control with or without chemotherapy in the treatment of patients with malignant pleural mesothelioma (MS01): a multicentre randomised trial
Lancet
(2008) - et al.
Meta-analysis of dose-fractionation radiotherapy trials for the palliation of painful bone metastases
Int J Radiat Oncol Biol Phys
(2003) - et al.
Factors influencing the outcome of radiotherapy in malignant mesothelioma of the pleura—a single-institution experience with 189 patients
Int J Radiat Oncol Biol Phys
(1999) - et al.
Radiation therapy in the management of patients with mesothelioma
Int J Radiat Oncol Biol Phys
(1982) - et al.
The role of palliative radiotherapy in malignant mesothelioma
Clin Oncol (R Coll Radiol)
(1991) Chemotherapy for malignant mesothelioma
Lung Cancer
(2005)- et al.
International consensus on palliative radiotherapy endpoints for future clinical trials in bone metastases
Radiother Oncol
(2002) - et al.
Radiotherapy treatment planning for patients with non-small cell lung cancer using positron emission tomography (PET)
Radiother Oncol
(2002) - et al.
Combined FDG-PET/CT in response evaluation of malignant pleural mesothelioma
Lung Cancer
(2010)
Radiotherapy in malignant pleural mesothelioma
Int J Radiat Oncol Biol Phys
Inverse planned stereotactic intensity modulated radiotherapy (IMRT) in the palliative treatment of malignant mesothelioma of the pleura: the Heidelberg experience
Lung Cancer
Radiation therapy of mesothelioma: the Heidelberg experience and future aspects
Lung Cancer
Mesothelioma incidence statistics
The treatment of malignant mesothelioma of the pleura: review of a 5-year experience, with special reference to radiotherapy
Am J Clin Oncol
Radiotherapy in the treatment of malignant mesothelioma of the pleura, with special reference to its use in palliation
Australas Radiol
Percutaneous cervical cordotomy for the control of pain in patients with pleural mesothelioma
Thorax
What is the role of radiotherapy in malignant pleural mesothelioma?
Oncologist
CT-guided percutaneous selective cordotomy for treatment of intractable pain in patients with malignant pleural mesothelioma
Acta Neurochir (Wien)
Cited by (38)
Role of interventional radiology in pain management in oncology patients
2023, Clinical RadiologyCitation Excerpt :This reduces pain pathways below the C4 dermatome or below the shoulder.126 A paucity of data exist for percutaneous cervical cordotomy in the literature.125 A recent UK national data collection involving 159 patients who underwent percutaneous cervical cordotomy is one of the largest.
Malignant Pleural Mesothelioma: Updates for Respiratory Physicians
2021, Clinics in Chest MedicineCitation Excerpt :Choice of analgesic also can be determined by coexisting symptoms such as night sweats, reduced appetite or anxiety/depression (amitriptyline), uncorrectable or distressing dyspnea (opioids), or need for control of epileptic events (gabapentin/pregabalin). Localized pain can be assisted by corticosteroid if felt to be related to progressive disease and tumoral edema, but radiotherapy also can be considered, as discussed previously.77 Interventional options including nerve blocks or intrathecal analgesia are considered when pain is refractory to the aforementioned oral or despite escalation to subcutaneous medication infusions.
How i treat malignant pleural mesothelioma
2020, ESMO OpenCitation Excerpt :Placement of indwelling pleural catheter is a suitable option for trapped lung syndrome. Radiotherapy should be considered in all patients with localised disease causing pain or obstructive symptoms, usually with hypofractionated regimens.16 Appearance of painful subcutaneous tumour nodules may be the consequence of malignant cells seeding along instrument tracts at sites of diagnostic or therapeutic intervention.
The role of radiation treatment in pleural mesothelioma: Highlights of the 14th International Conference of the International mesothelioma interest group
2019, Lung CancerCitation Excerpt :Although radiotherapy has an established role in palliation of pain in other malignancies the evidence base in MPM was historically limited to series mainly without prospective validated measures and with inconsistent results. SYSTEMS-1 [8,9] was the largest ever prospective trial of palliative RT in MPM and demonstrated effective pain relief in a subset of patients with short course simple palliative regimen of 20Gy/5. Response rate was 47% in evaluable patients at 5 weeks (35% ITT).
Radiotherapy for Pleural Mesothelioma
2019, Malignant Pleural Mesothelioma: A Guide for Clinicians
- 1
Joint lead authors.