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Luna J, Bobo A, Cabrera-Rodriguez JJ, Pagola M, Martín-Martín M, Ruiz MÁG, Montijano M, Rodríguez A, Pelari-Mici L, Corbacho A, Moreno M, Couñago F. GOECP/SEOR clinical guidelines on radiotherapy for malignant pleural mesothelioma. World J Clin Oncol 2021; 12:581-608. [PMID: 34513595 PMCID: PMC8394157 DOI: 10.5306/wjco.v12.i8.581] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2020] [Revised: 05/12/2021] [Accepted: 07/06/2021] [Indexed: 02/06/2023] Open
Abstract
Malignant pleural mesothelioma (MPM) is a rare tumor with poor prognosis and rising incidence. Palliative care is common in MPM as radical treatment with curative intent is often not possible due to metastasis or extensive locoregional involvement. Numerous therapeutic advances have been made in recent years, including the use of less aggressive surgical techniques associated with lower morbidity and mortality (e.g., pleurectomy/decortication), technological advancements in the field of radiotherapy (intensity-modulated radiotherapy, image-guided radiotherapy, stereotactic body radiotherapy, proton therapy), and developments in systemic therapies (chemotherapy and immunotherapy). These improvements have had as yet only a modest effect on local control and survival. Advances in the management of MPM and standardization of care are hampered by the evidence to date, limited by high heterogeneity among studies and small sample sizes. In this clinical guideline prepared by the oncological group for the study of lung cancer of the Spanish Society of Radiation Oncology, we review clinical, histologic, and therapeutic aspects of MPM, with a particular focus on all aspects relating to radiotherapy, including the current evidence base, associations with chemotherapy and surgery, treatment volumes and planning, technological advances, and reradiation.
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Affiliation(s)
- Javier Luna
- Department of Radiation Oncology, Institute of Oncohealth, Fundación Jiménez Díaz, Madrid 28040, Spain
| | - Andrea Bobo
- Department of Radiation Oncology, Institution of Ruber Internacional Hospital, Madrid 28034, Spain
| | | | - María Pagola
- Department of Radiation Oncology, Institution of Onkologikoa/Hospital Universitario Donostia, San Sebastián 20014, Spain
| | - Margarita Martín-Martín
- Department of Radiation Oncology, Institution of Hospital Universitario Ramón y Cajal, Madrid 28034, Spain
| | - María Ángeles González Ruiz
- Department of Radiation Oncology, Institution of Hospital Universitario Virgen de la Macarena, Sevilla 41009, Spain
| | - Miguel Montijano
- Department of Radiation Oncology, Institution of Genesis care Spain, Madrid 28005, Spain
| | - Aurora Rodríguez
- Department of Radiation Oncology, Institution of Ruber Internacional Hospital, Madrid 28034, Spain
| | - Lira Pelari-Mici
- Department of Radiation Oncology, Institution of Hospital Universitario Ramón y Cajal, Madrid 28034, Spain
| | - Almudena Corbacho
- Department of Radiation Oncology, Institution of Hospital de Mérida, Mérida 06800, Spain
| | - Marta Moreno
- Department of Oncology, Institution of University Navarra, Clinical University, Pamplona 31008, Spain
| | - Felipe Couñago
- Department of Radiation Oncology, Institution of Hospital Universitario Quirónsalud and Hospital LaLuz, European University of Madrid, Madrid 28028, Spain
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Schumann SO, Kocher G, Minervini F. Epidemiology, diagnosis and treatment of the malignant pleural mesothelioma, a narrative review of literature. J Thorac Dis 2021; 13:2510-2523. [PMID: 34012597 PMCID: PMC8107529 DOI: 10.21037/jtd-20-2761] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
The malignant pleural mesothelioma is a very aggressive tumor which is arising from mesothelial cells and is associated with asbestos exposure. It is a heterogeneous cancer that shows a complex pattern of molecular changes, including genetic, chromosomic, and epigenetic abnormalities. The malignant pleural mesothelioma is characterized by a silent and slow clinical progression with an average period of 20–40 years from the asbestos exposure phase to the start of the symptoms. Unfortunately, to date, the therapeutic options are very limited, especially if the tumor is detected late. This narrative review provides an extended overview of the present evidence in the literature regarding the epidemiology, diagnostic pathways and treatment approaches of the malignant pleural mesothelioma. The treatment of mesothelioma has evolved slowly over the last 20 years not only from a surgical point of view but also radiotherapy, chemotherapy and immunotherapy play nowadays a key role. Several surgical strategies are available ranging from extrapleural pneumonectomy to cytoreductive surgery but a multidisciplinary approach seems to be mandatory because a single approach has not proved to date to be resolutive. New non-surgical treatment options appear to be promising but the results have to be taken in account with caution because clear evidence with high-quality studies is still lacking
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Affiliation(s)
| | - Gregor Kocher
- Division of General Thoracic Surgery, Inselspital, Bern University Hospital, University of Bern, Switzerland
| | - Fabrizio Minervini
- Department of Thoracic Surgery, Lucerne Cantonal Hospital, Lucerne, Switzerland
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Mummudi N, Khan A, Tibdewal A, Kumar R, Jiwnani S, Karimundackal G, Pramesh C, Agarwal JP. Trimodality treatment in malignant pleural mesothelioma - Ordeal or real deal? Rep Pract Oncol Radiother 2020; 25:876-881. [PMID: 32982593 PMCID: PMC7498860 DOI: 10.1016/j.rpor.2020.08.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2020] [Revised: 06/29/2020] [Accepted: 08/11/2020] [Indexed: 10/23/2022] Open
Abstract
BACKGROUND Management of MPM is complex and controversial as there is a paucity of good quality evidence. We report the toxicity and outcomes in patients who received trimodality treatment for non-metastatic MPM at our institution. METHODS & MATERIALS We reviewed the electronic medical records of surgically managed MPM patients at our institution in the last decade. Dosimetric parameters of target volume and organs at risk were documented by the treatment planning workstation. SPSS was used for statistical analysis. RESULTS Between January 2008 and October 2018, 21 patients underwent surgery for MPM - all but 2 patients underwent extra-pleural pneumonectomy (EPP); epithelioid MPM was the most common histology. All patients, except 2, received neoadjuvant Pemetrexed/platinum doublet chemotherapy. Fourteen patients received adjuvant hemithoracic RT; ten patients were treated with a conformal technique at our institute and dosimetric data was available for analysis. Average time to start RT after surgery was 51 days (range 32-82 days). All patients were treated with a conformal technique using IMRT/VMAT to a dose of 45Gy in 25 fractions. Mean overall RT duration was 35 days (range 30-42 days). Grade I/II Pneumonitis was seen in 4 patients. One patient developed grade III acute lung toxicity unrelated to RT. At a median follow up of 25 months, 8 patients had died, of whom six died due to the disease and two died in the immediate post op period. Two-year DFS and OS were 58% and 73%, respectively. CONCLUSION In spite of the extensive surgery and complex hemithoracic RT, we demonstrated excellent dosimetry, toxicity profile and favorable outcomes in non-metastatic MPM.
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Affiliation(s)
- Naveen Mummudi
- Department of Radiation Oncology, Tata Memorial Centre, Homi Bhabha National Institute, India
| | - Asfiya Khan
- Department of Radiation Oncology, Tata Memorial Centre, Homi Bhabha National Institute, India
| | - Anil Tibdewal
- Department of Radiation Oncology, Tata Memorial Centre, Homi Bhabha National Institute, India
| | - Rajiv Kumar
- Department of Pathology, Tata Memorial Centre, Homi Bhabha National Institute, India
| | - Sabita Jiwnani
- Department of Thoracic Surgery, Tata Memorial Centre, Homi Bhabha National Institute, India
| | - George Karimundackal
- Department of Thoracic Surgery, Tata Memorial Centre, Homi Bhabha National Institute, India
| | - C.S. Pramesh
- Department of Thoracic Surgery, Tata Memorial Centre, Homi Bhabha National Institute, India
| | - Jai Prakash Agarwal
- Department of Radiation Oncology, Tata Memorial Centre, Homi Bhabha National Institute, India
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Abstract
The treatment of malignant pleural mesothelioma with radiation therapy has always been a technical challenge. For many years, radiation therapy was delivered after extrapleural pneumonectomy with acceptable results. As the utilization of pleurectomy/decortication increased, techniques, such as pleural intensity-modulated radiation therapy (IMRT) have been introduced. The experience with these techniques have grown and multiple trials using IMRT, both in the setting of extrapleural pneumonectomy or pleurectomy, are being conducted to assess its effectiveness.
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Affiliation(s)
- Kenneth E Rosenzweig
- Department of Radiation Oncology, Icahn School of Medicine at Mount Sinai, One Gustav L. Levy Place - Box 1236, New York, NY 10029, USA.
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Dumane VA, Tam J, Lo YC, Rosenzweig KE. RapidPlan for Knowledge-Based Planning of Malignant Pleural Mesothelioma. Pract Radiat Oncol 2020; 11:e219-e228. [PMID: 32562788 DOI: 10.1016/j.prro.2020.06.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2020] [Revised: 05/19/2020] [Accepted: 06/08/2020] [Indexed: 12/25/2022]
Abstract
PURPOSE Treatment planning for malignant pleural mesothelioma is a challenging task due to the relatively large size of the target and the need to spare critical organs that overlap with or are within the target volume. We aimed to develop a knowledge-based model using RapidPlan (RP) for patients with 2 intact lungs. METHODS AND MATERIALS Data from 57 patients treated with volumetric modulated arc therapy were chosen for training the dose estimation model at a single dose level. The prescription dose was 50.4 Gy in 1.8 Gy fractions. The model was validated on 23 new patients by comparing the clinical plan to the RP. Time taken to plan the RP was compared with that for the clinical plan. RESULTS For similar target coverage and plan inhomogeneity, RP significantly improved the sparing of the contralateral lung, heart, stomach, esophagus, and ipsilateral kidney. On average, the contralateral lung V5 Gy and V10 Gy were reduced by 13.9% (P < .001) and 7.9% (P < .001), respectively. The mean heart dose was reduced by 5 Gy (P < .001) and V30 Gy by 9.1% (P < .001). Mean dose to the stomach and esophagus were both reduced by 5 Gy (P < .001), and the ipsilateral kidney V18 Gy by 4.1% (P < .001). Mean total lung dose was reduced by 0.8 Gy with RP, which enabled an increase in prescription dose by 1 fraction Absolute volume of ipsilateral lung was adequately spared by both techniques, while sparing of all other organs, namely the cord, liver, and bowel, was not compromised with RP. Time taken with RP was 20 minutes, 45 seconds versus at least 4 hours for an experienced treatment planner. CONCLUSIONS The RP model for malignant pleural mesothelioma showed improved sparing of critical organs with a reduced treatment planning time and increased prescription dose.
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Affiliation(s)
- Vishruta A Dumane
- Department of Radiation Oncology, Icahn School of Medicine at Mount Sinai, New York, New York.
| | - James Tam
- Department of Radiation Oncology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Yeh-Chi Lo
- Department of Radiation Oncology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Kenneth E Rosenzweig
- Department of Radiation Oncology, Icahn School of Medicine at Mount Sinai, New York, New York
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Zeng J, Badiyan SN, Garces YI, Wong T, Zhang X, Simone CB, Chang JY, Knopf AC, Mori S, Iwata H, Meijers A, Li H, Bues M, Liu W, Schild SE, Rengan R. Consensus Statement on Proton Therapy in Mesothelioma. Pract Radiat Oncol 2020; 11:119-133. [PMID: 32461036 DOI: 10.1016/j.prro.2020.05.004] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2020] [Revised: 04/26/2020] [Accepted: 05/13/2020] [Indexed: 12/11/2022]
Abstract
PURPOSE Radiation therapy for mesothelioma remains challenging, as normal tissue toxicity limits the amount of radiation that can be safely delivered to the pleural surfaces, especially radiation dose to the contralateral lung. The physical properties of proton therapy result in better sparing of normal tissues when treating the pleura, both in the postpneumonectomy setting and the lung-intact setting. Compared with photon radiation, there are dramatic reductions in dose to the contralateral lung, heart, liver, kidneys, and stomach. However, the tissue heterogeneity in the thorax, organ motion, and potential for changing anatomy during the treatment course all present challenges to optimal irradiation with protons. METHODS The clinical data underlying proton therapy in mesothelioma are reviewed here, including indications, advantages, and limitations. RESULTS The Particle Therapy Cooperative Group Thoracic Subcommittee task group provides specific guidelines for the use of proton therapy for mesothelioma. CONCLUSIONS This consensus report can be used to guide clinical practice, insurance approval, and future research.
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Affiliation(s)
- Jing Zeng
- Department of Radiation Oncology, University of Washington School of Medicine, Seattle, Washington.
| | - Shahed N Badiyan
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, Missouri
| | - Yolanda I Garces
- Department of Radiation Oncology, Mayo Clinic Rochester, Rochester, Minnesota
| | - Tony Wong
- Seattle Cancer Care Alliance Proton Therapy Center, Seattle, Washington
| | - Xiaodong Zhang
- Department of Radiation Physics, Division of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas
| | | | - Joe Y Chang
- Department of Radiation Oncology, Division of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Antje C Knopf
- Division of Radiotherapy, University of Groningen, Groningen, Netherlands
| | - Shinichiro Mori
- Research Center for Charged Particle Therapy, National Institute of Radiological Sciences, Chiba, Japan
| | - Hiromitsu Iwata
- Department of Radiation Oncology, Nagoya Proton Therapy Center, Nagoya City West Medical Center, Nagoya, Japan
| | - Arturs Meijers
- Division of Radiotherapy, University of Groningen, Groningen, Netherlands
| | - Heng Li
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins Medicine, Baltimore, Maryland
| | - Martin Bues
- Department of Radiation Oncology, Mayo Clinic Arizona, Scottsdale, Arizona
| | - Wei Liu
- Department of Radiation Oncology, Mayo Clinic Arizona, Scottsdale, Arizona
| | - Steven E Schild
- Department of Radiation Oncology, Mayo Clinic Arizona, Scottsdale, Arizona
| | - Ramesh Rengan
- Department of Radiation Oncology, University of Washington School of Medicine, Seattle, Washington
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Patel R, Ludmir EB, Miccio JA, Menon H, Barsky AR, Mesko SM, Kodali M, Lautenschlaeger T, Adeberg S, Simone CB, Verma V. Disease-Related Outcomes and Toxicities of Intensity Modulated Radiation Therapy After Lung-Sparing Pleurectomy for Malignant Pleural Mesothelioma: A Systematic Review. Pract Radiat Oncol 2020; 10:423-433. [PMID: 32088429 DOI: 10.1016/j.prro.2020.02.007] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2019] [Revised: 01/06/2020] [Accepted: 02/08/2020] [Indexed: 12/15/2022]
Abstract
PURPOSE This review explores the use of intensity modulated radiation therapy (IMRT) after lung-sparing surgery in malignant pleural mesothelioma (MPM). Because severe toxicities have been documented after radiation therapy for MPM, its use remains controversial, especially as modern surgical management has shifted toward lung-sparing pleurectomy/decortication. IMRT is an advanced technique that may allow for safer radiation therapy delivery, but there remains limited data (including no summative data) to support this notion. METHODS AND MATERIALS We performed a systematic review evaluating the safety and efficacy of post-pleurectomy IMRT (P-IMRT). A systematic review of PubMed using Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines was conducted for publications of all dates that specifically reported clinical outcomes and/or toxicities of P-IMRT in patients with MPM. Ten original studies were included in this review. RESULTS The incidence of grade 3 pneumonitis ranged from 0% to 16%, with all but 2 studies reporting rates below 9%. Grade 4 and 5 pneumonitis were observed in less than 1.5% of cases, except in one publication that used hypofractionated radiation therapy to doses >60 Gy. Crude local failure rates ranged from 19% to 60%, median progression free survival ranged from 12 to 16 months, and median overall survival ranged from 19 to 28 months. CONCLUSIONS P-IMRT produces relatively few higher-grade toxicities and has reasonable disease-related outcomes, especially when delivered using conventionally fractionated regimens to doses of 45 to 54 Gy and exercising careful attention to dose constraints during treatment planning. IMRT can thus be considered in well-selected patients in whom adequate survival after pleurectomy is expected. These data also support the initiation of the phase III NRG-LU006 trial of extended pleurectomy/decortication and chemotherapy with or without IMRT.
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Affiliation(s)
| | - Ethan B Ludmir
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Joseph A Miccio
- Department of Therapeutic Radiology, Yale University, New Haven, Connecticut
| | - Hari Menon
- University of Arizona College of Medicine, Phoenix, Phoenix, Arizona
| | - Andrew R Barsky
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Shane M Mesko
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Manya Kodali
- Department of Radiation Oncology, Allegheny General Hospital, Pittsburgh, Pennsylvania
| | - Tim Lautenschlaeger
- Department of Radiation Oncology, Indiana University School of Medicine, Indianapolis, Indiana
| | - Sebastian Adeberg
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany
| | - Charles B Simone
- Department of Radiation Oncology, New York Proton Center, New York, New York
| | - Vivek Verma
- Department of Radiation Oncology, Allegheny General Hospital, Pittsburgh, Pennsylvania.
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Kuribayashi K, Doi H, Kijima T. Types of surgery post-neoadjuvant chemotherapy for pleural mesothelioma. Expert Rev Respir Med 2019; 13:1189-1194. [PMID: 31596628 DOI: 10.1080/17476348.2019.1679119] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Introduction: The surgical arm of the Mesothelioma and Radical Surgery (MARS) trial involved a multimodal approach, with combined therapy consisting of chemotherapy, complete gross resection, and radiation therapy. However, the MARS trial did not compare surgery with chemotherapy, and the survival and quality of life outcomes of this trial's surgical arm were inferior to those of the non-surgical arm. Methods for achieving complete gross resection (macroscopic complete response [MCR]) include extrapleural pneumonectomy (EPP), wherein the pleura, lung, diaphragm, and pericardium are removed en bloc, and pleurectomy/decortication (P/D), wherein the affected lung is preserved. Nonetheless, the most effective therapy remains unclear.Areas covered: Here, surgery post-neoadjuvant chemotherapy for malignant pleural mesothelioma with either EPP or P/D has been discussed, along with trimodal and bimodal therapies.Expert opinion: With the development of post-P/D radiation therapy, it is currently possible to truly compare EPP with P/D. Moreover, R0 resection cannot be achieved with either EPP or P/D; thus, both must incorporate debulking, although the two procedures are largely incompatible. Therefore, there is a need to rebuild the status of surgery as a multimodal therapy.
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Affiliation(s)
- Kozo Kuribayashi
- Division of Respiratory Medicine, Department of Internal Medicine, Hyogo College of Medicine, Nishinomiya, Japan
| | - Hiroshi Doi
- Department of Radiology, Hyogo College of Medicine, Nishinomiya, Japan
| | - Takashi Kijima
- Division of Respiratory Medicine, Department of Internal Medicine, Hyogo College of Medicine, Nishinomiya, Japan
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Riesterer O, Ciernik IF, Stahel RA, Xyrafas A, Aebersold DM, Plasswilm L, Mahmut Ozsahin E, Zwahlen DR, Nackaerts K, Zimmermann F, Sabrina Stark L, Weder W, Krayenbuehl J. Pattern of failure after adjuvant radiotherapy following extrapleural pneumonectomy of pleural mesothelioma in the SAKK 17/04 trial. Radiother Oncol 2019; 138:121-125. [PMID: 31252293 DOI: 10.1016/j.radonc.2019.05.024] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2018] [Revised: 05/31/2019] [Accepted: 05/31/2019] [Indexed: 12/21/2022]
Abstract
Postoperative radiotherapy after extrapleural pneumonectomy of malignant pleural mesothelioma was investigated in the randomized phase II trial SAKK17/04. The relapse rate within the high and/or low-dose PTV without previous distant failure was 24%, the isolated in-field-relapse rate within the PTVs was 5% and the distant relapse rate outside of the PTVs was 81%. Clinical outcome was mainly determined by distant disease progression outside of the radiation field.
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Affiliation(s)
- Oliver Riesterer
- Department of Radiation Oncology, University Hospital Zurich, University of Zurich, Switzerland; Center for Radiation Oncology KSA-KSB, Kantonsspital Aarau, Switzerland.
| | - I Frank Ciernik
- Department of Radiotherapy and Radiation Oncology, Dessau, Germany
| | - Rolf A Stahel
- Cancer Center Zurich, University Hospital Zurich, University of Zurich, Switzerland
| | - Alexandros Xyrafas
- Swiss Group for Clinical Cancer Research (SAKK) Coordinating Center, Bern, Switzerland
| | - Daniel M Aebersold
- Department of Radiation Oncology, Inselspital, University Hospital Bern, University of Bern, Switzerland
| | - Ludwig Plasswilm
- Department of Radiation Oncology, Kantonsspital St. Gallen, St. Gallen, University of Bern, Switzerland
| | - E Mahmut Ozsahin
- Department of Radiation Oncology, University Hospital Lausanne - CHUV, Lausanne, Switzerland
| | - Daniel R Zwahlen
- Department of Radiation Oncology, Kantonsspital Graubünden, Chur, Switzerland
| | - Kristiaan Nackaerts
- Department of Pneumology, KU Leuven, University Hospitals Leuven, Leuven, Belgium
| | - Frank Zimmermann
- Department of Radiation Oncology, University Hospital Basel, Basel, Switzerland
| | - L Sabrina Stark
- Department of Radiation Oncology, University Hospital Zurich, University of Zurich, Switzerland
| | - Walter Weder
- Thoracic Surgery Center, University Hospital Zurich, University of Zurich, Switzerland
| | - Jérôme Krayenbuehl
- Department of Radiation Oncology, University Hospital Zurich, University of Zurich, Switzerland
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Nelson DB, Rice DC, Mitchell KG, Tsao AS, Gomez DR, Sepesi B, Mehran RJ. Return to intended oncologic treatment after surgery for malignant pleural mesothelioma. J Thorac Cardiovasc Surg 2019; 158:924-929. [PMID: 31430846 DOI: 10.1016/j.jtcvs.2019.02.129] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2018] [Revised: 02/12/2019] [Accepted: 02/22/2019] [Indexed: 12/11/2022]
Abstract
OBJECTIVE Trimodality therapy may prolong survival for patients with resectable malignant pleural mesothelioma. However, many patients are unable to complete therapy. We sought to identify risk factors for failing to complete adjuvant intensity-modulated radiation therapy after cytoreduction for malignant pleural mesothelioma. METHODS We performed a single-institution review of those who received an extrapleural pneumonectomy or pleurectomy/decortication for malignant pleural mesothelioma from 2004 to 2017. Multivariable logistic regression was used to assess preoperative or intraoperative risk factors associated with failing to complete adjuvant intensity-modulated radiation therapy. RESULTS A total of 160 patients were identified, among whom 94 (59%) received an extrapleural pneumonectomy and 66 (41%) received a pleurectomy/decortication. Adjuvant intensity-modulated radiation therapy was completed among 105 patients (66%). Reasons for failing to complete adjuvant intensity-modulated radiation therapy included mortality (19), dose constraints (21), postoperative morbidity or delayed recovery (11), and refused or unknown status (4). On multivariable analysis, American Society of Anesthesiologists 3+ classification (P = .002) and smoking history (P = .022) were associated with failure to complete adjuvant intensity-modulated radiation therapy, whereas forced expiratory volume in 1 second 70% or less of predicted and pStage 4 (T4) were significant on univariable analysis only. Other factors, including extrapleural pneumonectomy or pleurectomy/decortication, margin status, age, and histology, were not associated with receiving adjuvant intensity-modulated radiation therapy. CONCLUSIONS Many patients are unable to complete adjuvant intensity-modulated radiation therapy after cytoreduction. Failure to complete adjuvant intensity-modulated radiation therapy was associated with worse preoperative comorbidity, but not the type of surgery or margin status.
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Affiliation(s)
- David B Nelson
- Department of Thoracic and Cardiovascular Surgery, The University of Texas MD Anderson Cancer Center, Houston, Tex
| | - David C Rice
- Department of Thoracic and Cardiovascular Surgery, The University of Texas MD Anderson Cancer Center, Houston, Tex
| | - Kyle G Mitchell
- Department of Thoracic and Cardiovascular Surgery, The University of Texas MD Anderson Cancer Center, Houston, Tex
| | - Anne S Tsao
- Department of Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Tex
| | - Daniel R Gomez
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Tex
| | - Boris Sepesi
- Department of Thoracic and Cardiovascular Surgery, The University of Texas MD Anderson Cancer Center, Houston, Tex
| | - Reza J Mehran
- Department of Thoracic and Cardiovascular Surgery, The University of Texas MD Anderson Cancer Center, Houston, Tex.
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Radiation Therapy in Mesothelioma. Radiat Oncol 2019. [DOI: 10.1007/978-3-319-52619-5_36-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022] Open
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12
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Die Radiotherapie des Pleuramesothelioms – Klinische Praxisleitlinie der American Society of Clinical Oncology. Strahlenther Onkol 2018; 194:953-957. [DOI: 10.1007/s00066-018-1354-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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13
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Dosimetric evaluation of a novel electron–photon mixed beam, produced by a medical linear accelerator. JOURNAL OF RADIOTHERAPY IN PRACTICE 2018. [DOI: 10.1017/s1460396917000711] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
AbstractAimThis study deals with the characteristics of simultaneous photon and electron beams in homogenous and inhomogeneous phantoms by experimental and Monte Carlo dosimetry, for therapeutic purposes. Materials and methods: Both 16 and 20 MeV high-energy electron beams were used as the original beam to strike perforated lead sheets to produce the mixed beam. The dosimetry results were achieved by measurement in an ion chamber in a water phantom and film dosimetry in a Perspex nasal phantom, and then compared with those calculated through a simulation approach. To evaluate two-dimensional dose distribution in the inhomogeneous medium, the dose–area histogram was obtained.ResultsThe highest percentage of photon contribution in mixed beam was found to be 36% for 2-mm thickness of lead layer with holes diameter of 0·2 cm for a 20 MeV primary electron energy. For small fields, the percentage depth dose parameters variations were found to be similar to pure electron beam within ±2%. The most feasible flatness in beam profile was 11% for pure electron and 7% for the mixed beam. Penumbra changes as function of depth was about ten times better than in pure electron field.ConclusionsThe results present some dosimetric advantages that can make this study a platform for the production of simultaneous mixed beams in future linear accelerators (LINACs), which through redesign of the LINAC head, which could lead to setup error reduction and a decrease of intra-fractional tumour cells repair.
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14
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Badiyan SN, Molitoris JK, Zhu M, Glass E, Diwanji T, Simone CB. Proton beam therapy for malignant pleural mesothelioma. Transl Lung Cancer Res 2018; 7:189-198. [PMID: 29876318 DOI: 10.21037/tlcr.2018.04.07] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Malignant pleural mesothelioma (MPM) is a rare disease with a poor prognosis. Surgical techniques have made incremental improvements over the last few decades while new systemic therapies, including immunotherapies, show promise as potentially effective novel therapies. Radiation therapy has historically been used only in the palliative setting or as adjuvant therapy after extrapleural pneumonectomy, but recent advances in treatment planning and delivery techniques utilizing intensity-modulated radiation therapy and more recently pencil-beam scanning (PBS) proton therapy, have enabled the delivery of radiation therapy as neoadjuvant or adjuvant therapy after an extended pleurectomy and decortication or as definitive therapy for patients with recurrent or unresectable disease. In particular, PBS proton therapy has the potential to deliver high doses of irradiation to the entire effected pleura while significantly reducing doses to nearby organs at risk. This article describes the evolution of radiation therapy for MPM and details how whole-pleural PBS proton therapy is delivered to patients at the Maryland Proton Treatment Center.
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Affiliation(s)
| | | | - Mingyao Zhu
- University of Maryland School of Medicine, Baltimore, MD, USA
| | - Erica Glass
- University of Maryland School of Medicine, Baltimore, MD, USA
| | - Tejan Diwanji
- University of Maryland School of Medicine, Baltimore, MD, USA
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Kindler HL, Ismaila N, Armato SG, Bueno R, Hesdorffer M, Jahan T, Jones CM, Miettinen M, Pass H, Rimner A, Rusch V, Sterman D, Thomas A, Hassan R. Treatment of Malignant Pleural Mesothelioma: American Society of Clinical Oncology Clinical Practice Guideline. J Clin Oncol 2018; 36:1343-1373. [PMID: 29346042 DOI: 10.1200/jco.2017.76.6394] [Citation(s) in RCA: 262] [Impact Index Per Article: 43.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Purpose To provide evidence-based recommendations to practicing physicians and others on the management of malignant pleural mesothelioma. Methods ASCO convened an Expert Panel of medical oncology, thoracic surgery, radiation oncology, pulmonary, pathology, imaging, and advocacy experts to conduct a literature search, which included systematic reviews, meta-analyses, randomized controlled trials, and prospective and retrospective comparative observational studies published from 1990 through 2017. Outcomes of interest included survival, disease-free or recurrence-free survival, and quality of life. Expert Panel members used available evidence and informal consensus to develop evidence-based guideline recommendations. Results The literature search identified 222 relevant studies to inform the evidence base for this guideline. Recommendations Evidence-based recommendations were developed for diagnosis, staging, chemotherapy, surgical cytoreduction, radiation therapy, and multimodality therapy in patients with malignant pleural mesothelioma. Additional information is available at www.asco.org/thoracic-cancer-guidelines and www.asco.org/guidelineswiki .
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Affiliation(s)
- Hedy L Kindler
- Hedy L. Kindler and Samuel G. Armato III, The University of Chicago, Chicago, IL; Nofisat Ismaila, American Society of Clinical Oncology; Mary Hesdorffer, Mesothelioma Applied Research Foundation, Alexandria, VA; Raphael Bueno, Harvard Medical School, Boston, MA; Thierry Jahan, University of California San Francisco, San Francisco, CA; Clyde Michael Jones, Baptist Cancer Center Physicians Foundation, Memphis, TN; Markku Miettinen, Anish Thomas and Raffit Hassan, Center for Cancer Research, National Cancer Institute, Bethesda, MD; Harvey Pass and Daniel Sterman, New York University Langone Medical Center; and Andreas Rimner and Valerie Rusch, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Nofisat Ismaila
- Hedy L. Kindler and Samuel G. Armato III, The University of Chicago, Chicago, IL; Nofisat Ismaila, American Society of Clinical Oncology; Mary Hesdorffer, Mesothelioma Applied Research Foundation, Alexandria, VA; Raphael Bueno, Harvard Medical School, Boston, MA; Thierry Jahan, University of California San Francisco, San Francisco, CA; Clyde Michael Jones, Baptist Cancer Center Physicians Foundation, Memphis, TN; Markku Miettinen, Anish Thomas and Raffit Hassan, Center for Cancer Research, National Cancer Institute, Bethesda, MD; Harvey Pass and Daniel Sterman, New York University Langone Medical Center; and Andreas Rimner and Valerie Rusch, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Samuel G Armato
- Hedy L. Kindler and Samuel G. Armato III, The University of Chicago, Chicago, IL; Nofisat Ismaila, American Society of Clinical Oncology; Mary Hesdorffer, Mesothelioma Applied Research Foundation, Alexandria, VA; Raphael Bueno, Harvard Medical School, Boston, MA; Thierry Jahan, University of California San Francisco, San Francisco, CA; Clyde Michael Jones, Baptist Cancer Center Physicians Foundation, Memphis, TN; Markku Miettinen, Anish Thomas and Raffit Hassan, Center for Cancer Research, National Cancer Institute, Bethesda, MD; Harvey Pass and Daniel Sterman, New York University Langone Medical Center; and Andreas Rimner and Valerie Rusch, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Raphael Bueno
- Hedy L. Kindler and Samuel G. Armato III, The University of Chicago, Chicago, IL; Nofisat Ismaila, American Society of Clinical Oncology; Mary Hesdorffer, Mesothelioma Applied Research Foundation, Alexandria, VA; Raphael Bueno, Harvard Medical School, Boston, MA; Thierry Jahan, University of California San Francisco, San Francisco, CA; Clyde Michael Jones, Baptist Cancer Center Physicians Foundation, Memphis, TN; Markku Miettinen, Anish Thomas and Raffit Hassan, Center for Cancer Research, National Cancer Institute, Bethesda, MD; Harvey Pass and Daniel Sterman, New York University Langone Medical Center; and Andreas Rimner and Valerie Rusch, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Mary Hesdorffer
- Hedy L. Kindler and Samuel G. Armato III, The University of Chicago, Chicago, IL; Nofisat Ismaila, American Society of Clinical Oncology; Mary Hesdorffer, Mesothelioma Applied Research Foundation, Alexandria, VA; Raphael Bueno, Harvard Medical School, Boston, MA; Thierry Jahan, University of California San Francisco, San Francisco, CA; Clyde Michael Jones, Baptist Cancer Center Physicians Foundation, Memphis, TN; Markku Miettinen, Anish Thomas and Raffit Hassan, Center for Cancer Research, National Cancer Institute, Bethesda, MD; Harvey Pass and Daniel Sterman, New York University Langone Medical Center; and Andreas Rimner and Valerie Rusch, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Thierry Jahan
- Hedy L. Kindler and Samuel G. Armato III, The University of Chicago, Chicago, IL; Nofisat Ismaila, American Society of Clinical Oncology; Mary Hesdorffer, Mesothelioma Applied Research Foundation, Alexandria, VA; Raphael Bueno, Harvard Medical School, Boston, MA; Thierry Jahan, University of California San Francisco, San Francisco, CA; Clyde Michael Jones, Baptist Cancer Center Physicians Foundation, Memphis, TN; Markku Miettinen, Anish Thomas and Raffit Hassan, Center for Cancer Research, National Cancer Institute, Bethesda, MD; Harvey Pass and Daniel Sterman, New York University Langone Medical Center; and Andreas Rimner and Valerie Rusch, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Clyde Michael Jones
- Hedy L. Kindler and Samuel G. Armato III, The University of Chicago, Chicago, IL; Nofisat Ismaila, American Society of Clinical Oncology; Mary Hesdorffer, Mesothelioma Applied Research Foundation, Alexandria, VA; Raphael Bueno, Harvard Medical School, Boston, MA; Thierry Jahan, University of California San Francisco, San Francisco, CA; Clyde Michael Jones, Baptist Cancer Center Physicians Foundation, Memphis, TN; Markku Miettinen, Anish Thomas and Raffit Hassan, Center for Cancer Research, National Cancer Institute, Bethesda, MD; Harvey Pass and Daniel Sterman, New York University Langone Medical Center; and Andreas Rimner and Valerie Rusch, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Markku Miettinen
- Hedy L. Kindler and Samuel G. Armato III, The University of Chicago, Chicago, IL; Nofisat Ismaila, American Society of Clinical Oncology; Mary Hesdorffer, Mesothelioma Applied Research Foundation, Alexandria, VA; Raphael Bueno, Harvard Medical School, Boston, MA; Thierry Jahan, University of California San Francisco, San Francisco, CA; Clyde Michael Jones, Baptist Cancer Center Physicians Foundation, Memphis, TN; Markku Miettinen, Anish Thomas and Raffit Hassan, Center for Cancer Research, National Cancer Institute, Bethesda, MD; Harvey Pass and Daniel Sterman, New York University Langone Medical Center; and Andreas Rimner and Valerie Rusch, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Harvey Pass
- Hedy L. Kindler and Samuel G. Armato III, The University of Chicago, Chicago, IL; Nofisat Ismaila, American Society of Clinical Oncology; Mary Hesdorffer, Mesothelioma Applied Research Foundation, Alexandria, VA; Raphael Bueno, Harvard Medical School, Boston, MA; Thierry Jahan, University of California San Francisco, San Francisco, CA; Clyde Michael Jones, Baptist Cancer Center Physicians Foundation, Memphis, TN; Markku Miettinen, Anish Thomas and Raffit Hassan, Center for Cancer Research, National Cancer Institute, Bethesda, MD; Harvey Pass and Daniel Sterman, New York University Langone Medical Center; and Andreas Rimner and Valerie Rusch, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Andreas Rimner
- Hedy L. Kindler and Samuel G. Armato III, The University of Chicago, Chicago, IL; Nofisat Ismaila, American Society of Clinical Oncology; Mary Hesdorffer, Mesothelioma Applied Research Foundation, Alexandria, VA; Raphael Bueno, Harvard Medical School, Boston, MA; Thierry Jahan, University of California San Francisco, San Francisco, CA; Clyde Michael Jones, Baptist Cancer Center Physicians Foundation, Memphis, TN; Markku Miettinen, Anish Thomas and Raffit Hassan, Center for Cancer Research, National Cancer Institute, Bethesda, MD; Harvey Pass and Daniel Sterman, New York University Langone Medical Center; and Andreas Rimner and Valerie Rusch, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Valerie Rusch
- Hedy L. Kindler and Samuel G. Armato III, The University of Chicago, Chicago, IL; Nofisat Ismaila, American Society of Clinical Oncology; Mary Hesdorffer, Mesothelioma Applied Research Foundation, Alexandria, VA; Raphael Bueno, Harvard Medical School, Boston, MA; Thierry Jahan, University of California San Francisco, San Francisco, CA; Clyde Michael Jones, Baptist Cancer Center Physicians Foundation, Memphis, TN; Markku Miettinen, Anish Thomas and Raffit Hassan, Center for Cancer Research, National Cancer Institute, Bethesda, MD; Harvey Pass and Daniel Sterman, New York University Langone Medical Center; and Andreas Rimner and Valerie Rusch, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Daniel Sterman
- Hedy L. Kindler and Samuel G. Armato III, The University of Chicago, Chicago, IL; Nofisat Ismaila, American Society of Clinical Oncology; Mary Hesdorffer, Mesothelioma Applied Research Foundation, Alexandria, VA; Raphael Bueno, Harvard Medical School, Boston, MA; Thierry Jahan, University of California San Francisco, San Francisco, CA; Clyde Michael Jones, Baptist Cancer Center Physicians Foundation, Memphis, TN; Markku Miettinen, Anish Thomas and Raffit Hassan, Center for Cancer Research, National Cancer Institute, Bethesda, MD; Harvey Pass and Daniel Sterman, New York University Langone Medical Center; and Andreas Rimner and Valerie Rusch, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Anish Thomas
- Hedy L. Kindler and Samuel G. Armato III, The University of Chicago, Chicago, IL; Nofisat Ismaila, American Society of Clinical Oncology; Mary Hesdorffer, Mesothelioma Applied Research Foundation, Alexandria, VA; Raphael Bueno, Harvard Medical School, Boston, MA; Thierry Jahan, University of California San Francisco, San Francisco, CA; Clyde Michael Jones, Baptist Cancer Center Physicians Foundation, Memphis, TN; Markku Miettinen, Anish Thomas and Raffit Hassan, Center for Cancer Research, National Cancer Institute, Bethesda, MD; Harvey Pass and Daniel Sterman, New York University Langone Medical Center; and Andreas Rimner and Valerie Rusch, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Raffit Hassan
- Hedy L. Kindler and Samuel G. Armato III, The University of Chicago, Chicago, IL; Nofisat Ismaila, American Society of Clinical Oncology; Mary Hesdorffer, Mesothelioma Applied Research Foundation, Alexandria, VA; Raphael Bueno, Harvard Medical School, Boston, MA; Thierry Jahan, University of California San Francisco, San Francisco, CA; Clyde Michael Jones, Baptist Cancer Center Physicians Foundation, Memphis, TN; Markku Miettinen, Anish Thomas and Raffit Hassan, Center for Cancer Research, National Cancer Institute, Bethesda, MD; Harvey Pass and Daniel Sterman, New York University Langone Medical Center; and Andreas Rimner and Valerie Rusch, Memorial Sloan Kettering Cancer Center, New York, NY
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The role of radical radiotherapy in the management of malignant pleural mesothelioma: A systematic review. Radiother Oncol 2017; 125:1-12. [PMID: 28859932 DOI: 10.1016/j.radonc.2017.08.003] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2017] [Revised: 05/19/2017] [Accepted: 08/05/2017] [Indexed: 11/24/2022]
Abstract
Malignant pleural mesothelioma (MPM) is a devastating disease with limited treatment options and a dismal prognosis. Attempts to employ radical radiotherapy in this disease have been limited by the complex shape of the pleura and the dose restrictions necessitated by the close proximity of radiosensitive structures. Recent shifts towards a 'lung sparing' surgical approach in MPM have further heightened these challenges. The aim of this systematic review is to assess recent advances in radiotherapy planning and delivery, to ascertain how these developments have impacted on the feasibility of delivering photon-based, high-dose radiotherapy with radical intent in MPM. Three electronic databases were searched and a total of 249 articles reviewed. The challenge of generating high quality, practice-defining data for diseases such as MPM was highlighted by the identification of just two randomised studies. Much of the literature consisted of low quality, retrospective data with small cohorts and inconsistent reporting on radiotherapy techniques and dosimetry. Nevertheless, a number of prospective phase II studies were identified to suggest that radical doses of radiotherapy can be delivered safely after a lung sparing procedure in MPM, reporting encouraging survival data and acceptable levels of toxicity.
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Harrabi SB, Koerber SA, Adeberg S, Katayama S, Herfarth K, Debus J, Sterzing F. Malignant pleural mesothelioma - Pleural cavity irradiation after decortication with helical tomotherapy. Rep Pract Oncol Radiother 2017; 22:402-407. [PMID: 28831280 DOI: 10.1016/j.rpor.2017.07.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2016] [Revised: 11/08/2016] [Accepted: 07/18/2017] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND Malignant pleural mesothelioma (MPM) is a rare and aggressive disease that poses a treatment challenge in spite of recent technical developments. The aim of this retrospective analysis is to assess the feasibility of administering intensity-modulated radiotherapy (IMRT) to the pleural cavity using helical tomotherapy in patients who had undergone pleurectomy/decortication (P/D) and also the resulting toxicity levels. PATIENTS AND METHODS Ten patients who had MPM and had undergone P/D were treated with pleural cavity irradiation that included a median dose of 52.2 Gy using helical tomotherapy. The median age of the patients was 53 years (31-74). In addition to clinical and diagnostic findings from regular follow-up examinations, we evaluated the dose distribution for other organs at risk to assess treatment in relation to toxicity, with special regard for the underlying intact lung. RESULTS The mean lung dose on the treatment site was 32.8 Gy (±6.8). The V20 Gy was 71.7% (±17.2). No treatment-related toxicity that exceeded grade III according to common toxicity criteria (CTC) was observed. Median progression-free survival (PFS) was 13 months with a median overall survival (OAS) of 19 months. CONCLUSION The findings of this analysis provide data indicating that sparing the underlying lung in patients with MPM after P/D is not only feasible with helical tomotherapy, but that this treatment also causes reasonably few side effects.
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Affiliation(s)
- Semi B Harrabi
- Department of Radiation Oncology, University Hospital of Heidelberg, Im Neuenheimer Feld 400, 69120 Heidelberg, Germany.,German Cancer Research Center (DKFZ), Im Neuenheimer Feld 280, 69120 Heidelberg, Germany.,Heidelberg Institute for Radiation Oncology (HIRO), Im Neuenheimer Feld 400, 69120 Heidelberg, Germany
| | - Stefan A Koerber
- Department of Radiation Oncology, University Hospital of Heidelberg, Im Neuenheimer Feld 400, 69120 Heidelberg, Germany.,Heidelberg Institute for Radiation Oncology (HIRO), Im Neuenheimer Feld 400, 69120 Heidelberg, Germany
| | - Sebastian Adeberg
- Department of Radiation Oncology, University Hospital of Heidelberg, Im Neuenheimer Feld 400, 69120 Heidelberg, Germany.,Heidelberg Institute for Radiation Oncology (HIRO), Im Neuenheimer Feld 400, 69120 Heidelberg, Germany
| | - Sonja Katayama
- Department of Radiation Oncology, University Hospital of Heidelberg, Im Neuenheimer Feld 400, 69120 Heidelberg, Germany.,Heidelberg Institute for Radiation Oncology (HIRO), Im Neuenheimer Feld 400, 69120 Heidelberg, Germany
| | - Klaus Herfarth
- Department of Radiation Oncology, University Hospital of Heidelberg, Im Neuenheimer Feld 400, 69120 Heidelberg, Germany.,Heidelberg Institute for Radiation Oncology (HIRO), Im Neuenheimer Feld 400, 69120 Heidelberg, Germany
| | - Juergen Debus
- Department of Radiation Oncology, University Hospital of Heidelberg, Im Neuenheimer Feld 400, 69120 Heidelberg, Germany.,German Cancer Research Center (DKFZ), Im Neuenheimer Feld 280, 69120 Heidelberg, Germany.,Heidelberg Institute for Radiation Oncology (HIRO), Im Neuenheimer Feld 400, 69120 Heidelberg, Germany
| | - Florian Sterzing
- Department of Radiation Oncology, University Hospital of Heidelberg, Im Neuenheimer Feld 400, 69120 Heidelberg, Germany.,German Cancer Research Center (DKFZ), Im Neuenheimer Feld 280, 69120 Heidelberg, Germany.,Heidelberg Institute for Radiation Oncology (HIRO), Im Neuenheimer Feld 400, 69120 Heidelberg, Germany
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18
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Rosenzweig KE. Malignant pleural mesothelioma: adjuvant therapy with radiation therapy. ANNALS OF TRANSLATIONAL MEDICINE 2017; 5:242. [PMID: 28706910 DOI: 10.21037/atm.2017.06.25] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
It is a challenge to treat malignant pleural mesothelioma with radiation therapy (RT). For many years, conventional RT was delivered after extrapleural pneumonectomy (EPP) with acceptable results. However, the benefit of RT has never been definitively proven. Intensity modulated radiation therapy (IMRT) has been used, but some of the early experiences revealed fatal toxicity. As experience has increased, it now appears that RT, particularly with IMRT, is both feasible and effective.
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Affiliation(s)
- Kenneth E Rosenzweig
- Department of Radiation Oncology, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
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19
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Doi Y, Kimura T, Nakashima T, Takeuchi Y, Takahashi I, Nishibuchi I, Murakami Y, Nagata Y. Functional image guided radiation therapy planning in volumetric modulated arc therapy for patients with malignant pleural mesothelioma. Adv Radiat Oncol 2017; 2:183-191. [PMID: 28740930 PMCID: PMC5514243 DOI: 10.1016/j.adro.2017.01.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2016] [Revised: 01/18/2017] [Accepted: 01/25/2017] [Indexed: 11/16/2022] Open
Abstract
PURPOSE To investigate the incorporation of functional lung image-derived low-attenuation area (LAA) based on 4-dimensional computed tomography (4D-CT) in volumetric modulated arc therapy (VMAT) planning for patients with malignant pleural mesothelioma (MPM) after extrapleural pneumonectomy. METHODS AND MATERIALS Twelve patients with MPM after extrapleural pneumonectomy were included. The primarily affected side was the right in 6 patients and the left in 6 patients. LAA was generated from 4D-CT data according to CT values with a threshold of less than -860 Hounsfield units (HU). Functional lung image was defined as the area where LAA was excluded from contralateral lung image. Two radiation therapy plans were designed: (1) Plan C, conventional VMAT and (2) Plan F, functional VMAT plan based on the functional lung. Both plans were compared in each patient with respect to the following dosimetric parameters: fV20, V20, fV10, V10, fV5, and V5, the percentages of functional or contralateral lung volumes irradiated with >20 Gy, 10 Gy, or 5 Gy, respectively; functional mean lung dose (fMLD) and mean lung dose (MLD), the mean dose to the functional or contralateral lung, respectively; maximum dose to the cord; mean doses to the liver and heart; and planning target volume homogeneity index. RESULTS fV5 and MLD were significantly lower in Plan F (fV5, median 57.5% in Plan C vs 38.5% in Plan F, P < .01; MLD, median 7.0 Gy in Plan C vs 6.4 Gy in Plan F, P = .04). fV10, V5, and fMLD were also significantly lower in Plan F. Compared with Plan C, planning target volume homogeneity index and liver, heart, and cord doses were not significantly elevated in Plan F. CONCLUSIONS Significant reductions in fV5, fV10, fMLD, V5, and MLD were achieved with the functional image guided VMAT plan without negative effects on other factors. LAA-based functional image guided radiation therapy planning in VMAT is a feasible method to spare the functional lung in patients with MPM.
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Affiliation(s)
- Yoshiko Doi
- Department of Radiation Oncology, Hiroshima University Hospital, Hiroshima City, Japan
| | - Tomoki Kimura
- Department of Radiation Oncology, Hiroshima University Hospital, Hiroshima City, Japan
| | - Takeo Nakashima
- Division of Radiation Oncology, Hiroshima University Hospital, Hiroshima City, Japan
| | - Yuki Takeuchi
- Department of Radiation Oncology, Hiroshima University Hospital, Hiroshima City, Japan
| | - Ippei Takahashi
- Department of Radiation Oncology, Hiroshima University Hospital, Hiroshima City, Japan
| | - Ikuno Nishibuchi
- Department of Radiation Oncology, Hiroshima University Hospital, Hiroshima City, Japan
| | - Yuji Murakami
- Department of Radiation Oncology, Hiroshima University Hospital, Hiroshima City, Japan
| | - Yasushi Nagata
- Department of Radiation Oncology, Hiroshima University Hospital, Hiroshima City, Japan
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Rosenzweig K, Giraud P. Radiation therapy for malignant pleural mesothelioma. Cancer Radiother 2017; 21:73-76. [DOI: 10.1016/j.canrad.2016.09.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2016] [Revised: 08/20/2016] [Accepted: 09/11/2016] [Indexed: 12/22/2022]
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21
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Ulger S, Cetin E, Catli S, Sarac H, Kilic D, Bora H. Intensity-Modulated Radiation Therapy Improves the Target Coverage Over 3-D Planning While Meeting Lung Tolerance Doses for All Patients With Malignant Pleural Mesothelioma. Technol Cancer Res Treat 2016; 16:332-338. [PMID: 28462689 DOI: 10.1177/1533034616678110] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
PURPOSE To investigate high conformality on target coverage and the ability on creating strict lung dose limitation of intensity-modulated radiation therapy in malignant pleural mesothelioma. PATIENTS AND METHODS Twenty-four radiation therapy plannings were evaluated and compared with dosimetric outcomes of conformal radiation therapy and intensity-modulated radiation therapy. Hemithoracal radiation therapy was performed on 12 patients with a fraction of 1.8 Gy to a total dose of 50.4 Gy. All organs at risk were contoured. Radiotherapy plannings were differed according to the technique; conformal radiation therapy was planned with conventionally combined photon-electron fields, and intensity-modulated radiation therapy was planned with 7 to 9 radiation beam angles optimized in inverse planning. Strict dose-volume constraints were applied. RESULTS Intensity-modulated radiation therapy was statistically superior in target coverage and dose homogeneity (intensity-modulated radiation therapy-planning target volume 95 mean 100%; 3-dimensional conformal radiation therapy-planning target volume 95 mean 71.29%, P = .0001; intensity-modulated radiation therapy-planning target volume 105 mean 11.14%; 3-dimensional conformal radiation therapy-planning target volume 105 mean 35.69%, P = .001). The dosimetric results of the remaining lung was below the limitations on intensity-modulated radiation therapy planning data (intensity-modulated radiation therapy-lung mean dose mean 7.5 [range: 5.6%-8.5%]; intensity-modulated radiation therapy-lung V5 mean 55.55% [range: 47%-59.9%]; intensity-modulated radiation therapy-lung V20 mean 4.5% [range: 0.5%-9.5%]; intensity-modulated radiation therapy-lung V13 mean 13.43% [range: 4.2%-22.9%]). CONCLUSION With a complex and large target volume of malignant pleural mesothelioma, intensity-modulated radiation therapy has the ability to deliver efficient tumoricidal radiation dose within the safe dose limits of the remaining lung tissue.
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Affiliation(s)
- Sukran Ulger
- 1 Department of Radiation Oncology, Faculty of Medicine, Gazi University, Ankara, Turkey
| | - Eren Cetin
- 1 Department of Radiation Oncology, Faculty of Medicine, Gazi University, Ankara, Turkey
| | - Serap Catli
- 1 Department of Radiation Oncology, Faculty of Medicine, Gazi University, Ankara, Turkey
| | - Hilal Sarac
- 1 Department of Radiation Oncology, Faculty of Medicine, Gazi University, Ankara, Turkey
| | - Diclehan Kilic
- 1 Department of Radiation Oncology, Faculty of Medicine, Gazi University, Ankara, Turkey
| | - Huseyin Bora
- 1 Department of Radiation Oncology, Faculty of Medicine, Gazi University, Ankara, Turkey
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Wolf AS, Rosenzweig KE, Flores RM. Radiation therapy for malignant pleural mesothelioma. Lung Cancer Manag 2015. [DOI: 10.2217/lmt.15.27] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Malignant pleural mesothelioma is an aggressive tumor where the ability to control the primary tumor (local control) presents a significant challenge. External beam radiation has the potential to improve local control when following established safe and effective protocols. Radiation is primarily used as adjuvant treatment after extrapleural pneumonectomy or pleurectomy/decortication and as palliative treatment in some cases. The target volume for radiotherapy of malignant pleural mesothelioma can be quite extensive and thus toxicity is its chief limitation.
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Affiliation(s)
- Andrea S Wolf
- Thoracic Surgery Department, Icahn School of Medicine, Mount Sinai Health System, New York, NY, USA
| | - Kenneth E Rosenzweig
- Thoracic Surgery Department, Icahn School of Medicine, Mount Sinai Health System, New York, NY, USA
| | - Raja M Flores
- Thoracic Surgery Department, Icahn School of Medicine, Mount Sinai Health System, New York, NY, USA
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Khaledi N, Arbabi A, Sardari D, Mohammadi M, Ameri A. Simultaneous production of mixed electron--photon beam in a medical LINAC: A feasibility study. Phys Med 2015; 31:391-7. [PMID: 25773884 DOI: 10.1016/j.ejmp.2015.02.014] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2014] [Revised: 02/20/2015] [Accepted: 02/23/2015] [Indexed: 10/23/2022] Open
Abstract
PURPOSE The electron or photon beams might be used for treatment of tumors. Each beam has its own advantage and disadvantages. Combo beam can increase the advantages. No investigation has been performed for producing simultaneous mixed electron and photon beam. In current study a device has been added to the Medical Linac to produce a mixed photon-electron beam. METHODS Firstly a Varian 2300CD head was simulated by MCNP Monte Carlo Code. Two sets of perforated lead sheets with 1 and 2 mm thickness and 0.2, 0.3, and 0.5 cm punches then placed at the top of the applicator holder tray. This layer produces bremsstrahlung x-ray upon impinging fraction electrons on it. The remaining fraction of electrons passes through the holes. The simulation was performed for 10 × 10, 6 × 6, and 4 × 4 cm(2) field size. RESULTS For 10 × 10 cm(2) field size, among the punched targets, the largest penumbra difference between the depth of 1 and 7 cm was 72%. This difference for photon and electron beams were 31% and 325% respectively. A maximum of 39% photon percentage was produced by 2 mm target with 0.2 cm holes diameter layer. The minimum surface dose value was 4% lesser than pure electron beam. For small fields, unlike the pure electron beam, the PDD, penumbra, and flatness variations were negligible. CONCLUSIONS The advantages of mixing the electron and photon beam is reduction of pure electron's penumbra dependency with the depth, especially for small fields, also decreasing of dramatic changes of PDD curve with irradiation field size.
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Affiliation(s)
- Navid Khaledi
- Department of Medical Radiation Engineering, Science and Research Branch, Islamic Azad University, Tehran, Iran
| | - Azim Arbabi
- Department of Radiotherapy, Imam Hossein Hospital, Shahid Beheshti Medical University, Tehran, Iran
| | - Dariush Sardari
- Department of Medical Radiation Engineering, Science and Research Branch, Islamic Azad University, Tehran, Iran.
| | - Mohammad Mohammadi
- Department of Medical Physics, Hamedan Medical University, Hamedan, Iran
| | - Ahmad Ameri
- Department of Radiotherapy, Imam Hossein Hospital, Shahid Beheshti Medical University, Tehran, Iran
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Kimura T, Doi Y, Nakashima T, Imano N, Katsuta T, Takahashi S, Kenjo M, Ozawa S, Murakami Y, Nagata Y. Clinical experience of volumetric modulated arc therapy for malignant pleural mesothelioma after extrapleural pneumonectomy. JOURNAL OF RADIATION RESEARCH 2015; 56:315-324. [PMID: 25599996 PMCID: PMC4380050 DOI: 10.1093/jrr/rru102] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 06/19/2014] [Revised: 09/30/2014] [Accepted: 10/05/2014] [Indexed: 06/04/2023]
Abstract
The purpose of this study was to evaluate the efficacy and safety of volumetric modulated arc therapy (VMAT) after extrapleural pneumonectomy (EPP) in patients with malignant pleural mesothelioma (MPM). A total of 15 patients who received VMAT after EPP were enrolled. All patients were males, and the median age was 67 years (Stage IB in two, II in six, and III in seven patients). The clinical target volume (CTV) included the entire preoperative ipsilateral hemithorax and involved nodal stations. The CTV was generally expanded by 10-15 mm beyond the planning target volume (PTV). The dose prescription was designed to cover 95% of the PTV with 54 Gy in 30 fractions. The median follow-up period was 11 months. Treatment-related toxicities were evaluated by Common Terminology Criteria for Adverse Events (CTCAE) ver. 4. One-year local control, disease-free survival, and overall survival rates were 55.7% [95% confidence interval (CI): 25.6-85.8%], 29.3% (95% CI: 5.3-53.3%), and 43.1% (95% CI: 17.1-69.0%), respectively. According to the histological analysis, the one-year LC rate was significantly worse in patients with non-epithelial type (biphasic and sarcomatoid types) than in patients with epithelial type [epithelial type: 83.3% (95% CI, 53.5-100%), non-epithelial type: 0% (95% CI, 0%), P = 0.0011]. Grade 3 pneumonitis after VMAT was observed in three patients (20.0%); however, no patients died of pulmonary toxicity. VMAT appears to be relatively safe for patients with MPM after EPP because of the low pulmonary dose.
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Affiliation(s)
- Tomoki Kimura
- Department of Radiation Oncology, Graduate School of Biomedical Sciences, Hiroshima University, 1-2-3, Kasumi, Minami-ku, Hiroshima City, 734-8551, Japan
| | - Yoshiko Doi
- Department of Radiation Oncology, Graduate School of Biomedical Sciences, Hiroshima University, 1-2-3, Kasumi, Minami-ku, Hiroshima City, 734-8551, Japan
| | - Takeo Nakashima
- Division of Radiation Oncology, Hiroshima University Hospital
| | - Nobuki Imano
- Department of Radiation Oncology, Graduate School of Biomedical Sciences, Hiroshima University, 1-2-3, Kasumi, Minami-ku, Hiroshima City, 734-8551, Japan
| | - Tsuyoshi Katsuta
- Department of Radiation Oncology, Graduate School of Biomedical Sciences, Hiroshima University, 1-2-3, Kasumi, Minami-ku, Hiroshima City, 734-8551, Japan
| | | | - Masahiro Kenjo
- Department of Radiation Oncology, Graduate School of Biomedical Sciences, Hiroshima University, 1-2-3, Kasumi, Minami-ku, Hiroshima City, 734-8551, Japan
| | - Shuichi Ozawa
- Department of Radiation Oncology, Graduate School of Biomedical Sciences, Hiroshima University, 1-2-3, Kasumi, Minami-ku, Hiroshima City, 734-8551, Japan
| | - Yuji Murakami
- Department of Radiation Oncology, Graduate School of Biomedical Sciences, Hiroshima University, 1-2-3, Kasumi, Minami-ku, Hiroshima City, 734-8551, Japan
| | - Yasushi Nagata
- Department of Radiation Oncology, Graduate School of Biomedical Sciences, Hiroshima University, 1-2-3, Kasumi, Minami-ku, Hiroshima City, 734-8551, Japan
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Updated patterns of failure after multimodality therapy for malignant pleural mesothelioma. J Thorac Cardiovasc Surg 2015; 149:1374-81. [PMID: 25772281 DOI: 10.1016/j.jtcvs.2014.10.128] [Citation(s) in RCA: 68] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2014] [Revised: 09/21/2014] [Accepted: 10/05/2014] [Indexed: 12/11/2022]
Abstract
OBJECTIVE We have previously described patterns of failure after extrapleural pneumonectomy and multimodality therapy for malignant pleural mesothelioma and sought to update our results with a larger cohort of recent patients. METHODS A total of 169 patients underwent extrapleural pneumonectomy without preoperative chemotherapy between 2001 and 2010. Data for treatment, recurrence, and survival were determined from medical records. A thoracic radiologist reviewed postoperative computed tomography or positron emission tomography computed tomography scans to determine sites of recurrence. Time to recurrence was estimated by the Kaplan-Meier method. Rates were compared using the Fisher exact test. RESULTS The median age of patients was 62 years. Histology on final pathology was epithelial for 104 patients (62%) and nonepithelial for 65 patients (38%). A total of 132 patients (78%) received heated intraoperative chemotherapy; 77 patients (45%) received adjuvant chemotherapy, and 71 patients (42%) received adjuvant radiation therapy. Most chemotherapy regimens included platinum or pemetrexed. Median radiation therapy dose was 54 Gy. Among 158 evaluable patients, a recurrence developed in 118 (75%). Median follow-up was 83 months, median time to recurrence was 13.1 months, and median survival was 15 months. Sites of first recurrence were in the ipsilateral hemithorax or mediastinum for 54% of patients, in the abdomen for 39% of patients, in the contralateral hemithorax for 28% of patients, and in other distant sites for 5% of patients. Some patients had simultaneous recurrences in multiple sites. CONCLUSIONS The most common site of recurrence after extrapleural pneumonectomy and planned multimodality therapy remains the ipsilateral hemithorax (including mediastinum), and true distant failure (other than the abdomen or contralateral hemithorax) remains unusual. The distribution of recurrences is strikingly similar to our prior report.
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Krayenbuehl J, Dimmerling P, Ciernik IF, Riesterer O. Clinical outcome of postoperative highly conformal versus 3D conformal radiotherapy in patients with malignant pleural mesothelioma. Radiat Oncol 2014; 9:32. [PMID: 24456714 PMCID: PMC3946177 DOI: 10.1186/1748-717x-9-32] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2013] [Accepted: 01/03/2014] [Indexed: 12/29/2022] Open
Abstract
Background Radiotherapy (RT) is currently under investigation as part of a trimodality treatment of malignant pleural mesothelioma (MPM). The introduction of highly conformal radiotherapy (HCRT) technique improved dose delivery and target coverage in comparison to 3-dimensional conformal radiotherapy (3DCRT). The following study was undertaken to investigate the clinical outcome of both radiation techniques. Methods Thirty-nine MPM patients were treated with neoadjuvant chemotherapy, extrapleural pneumonectomy (EPP) and adjuvant RT. Twenty-five patients were treated with 3DCRT, and 14 with HCRT (Intensity modulated radiotherapy or volumetric modulated arc therapy). Overall survival, disease free survival, locoregional recurrence and pattern of recurrence were assessed. A matched pair analysis was performed including 11 patients of each group. Results After matching for gender, age, histology, tumor stage and resection status, HCRT seemed superior to 3DCRT with a local relapse rate of 27.3% compared to 72.7% after 3DCRT (p = 0.06). The median time to local relapse was increased by 49% with HCRT in comparison to 3DCRT from 10.9 ± 5.4 months to 16.2 ± 3.1 months (p = 0.06). The median overall survival was 22.3 ± 15.3 months for HCRT and 21.2 ± 9.2 months for 3DCRT (p = 0.57). Recurrence analysis showed that in-field local relapses occurred in previously underdosed regions of the tumor bed in 16% of patients treated with 3DCRT and in 0% of HCRT patients. Conclusions The use of HCRT increases the probability of local control as compared to 3DCRT by improving target volume coverage. HCRT did not improve overall survival in this patient series due to the high rate of distant recurrences.
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Affiliation(s)
| | | | | | - Oliver Riesterer
- Department of Radiation Oncology, Zurich University Hospital, Rämistrasse 100, 8091 Zurich, Switzerland.
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Rosenzweig KE. Current Readings: Improvements in Intensity-Modulated Radiation Therapy for Malignant Pleural Mesothelioma. Semin Thorac Cardiovasc Surg 2013; 25:245-50. [DOI: 10.1053/j.semtcvs.2013.10.004] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/16/2013] [Indexed: 11/11/2022]
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Rimner A, Rosenzweig KE. Novel radiation therapy approaches in malignant pleural mesothelioma. Ann Cardiothorac Surg 2013; 1:457-61. [PMID: 23977536 DOI: 10.3978/j.issn.2225-319x.2012.10.07] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2012] [Accepted: 10/26/2012] [Indexed: 11/14/2022]
Affiliation(s)
- Andreas Rimner
- Department of Radiation Oncology, Memorial Sloan-Kettering Cancer Center, New York, NY, USA
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Gomez DR, Hong DS, Allen PK, Welsh JS, Mehran RJ, Tsao AS, Liao Z, Bilton SD, Komaki R, Rice DC. Patterns of failure, toxicity, and survival after extrapleural pneumonectomy and hemithoracic intensity-modulated radiation therapy for malignant pleural mesothelioma. J Thorac Oncol 2013; 8:238-45. [PMID: 23247629 DOI: 10.1097/jto.0b013e31827740f0] [Citation(s) in RCA: 89] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
INTRODUCTION We investigated safety, efficacy, and recurrence after postoperative hemithoracic intensity-modulated radiation therapy (IMRT) in patients with malignant pleural mesothelioma treated with extrapleural pneumonectomy (EPP), during the past decade at a single institution. METHODS In 2001-2011, 136 consecutive patients with malignant pleural mesothelioma underwent EPP with planned adjuvant IMRT. Eighty-six patients (64%) underwent hemithoracic IMRT; the rest were not eligible because of postoperative complications, disease progression, or poor performance status. We assessed toxicity, survival, and patterns of failure in these 86 patients. Toxicity was scored with the Common Terminology Criteria for Adverse Events version 4.0; survival outcomes were estimated with the Kaplan-Meier method; and locoregional patterns of failure were classified as in-field, marginal, or out-of-field. Risk factors related to survival were identified by univariate and multivariate Cox regression analysis. RESULTS Median overall survival time for all 86 patients receiving IMRT was 14.7 months. Toxicity rates of grade of 3 or more were: skin 17%, lung 12%, heart 2.3%, and gastrointestinal toxicity 16%. Five patients experienced grade 5 pulmonary toxicity. Rates of locoregional recurrence-free survival, distant metastasis-free survival, and overall survival (OS) were 88%, 55%, and 55% at 1 year and 71%, 40%, and 32% at 2 years. On multivariate analysis, pretreatment forced expiratory volume in 1 second, nonepithelioid histology, and nodal status were associated with distant metastasis-free survival and OS. CONCLUSION IMRT after EPP is associated with low rates of locoregional recurrence, though some patients experience life-threatening lung toxicity. Tumor histology and nodal status can be helpful in identifying patients for this aggressive treatment.
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Affiliation(s)
- Daniel R Gomez
- Department of Radiation Oncology, The University of Texas M.D. Anderson Cancer Center, Houston, Texas 77054, USA.
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Krayenbuehl J, Riesterer O, Graydon S, Dimmerling P, Kloeck S, Ciernik IF. Intensity-modulated radiotherapy and volumetric-modulated arc therapy for malignant pleural mesothelioma after extrapleural pleuropneumonectomy. J Appl Clin Med Phys 2013; 14:4130. [PMID: 23835378 PMCID: PMC5714527 DOI: 10.1120/jacmp.v14i4.4130] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2012] [Revised: 02/27/2013] [Accepted: 02/13/2013] [Indexed: 12/23/2022] Open
Abstract
Radiotherapy reduces the local relapse rate after pleuropneumonectomy of malignant pleural mesothelioma (MPM). The optimal treatment technique with photons remains undefined. Comparative planning for intensity‐modulated radiotherapy (IMRT) and volumetric‐modulated arc therapy (VMAT) was performed. Six MPM patients with significant postoperative intrathoracic air cavities were planned with IMRT and VMAT. A dose comparison for the targets and organ at risks (OAR) was performed. Robustness was assessed in respect to the variation of target dose with change in volume of air cavities. VMAT reduced the dose to the contralateral lung by reducing the volume covered by 13 Gy and 20 Gy by a factor 1.8 and 2.8, in respect to IMRT (p=0.02). Dose distribution with VMAT was the most stable technique in regard to postsurgical air cavity variation. For IMRT, V90,V95, and the minimal target dose decreased by 40%, 64%, and 12% compared to 29%, 47%, and 7% with VMAT when air cavity decreased. Two arcs compared to one arc decreased the dose to all the organs at risk (OAR) while leaving PTV dose coverage unchanged. Increasing the number of arcs from two to three did not reduce the dose to the OAR further, but increased the beam‐on time by 50%. Using partial arcs decreased the beam‐on time by 43%. VMAT allows a lower lung dose and is less affected by the air cavity variation than IMRT. The best VMAT plans were obtained with two partial arcs. VMAT seems currently the most suitable technique for the treatment of MPM patients when air cavities are remaining and no adaptive radiotherapy is performed. PACS number: 87.55.D‐
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Affiliation(s)
- Jerome Krayenbuehl
- Department of Radiation Oncology, University Hospital Zurich, Zurich, Switzerland.
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Alexander A, Soisson E, Renaud MA, Seuntjens J. Direct aperture optimization for FLEC-based MERT and its application in mixed beam radiotherapy. Med Phys 2012; 39:4820-31. [DOI: 10.1118/1.4736423] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
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Lorentini S, Amichetti M, Spiazzi L, Tonoli S, Magrini SM, Fellin F, Schwarz M. Adjuvant intensity-modulated proton therapy in malignant pleural mesothelioma. A comparison with intensity-modulated radiotherapy and a spot size variation assessment. Strahlenther Onkol 2012; 188:216-25. [PMID: 22318326 DOI: 10.1007/s00066-011-0038-3] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2011] [Accepted: 10/04/2011] [Indexed: 12/25/2022]
Abstract
PURPOSE Intensity-modulated radiation therapy (IMRT) is the state-of-the-art treatment for patients with malignant pleural mesothelioma (MPM). The goal of this work was to assess whether intensity-modulated proton therapy (IMPT) could further improve the dosimetric results allowed by IMRT. PATIENTS AND METHODS We re-planned 7 MPM cases using both photons and protons, by carrying out IMRT and IMPT plans. For both techniques, conventional dose comparisons and normal tissue complication probability (NTCP) analysis were performed. In 3 cases, additional IMPT plans were generated with different beam dimensions. RESULTS IMPT allowed a slight improvement in target coverage and clear advantages in dose conformity (p < 0.001) and dose homogeneity (p = 0.01). Better organ at risk (OAR) sparing was obtained with IMPT, in particular for the liver (D(mean) reduction of 9.5 Gy, p = 0.001) and ipsilateral kidney (V(20) reduction of 58%, p = 0.001), together with a very large reduction of mean dose for the contralateral lung (0.2 Gy vs 6.1 Gy, p = 0.0001). NTCP values for the liver showed a systematic superiority of IMPT with respect to IMRT for both the esophagus (average NTCP 14% vs. 30.5%) and the ipsilateral kidney (p = 0.001). Concerning plans obtained with different spot dimensions, a slight loss of target coverage was observed along with sigma increase, while maintaining OAR irradiation always under planning constraints. CONCLUSION Results suggest that IMPT allows better OAR sparing with respect to IMRT, mainly for the liver, ipsilateral kidney, and contralateral lung. The use of a spot dimension larger than 3 × 3 mm (up to 9 × 9 mm) does not compromise dosimetric results and allows a shorter delivery time.
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Affiliation(s)
- S Lorentini
- ATreP - Agenzia Provinciale per la Protonterapia, Via F.lli Perini, 181, 38122, Trento, Italy
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Intensity-modulated radiotherapy after extrapleural pneumonectomy in the combined-modality treatment of malignant pleural mesothelioma. J Thorac Oncol 2011; 6:1132-41. [PMID: 21532502 DOI: 10.1097/jto.0b013e3182199819] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
INTRODUCTION Local therapy is becoming increasingly important as a part of the definitive treatment for malignant pleural mesothelioma after extrapleural pneumonectomy (EPP) because of the emergence of trimodality therapy consisted of chemotherapy, EPP, and adjuvant radiotherapy. Herein, we explore the current evidence and indications for adjuvant intensity-modulated radiotherapy (IMRT), as well as how to further improve this technique and adapt new technology in the delivering adjuvant radiotherapy in the setting of trimodality therapy. METHODS A systematic review of relevant studies identified through PubMed, ISI Web of Knowledge (Web of Science), the Cochrane Library, and the National Guideline Clearinghouse search engines was performed. RESULTS Local control remains poor despite the inclusion of conventional adjuvant radiation therapy in trimodality therapy. This can be improved by the delivery of adjuvant IMRT. However, IMRT can be associated with severe pulmonary toxicity if the radiation dose to the remaining lung is not kept to a very low level. This is especially true when patients are receiving chemotherapy. New advances in technology can allow for lower doses to the contralateral lung, decreased treatment delivery time, and improved target dose coverage. CONCLUSION Excellent local control can be achieved through adjuvant IMRT after EPP for malignant pleural mesothelioma. Severe pulmonary toxicity may be avoided by setting stringent dose constraints for the contralateral lung. This can be aided by the advances in technology. Post-treatment surveillance may be reliably conducted by periodical [18F]-fluorodeoxyglucose-positron emission tomography imaging.
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Abstract
Malignant mesothelioma (MM) is an aggressive tumour that commonly affects the mesothelial surfaces of the pleural and peritoneal cavities, and occasionally, the tunica vaginalis and the pericardium. Formerly a rare tumour, MM is increasing in incidence in Australia due to the heavy nationwide use of asbestos from 1940 until the 1980s. The incidence is expected to peak in Australia in the next decade, mirroring the long latency period between asbestos exposure and development of MM. Diagnosis of MM can be difficult. Definitive pathological diagnosis is required and it often requires an experienced pathologist to differentiate MM from other benign or malignant processes. Treatment of MM requires a multidisciplinary approach, regardless of palliative or curative intent. Treatment options, such as surgery, chemotherapy, radiotherapy and active symptom control or a combination of these, may be used. Further research is needed to advance the therapeutic options for MM, and strategies to realize personalisation of therapy through discovery of predictive markers. In the Australian society where asbestos contamination of the built environment is very high, education and stringent public health measures are required to prevent a second wave of increased MM incidence.
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Affiliation(s)
- S C-H Kao
- Department of Medical Oncology, Sydney Cancer Centre, Concord Repatriation General Hospital, Sydney, New South Wales, Australia
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Sylvestre A, Mahé MA, Lisbona A, Zefkili S, Savignoni A, Bonnette P, Barthes FLP, Paris E, Perigaud C, Yassa M, Giraud P. Mesothelioma at era of helical tomotherapy: results of two institutions in combining chemotherapy, surgery and radiotherapy. Lung Cancer 2011; 74:486-91. [PMID: 21663996 DOI: 10.1016/j.lungcan.2011.05.012] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2011] [Revised: 04/28/2011] [Accepted: 05/04/2011] [Indexed: 10/18/2022]
Abstract
PURPOSE There is a scarce clinical experience about adjuvant helical tomotherapy (HT) in patients affected by malignant pleural mesothelioma (MPM) even though it appears as a useful technique to treat complex volume as the pleural cavity, and seems to have better dose distribution than the "classic" intensity modulated radiotherapy (IMRT). METHODS AND MATERIALS Twenty-four patients received adjuvant radiotherapy (RT) by HT from August 1st, 2007 to December 1st, 2009 at Curie Institute (Paris) and René Gauducheau Cancer Center (Nantes). Thirteen patients had neoadjuvant chemotherapy. Extrapleural pleuropneumonectomy (EPP) was done in 23 patients. Median dose to PTV was 50Gy [48.7-55.9Gy] (2Gy/fraction). Acute and long term toxicities, disease free survival (DFS), overall survival (OS) and relapses are presented. RESULTS Average follow up after RT was 7 months. The disease was staged mostly as T2-T3, N1-N2. Nineteen patients had epithelial type histology. Most patients tolerated radiotherapy with grade 1-2 side effects: redness of the skin, light cough or dyspnea, fatigue, nausea and odynophagia, mild increase of the post-operative thoracic pain. Grade 3 pneumonitis was suspected in 2 patients. Two grade 5 pneumonitis were also suspected. Eleven patients had a follow up of more than 6 months and no long term side effects related with HT were noted. At 24 months, 51.8% of patients were free of disease. Thirty percent of patients relapsed, with 2 patients presenting local relapses. Two patients died from recurrence. CONCLUSION With limited follow up, HT has comparable toxicity to those observed with traditional IMRT. Higher radiation dose and good coverage results in excellent local control.
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Affiliation(s)
- Alma Sylvestre
- Department of Radiation Oncology, European Georges-Pompidou Hospital, Paris, France
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[Value of tomotherapy in malignant pleural mesothelioma: first clinical results]. Rev Mal Respir 2011; 28:609-17. [PMID: 21645831 DOI: 10.1016/j.rmr.2011.03.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2010] [Accepted: 10/14/2010] [Indexed: 12/29/2022]
Abstract
INTRODUCTION There is little clinical data about the place of helicoidal tomotherapy (HT) in the treatment of malignant pleural mesothelioma (MPM). This new form of intensity modulated radiotherapy (IMRT) has great theoretical advantages in large and complex volumes when compared to "traditional" forms of radiotherapy. PATIENTS AND METHODS Fourteen patients diagnosed with MPM received adjuvant radiotherapy by HT. The patients were treated at the Curie Institute and the René Gauducheau Centre, starting in August 12007. All patients had a complete initial staging, an extrapleural pneumonectomy (EPP), and a minimum follow-up of six months. The median dose prescribed to the surgical cavity was 50 Gy (48-54 Gy) in 2 Gy (1.80-2.07) fractions. High dose regions received concomitant 57 Gy (54-69 Gy) in 2.16 Gy (2.00-2.30 Gy) fractions. RESULTS Median follow-up was 12.6 months after ending HT. Seven patients received neoadjuvant chemotherapy (cisplatin or carboplatin, and pemetrexed). Eight patients were staged pT3 and five were staged pN1-2. HT was well tolerated. Two patients had suspected G5 radiation pneumonitis within 6 months of ending HT. Of the 12 patients who survived treatment, six relapsed (in average 5.1 months after HT): distant. Four relapses were distant; two relapses were both local and distant. Three patients died after their initial relapse. After initial diagnosis, the median survival was 18.4 months. A learning curve was observed in the optimization of the dosimetric parameters. CONCLUSION Helicoidal tomotherapy is a reliable, quite well tolerated, and efficient way of treating MPM patients after an EPP.
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Abstract
OBJECTIVE A review of the evidence supporting the use of radiotherapy in patients with mesothelioma was performed. METHODS Relevant publications were searched for on Medline. RESULTS In a Medline search on radiotherapy and mesothelioma, 611 hits were obtained. A limited number of prospective phase II trials of radiotherapy as part of trimodality protocols for early disease and in the palliation of pain were found, along with three small randomized controlled trials of port-site prophylaxis. CONCLUSION No randomized data exist to support the use of radiotherapy after radical surgery, although there are a large number of publications describing its use as an integral part of therapy, including seven phase II studies. One ongoing trial is randomizing patients to radiotherapy or not after extrapleural pneumonectomy. None of these studies provided any assessment of radiotherapy independent of the other modalities investigated, nor did any formally assess intensity-modulated radiotherapy. There have been several reports of excessive toxicity with this technique, and its use should be limited to phase I studies until the basis of this toxicity is better understood. Three trials have looked at port-site prophylaxis, one supporting its use and two showing no evidence of benefit. Two studies addressed pain control prospectively, one showing definite but short-lived benefits. Implications. Radiotherapy is widely used in treating mesothelioma with little supporting evidence. More randomized trials are required to justify this use in all three common settings for its use.
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Cilla S, Digesù C, Silvano G, Macchia G, Massaccesi M, Deodato F, DA Padula G, Fidanzio A, Piermattei A, Morganti AG. Intensity-Modulated Radiation Therapy with Simultaneous Integrated Boost in Unresected Left-Sided Pleural Mesothelioma: A Case Report. TUMORI JOURNAL 2010; 96:618-22. [DOI: 10.1177/030089161009600417] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
A 77-year-old male patient with unresected malignant pleural mesothelioma, clinical stage T3N0M0 according to the New International Staging System for Diffuse Malignant Pleural Mesothelioma, received intensity-modulated radiotherapy (IMRT) with a simultaneous integrated boost (SIB) after 6 cycles of chemotherapy with cisplatin and pemetrexed. SIB-IMRT delivered 40.5 Gy (1.5 Gy/fraction) to the left pleura and 50 Gy (1.85 Gy/fraction) to the sites of macroscopic disease. Radiotherapy was well tolerated. Two months after the end of radiotherapy the patient showed grade 2 lung toxicity (febrile episodes accompanied by dry cough) that was successfully treated with steroid therapy. Local control lasted for 2 years after SIB-IMRT. Then the tumor recurred marginally to the radiation field and the patient underwent chemotherapy with pemetrexed. Three years from the diagnosis, the patient is alive and in good general condition. He only takes prednisone 5 mg/daily for exertional dyspnea. To the best of our knowledge this is the first reported use of SIB-IMRT in unresected malignant pleural mesothelioma. Considering the dosimetric advantages of SIB-IMRT and the clinical results observed in our patient, additional evaluation of this technique seems justified.
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Affiliation(s)
- Savino Cilla
- Department of Medical Physics, John Paul II Center for High Technology Research and Education in Biomedical Sciences, Catholic University, Campobasso, Italy
| | - Cinzia Digesù
- Department of Radiotherapy, John Paul II Center for High Technology Research and Education in Biomedical Sciences, Catholic University, Campobasso, Italy
| | | | - Gabriella Macchia
- Department of Radiotherapy, John Paul II Center for High Technology Research and Education in Biomedical Sciences, Catholic University, Campobasso, Italy
| | - Mariangela Massaccesi
- Department of Radiotherapy, John Paul II Center for High Technology Research and Education in Biomedical Sciences, Catholic University, Campobasso, Italy
| | - Francesco Deodato
- Department of Radiotherapy, John Paul II Center for High Technology Research and Education in Biomedical Sciences, Catholic University, Campobasso, Italy
| | - Gilbert DA Padula
- Department of Radiation Oncology, The Lacks Cancer Center, Saint Mary's Health Care, Grand Rapids, MI, USA
| | - Andrea Fidanzio
- Department of Medical Physics, Catholic University, Rome, Italy
| | - Angelo Piermattei
- Department of Medical Physics, John Paul II Center for High Technology Research and Education in Biomedical Sciences, Catholic University, Campobasso, Italy
| | - Alessio G Morganti
- Department of Radiotherapy, John Paul II Center for High Technology Research and Education in Biomedical Sciences, Catholic University, Campobasso, Italy
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Proton therapy for malignant pleural mesothelioma after extrapleural pleuropneumonectomy. Int J Radiat Oncol Biol Phys 2010; 78:628-34. [PMID: 20385451 DOI: 10.1016/j.ijrobp.2009.11.006] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2009] [Revised: 11/06/2009] [Accepted: 11/16/2009] [Indexed: 12/23/2022]
Abstract
PURPOSE To perform comparative planning for intensity-modulated radiotherapy (IMRT) and proton therapy (PT) for malignant pleural mesothelioma after radical surgery. METHODS AND MATERIALS Eight patients treated with IMRT after extrapleural pleuropneumonectomy (EPP) were replanned for PT, comparing dose homogeneity, target volume coverage, and mean and maximal dose to organs at risk. Feasibility of PT was evaluated regarding the dose distribution with respect to air cavities after EPP. RESULTS Dose coverage and dose homogeneity of the planning target volume (PTV) were significantly better for PT than for IMRT regarding the volume covered by >95% (V95) for the high-dose PTV. The mean dose to the contralateral kidney, ipsilateral kidney, contralateral lung, liver, and heart and spinal cord dose were significantly reduced with PT compared with IMRT. After EPP, air cavities were common (range, 0-850 cm(3)), decreasing from 0 to 18.5 cm(3)/day. In 2 patients, air cavity changes during RT decreased the generalized equivalent uniform dose (gEUD) in the case of using an a value of < - 10 to the PTV2 to <2 Gy in the presence of changing cavities for PT, and to 40 Gy for IMRT. Small changes were observed for gEUD of PTV1 because PTV1 was reached by the beams before air. CONCLUSION Both PT and IMRT achieved good target coverage and dose homogeneity. Proton therapy accomplished additional dose sparing of most organs at risk compared with IMRT. Proton therapy dose distributions were more susceptible to changing air cavities, emphasizing the need for adaptive RT and replanning.
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Scorsetti M, Bignardi M, Clivio A, Cozzi L, Fogliata A, Lattuada P, Mancosu P, Navarria P, Nicolini G, Urso G, Vanetti E, Vigorito S, Santoro A. Volumetric modulation arc radiotherapy compared with static gantry intensity-modulated radiotherapy for malignant pleural mesothelioma tumor: a feasibility study. Int J Radiat Oncol Biol Phys 2010; 77:942-9. [PMID: 20381267 DOI: 10.1016/j.ijrobp.2009.09.053] [Citation(s) in RCA: 60] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2009] [Revised: 08/12/2009] [Accepted: 09/18/2009] [Indexed: 12/23/2022]
Abstract
PURPOSE A planning study was performed to evaluate RapidArc (RA), a volumetric modulated arc technique, on malignant pleural mesothelioma. The benchmark was conventional fixed-field intensity-modulated radiotherapy (IMRT). METHODS AND MATERIALS The computed tomography data sets of 6 patients were included. The plans for IMRT with nine fixed beams were compared against double-modulated arcs with a single isocenter. All plans were optimized for 15-MV photon beams. The dose prescription was 54 Gy to the planning target volume. The planning objectives for the planning target volume were a minimal dose of >95% and maximal dose of <107%. For the organs at risk, the parameters were as follows: contralateral lung, percentage of volume receiving 5 Gy (V(5 Gy)) <60%, V(20 Gy) < 10%, mean <10.0 Gy; liver, V(30 Gy) <33%, mean <31 Gy; heart, V(45 Gy) <30%, V(50 Gy) <20%, dose received by 1% of the volume (D(1%)) <60 Gy; contralateral kidney, V(15 Gy) <20%; spine, D(1%) <45 Gy; esophagus, V(55 Gy) <30%; and spleen, V(40 Gy) <50%. The monitor units (MUs) and delivery time were scored to measure the treatment efficiency. The pretreatment portal dosimetry scored delivery to the calculation agreement with the Gamma Agreement Index. RESULTS RA and IMRT provided equivalent coverage and homogeneity. Both techniques fulfilled objectives on organs at risk with a tendency of RA to improve sparing. The conformity index was 1.9 +/- 0.1 for RA and IMRT. The number of MU/2 Gy was 734 +/- 82 for RA and 2,195 +/- 317 for IMRT. The planning vs. delivery agreement revealed a Gamma Agreement Index for IMRT of 96.0% +/- 2.6% and for RA of 95.7% +/- 1.5%. The treatment time was 3.7 +/- 0.3 min for RA and 13.4 +/- 0.1 min for IMRT. CONCLUSION RA demonstrated compared with conventional IMRT, similar target coverage and better dose sparing to the organs at risks. The number of MUs and the time required to deliver a 2-Gy fraction were much lower for RA, allowing the possibility to incorporate this technique in the treatment options for mesothelioma patients.
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Affiliation(s)
- Marta Scorsetti
- Department of Radiation Oncology, Istituto Clinico Humanitas, Rozzano, Italy
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Baldini EH. Radiation therapy options for malignant pleural mesothelioma. Semin Thorac Cardiovasc Surg 2009; 21:159-63. [PMID: 19822288 DOI: 10.1053/j.semtcvs.2009.06.009] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/25/2009] [Indexed: 12/23/2022]
Abstract
The role of radiation therapy (RT) in the curative treatment of malignant pleural mesothelioma remains undefined. No data clearly support treatment of unresected mesothelioma with definitive RT. Early reports showed that RT was associated with unacceptable toxicity, but recent limited data suggest that treatment with intensity-modulated radiation therapy (IMRT) may be tolerable. Adjuvant RT after pleurectomy is also challenging, and similarly, no clear efficacy has been demonstrated. Some approaches, such as IMRT to the circumferential pleural envelope, appear feasible, but the fact that this approach does not address the disease in the fissures is problematic. The best setting in which to deliver RT is after extrapleural pneumonectomy, but the large and irregular target volume and multiple and adjacent sensitive normal structures make this complex. The Memorial Sloan-Kettering Cancer Center matched photon/electron technique is associated with acceptable efficacy and toxicity, but is limited in that it does not achieve complete coverage of the target volume to the prescription dose. The best dosimetry is achieved using IMRT, and this approach is the most promising to date. However, the toxicity profile can be severe, and the relevant predictive factors for complications are not fully understood. For these reasons, physicians should exercise caution, and IMRT after extrapleural pneumonectomy is probably best offered only by experienced teams or on protocol until further data have been gathered. New techniques such as helical tomotherapy and/or IMRT with the addition of electrons may also have a role in future treatment. RT can palliate symptoms provided the disease is confined to a tolerable radiation field.
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Affiliation(s)
- Elizabeth H Baldini
- Department of Radiation Oncology, Dana-Farber/Brigham and Women's Hospital Cancer Center, Harvard Medical School, Boston, Massachusetts 02115, USA.
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Hemithoracic Radiotherapy After Extrapleural Pneumonectomy for Malignant Pleural Mesothelioma: A Dosimetric Comparison of Two Well-Described Techniques. J Thorac Oncol 2009; 4:1431-7. [DOI: 10.1097/jto.0b013e3181b9eb85] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Doyle LA, Showalter TN, Werner-Wasik M, Weksler B, Xiao Y, Yu Y, Macrone A, Liu H, Harrison A. High-dose-rate surface brachytherapy to boost elongated, curvilinear incisional scars after extrapleural pneumonectomy for malignant pleural mesothelioma treated with adjuvant intensity-modulated radiation therapy. Brachytherapy 2009; 9:86-90. [PMID: 19846346 DOI: 10.1016/j.brachy.2009.08.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2009] [Revised: 08/19/2009] [Accepted: 08/20/2009] [Indexed: 11/27/2022]
Abstract
PURPOSE Providing adequate dosimetric coverage of elongated, curvilinear incisions during adjuvant intensity-modulated radiation therapy (IMRT) after extrapleural pneumonectomy (EPP) for malignant pleural mesothelioma (MPM) creates technical challenges. We explored high-dose-rate (HDR) surface brachytherapy to supplement dose to multiple curvilinear incisions. This modality circumvents the technical limitations of relying on multiple en face electron fields while minimizing dose to adjacent normal tissues. METHODS AND MATERIALS A 59-year-old man presented with a left-sided, Stage III, T3N2M0, epithelioid MPM. After undergoing a left EPP, adjuvant IMRT was recommended to improve local control. An eight-field IMRT plan was designed to encompass the postoperative hemithorax. Incisional scars were lengthy and extended beyond the hemithoracic target volume. Both en face electron and surface HDR plans were prepared and evaluated based on dosimetric coverage of the incisional scars, dose to normal tissues, reliability of setup, and treatment delivery. RESULTS HDR was preferred. The patient was planned and treated in the right lateral decubitus position. HDR source catheters were placed along the incisions atop 5-mm bolus. A composite plan including IMRT and brachytherapy dose contributions was produced. Boosts of incisional scars were performed in six fractions (three fractions per week) of 3 Gy prescribed to 12 mm from the catheter. HDR brachytherapy was well tolerated. CONCLUSIONS Surface HDR brachytherapy is a viable option for supplemental dose to incisional scars at risk of local recurrence after EPP for MPM. Advantages over electron beam therapy include avoidance of field abutments and feathering, less tissue-bone interface dose uncertainty and reproducibility of treatment delivery.
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Affiliation(s)
- Laura A Doyle
- Department of Radiation Oncology, Jefferson Medical College of Thomas Jefferson University, Bodine Center for Cancer Treatment, 111 South 11th Street, Philadelphia, PA 19107, USA.
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Renaud J, Yartsev S, Dar AR, Van Dyk J. Adaptive Radiation Therapy for Localized Mesothelioma with Mediastinal Metastasis Using Helical Tomotherapy. Med Dosim 2009; 34:233-42. [DOI: 10.1016/j.meddos.2008.10.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2008] [Revised: 10/08/2008] [Accepted: 10/23/2008] [Indexed: 11/24/2022]
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Patterns of local and nodal failure in malignant pleural mesothelioma after extrapleural pneumonectomy and photon-electron radiotherapy. J Thorac Oncol 2009; 4:746-50. [PMID: 19404212 DOI: 10.1097/jto.0b013e3181a5292c] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
INTRODUCTION Multimodality therapy including extrapleural pneumonectomy (EPP), chemotherapy, and radiotherapy (RT) is often recommended for fit patients with early stage malignant pleural mesothelioma. Planning RT after an EPP is difficult due to the large target area, the high doses required to prevent recurrence, and the proximity of critical structures. We studied patterns of local and nodal recurrence in patients treated at our institution with EPP and RT, and whether advanced treatment planning techniques, such as intensity modulated radiotherapy (IMRT), could have been of potential benefit. METHODS From 1993 to 2008, 86 patients with malignant pleural mesothelioma underwent EPP followed by hemithoracic RT (median dose: 54 Gy). The RT technique included a combination of photons and electrons to maximize dose to the target, whereas minimizing dose to normal tissues. After treatment, patients were followed with serial imaging and patterns of local and nodal failure were studied. RESULTS Median follow-up time for 78 analyzed patients was 17 months. Eight percent were in stage I, 35% stage II, 55% stage III, and 2% stage IV. Ten percent of all patients developed late grade 3 pulmonary toxicity and no patient died of RT. Fifteen patients failed in local and/or nodal sites and did not have a distant component to their failure pattern. Of these 15 patients, 10 failed in regions of dose inhomogeneity and could have possibly benefited from IMRT. CONCLUSIONS The photon-electron technique was tolerable, but IMRT may provide better target coverage in some patients. IMRT's advantages must be balanced against the increased risk of fatal pulmonary toxicity.
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