1
|
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.
Collapse
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
| |
Collapse
|
2
|
Shampain KL, Hackett CE, Towfighi S, Aslam A, Masch WR, Harris AC, Chang SD, Khanna K, Mendiratta V, Gabr AM, Owen D, Mendiratta-Lala M. SBRT for HCC: Overview of technique and treatment response assessment. Abdom Radiol (NY) 2021; 46:3615-3624. [PMID: 33963419 DOI: 10.1007/s00261-021-03107-7] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2021] [Revised: 04/20/2021] [Accepted: 04/24/2021] [Indexed: 02/06/2023]
Abstract
Stereotactic body radiation therapy (SBRT) is an emerging locoregional treatment (LRT) modality used in the management of patients with hepatocellular carcinoma (HCC). The decision to treat HCC with LRT is evaluated in a multidisciplinary setting, and the specific LRT chosen depends on the treatment intent, such as bridge-to-transplant, down-staging to transplant, definitive/curative treatment, and/or palliation, as well as underlying patient clinical factors. Accurate assessment of treatment response is necessary in order to guide clinical management in these patients. Patients who undergo LRT need continuous imaging evaluation to assess treatment response and to evaluate for recurrence. Thus, an accurate understanding of expected post-SBRT imaging findings is critical to avoid misinterpreting normal post-treatment changes as local progression or viable tumor. SBRT-treated HCC demonstrates unique imaging findings that differ from HCC treated with other forms of LRT. In particular, SBRT-treated HCC can demonstrate persistent APHE and washout on short-term follow-up imaging. This brief review summarizes current evidence for the use of SBRT for HCC, including patient population, SBRT technique and procedure, tumor response assessment on contrast-enhanced cross-sectional imaging with expected findings, and pitfalls in treatment response evaluation.
Collapse
Affiliation(s)
| | | | - Sohrab Towfighi
- Department of Radiology, University of British Columbia, Vancouver, BC, Canada
| | - Anum Aslam
- Department of Radiology, University of Michigan, Ann Arbor, MI, USA
| | - William R Masch
- Department of Radiology, University of Michigan, Ann Arbor, MI, USA
| | - Alison C Harris
- Department of Radiology, University of British Columbia, Vancouver, BC, Canada
| | - Silvia D Chang
- Department of Radiology, University of British Columbia, Vancouver, BC, Canada
| | - Kanika Khanna
- Department of Hepatology, Henry Ford Hospital, Detroit, MI, USA
| | | | - Ahmed M Gabr
- Department of Radiology and Medical Imaging, University of Virginia, Charlottesville, VA, USA
| | - Dawn Owen
- Department of Radiation Oncology, Mayo Clinic Rochester, Rochester, MN, USA
| | | |
Collapse
|
3
|
Drug Regimen for Patients after a Pneumonectomy. JOURNAL OF RESPIRATION 2021. [DOI: 10.3390/jor1020013] [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] Open
Abstract
Pneumonectomy is an entire lung removal and is indicated for both malignant and benign diseases. Due to its invasiveness and postoperative complications, pneumonectomy is still associated with high mortality and morbidity. Appropriate postoperative management is crucial in pneumonectomy patients to improve quality of life and overall survival rates. Diverse drug regimens are under development to be used in adjuvant chemotherapy or to improve respiratory health after a pneumonectomy. The most common causes for a pneumonectomy are non-small cell lung cancer, malignant pleural mesothelioma, and tuberculosis; thus, an appropriate drug regimen is necessary. The uncommon incidence of pneumonectomy cases remains the major obstacle in studies of postoperative drug regimens. As the majority of current studies include post-lobectomy and post-segmentectomy patients, it is highly recommended that further research of postoperative drug regimens be focused on post-pneumonectomy patients.
Collapse
|
4
|
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
Collapse
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
| |
Collapse
|
5
|
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.
Collapse
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.
| |
Collapse
|
6
|
Ueda Y, Miyazaki M, Sumida I, Ohira S, Tamura M, Monzen H, Tsuru H, Inui S, Isono M, Ogawa K, Teshima T. Knowledge-based planning for oesophageal cancers using a model trained with plans from a different treatment planning system. Acta Oncol 2020; 59:274-283. [PMID: 31755332 DOI: 10.1080/0284186x.2019.1691257] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Background: This study aimed to evaluate knowledge-based volume modulated arc therapy (VMAT) plans for oesophageal cancers using a model trained with plans optimised with a different treatment planning system (TPS) and to compare lung dose sparing in two TPSs, Eclipse and RayStation.Materials and methods: A total of 64 patients with stage I-III oesophageal cancers were treated using hybrid VMAT (H-VMAT) plans optimised using RayStation. Among them, 40 plans were used for training the model for knowledge-based planning (KBP) in RapidPlan. The remaining 24 plans were recalculated using RapidPlan to validate the KBP model. H-VMAT plans calculated using RapidPlan were compared with H-VMAT plans optimised using RayStation with respect to planning target volume doses, lung doses, and modulation complexity.Results: In the lung, there were significant differences between the volume ratios receiving doses in excess of 5, 10, and 20 Gy (V5, V10, and V20). The V5 for the lung with H-VMAT plans optimised using RapidPlan was significantly higher than that of H-VMAT plans optimised using RayStation (p < .01), with a mean difference of 10%. Compared to H-VMAT plans optimised using RayStation, the V10 and V20 for the lung were significantly lower with H-VMAT plans optimised using RapidPlan (p = .04 and p = .02), with differences exceeding 1.0%. In terms of modulation complexity, the change in beam output at each control point was more constant with H-VMAT plans optimised using RapidPlan than with H-VMAT plans optimised using RayStation. The range of the change with H-VMAT plans optimised using RapidPlan was one third that of H-VMAT plans optimised using RayStation.Conclusion: Two optimisers in Eclipse and RayStation had different dosimetric performance in lung sparing and modulation complexity. RapidPlan could not improve low lung doses, however, it provided an appreciate intermediated doses compared to plans optimised with RayStation.
Collapse
Affiliation(s)
- Yoshihiro Ueda
- Department of Radiation Oncology, Osaka International Cancer Institute, Osaka, Japan
- Department of Radiation Oncology, Graduate School of Medicine, Osaka University, Osaka, Japan
| | - Masayoshi Miyazaki
- Department of Radiation Oncology, Osaka International Cancer Institute, Osaka, Japan
| | - Iori Sumida
- Department of Radiation Oncology, Graduate School of Medicine, Osaka University, Osaka, Japan
| | - Shingo Ohira
- Department of Radiation Oncology, Osaka International Cancer Institute, Osaka, Japan
| | - Mikoto Tamura
- Department of Medical Physics, Graduate School of Medical Sciences, Kindai University, Osaka, Japan
| | - Hajime Monzen
- Department of Medical Physics, Graduate School of Medical Sciences, Kindai University, Osaka, Japan
| | - Haruhi Tsuru
- Department of Radiation Oncology, Osaka International Cancer Institute, Osaka, Japan
| | - Shoki Inui
- Department of Radiation Oncology, Osaka International Cancer Institute, Osaka, Japan
| | - Masaru Isono
- Department of Radiation Oncology, Osaka International Cancer Institute, Osaka, Japan
| | - Kazuhiko Ogawa
- Department of Radiation Oncology, Graduate School of Medicine, Osaka University, Osaka, Japan
| | - Teruki Teshima
- Department of Radiation Oncology, Osaka International Cancer Institute, Osaka, Japan
| |
Collapse
|
7
|
Dosimetric Comparison of Lung-Sparing Radiation Therapy between Volumetric Arc Therapy and Helical Tomotherapy for Unresectable Malignant Pleural Mesothelioma. BIOMED RESEARCH INTERNATIONAL 2019; 2019:4568958. [PMID: 31930123 PMCID: PMC6942749 DOI: 10.1155/2019/4568958] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/14/2019] [Revised: 11/28/2019] [Accepted: 12/10/2019] [Indexed: 12/20/2022]
Abstract
Objective To compare volumetric arc therapy (VMAT) and helical tomotherapy (HT) plans in terms of dosimetric parameters in positron emission tomography- (PET-) computerized tomography- (CT-) based radiation therapy planning in unresectable malignant pleural mesothelioma (MPM). Methods CT and coregistered PET-CT data from seven patients with histologically-proven MPM were utilized for VMAT and HT plans. Target volumes and organs at risk (OARs) were delineated. The prescription doses for planning target volume 1 (PTV1) and PTV2 were 45.0 Gy and 54 Gy in 1.8 Gy/fr, respectively. Each technique was evaluated in terms of target volume coverage and OAR doses. Findings Although the maximum (p=0.001) and mean (p < 0.001) doses of PTV1, and PTV2 (p < 0.001 for maximum and p=0.001 for mean doses) favored the HT technique over VMAT, both techniques efficiently covered the target volumes. Additionally, HT also provided more homogeneous dose distribution (p < 0.001) and numerically lower doses received by most OARs, but again both rotational techniques were successful in keeping the OAR doses below the universally accepted limits. The major disadvantage of the HT technique was the requirement for longer treatment times (7.4 versus 2.5 minutes/fr; p < 0.001) to accomplish the intended treatment. Conclusion Results of this dosimetric comparison clearly demonstrated the possibility of safe hemithoracic irradiation of medically/technically unresectable MPM patients with either of the two rotational RT techniques, namely the VMAT and HT. Clinically, considering their poor prognosis, these promising findings may open a potential new window for curative treatment of unresectable MPM patients, if further confirmed by future clinical studies.
Collapse
|
8
|
Cardiotoxicity of mediastinal radiotherapy. Rep Pract Oncol Radiother 2019; 24:629-643. [PMID: 31719801 DOI: 10.1016/j.rpor.2019.09.002] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2019] [Accepted: 09/21/2019] [Indexed: 12/16/2022] Open
Abstract
Aim To explore available recent literature related to cardiotoxicity following mediastinal radiation. Background Radiotherapy-related heart injury is well documented, with no apparent safety threshold dose. The number of long-term cancer survivors exposed to mediastinal radiotherapy at some point of their treatment is increasing. Heart dosimetric parameters are of great importance in developing a treatment plan, but few data are available regarding radiosensitivity and dose-volume constraints for specific heart structures. Materials and Methods In October 2018, we identified articles published after 1990 through a PubMed/MEDLINE database search. The authors examined rough search results and manuscripts not relevant for the topic were excluded. We extracted clinical outcomes following mediastinal radiotherapy of childhood cancers, lymphoma, medulloblastoma, thymic cancers and hematopoietic cell transplantation survivors and evaluated treatment planning data, whenever available. Results A total of 1311 manuscripts were identified in our first-round search. Of these manuscripts, only 115 articles, matching our selection criteria, were included. Conclusions Studies uniformly show a linear radiation dose-response relationship between mean absorbed dose to the heart (heart-Dmean) and the risk of dying as a result of cardiac disease, particularly when heart-Dmean exceeds 5 Gy. Limited data are available regarding dose-volume predictors for heart substructures and the risk of subsequent cardiac toxicity. An individual patient's cardiotoxicity risk can be modified with advanced treatment planning techniques, including deep inspiration breath hold. Proton therapy is currently showing advantages in improving treatment planning parameters when compared to advanced photon techniques in lymphoma, thymic malignancies, malignant mesothelioma and craniospinal irradiation.
Collapse
Key Words
- 2D-RT, two-dimensional radiotherapy
- 3D-CRT, three-dimensional conformal radiation therapy
- CI, confidence interval
- CSI, craniospinal irradiation
- CVD, Cardiovascular disease
- Cardiotoxicity
- Dmax, maximum absorbed dose in a specified volume
- Dmean, mean absorbed radiation dose in a specified volume
- Dose-volume predictors
- EQD2, equivalent dose in 2 Gy fractions
- G, grade
- Gy, Gray
- HR, hazard ratio
- HT, Helical tomotherapy
- IFRT, involved field radiotherapy
- IMRT, intensity modulated radiation therapy
- INRT, involved node radiotherapy
- ISRT, involved site radiotherapy
- LAD, left anterior descending artery
- Mediastinal radiotherapy
- Mediastinal tumours
- Mv, megavoltage
- NTCP, normal tissue complication probability
- Normal tissue complication probability
- OAR, organs at risk
- OR, odds ratio
- PTV, planning target volume
- RR, relative risks
- TBI, total body irradiation
- VMAT, volumetric modulated arc therapy
- Vx, receiving at last x Gy
Collapse
|
9
|
Trovo M, Franceschini D, Furlan C, Pietrobon F, Vagge S, Farina E, Revelant A, Visani L, Maragna V, Parisi G, Scotti V. Extra-pleural pneumonectomy in the era of image-guided intensity-modulated radiotherapy. Radiol Med 2019; 124:854-859. [PMID: 30963379 DOI: 10.1007/s11547-019-01030-y] [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] [Received: 07/18/2018] [Accepted: 03/14/2019] [Indexed: 10/27/2022]
Abstract
PURPOSE To assess the outcome of malignant pleural mesothelioma patients treated with extra-pleural pneumonectomy (EPP) and adjuvant radiotherapy (RT), using the most advanced radiotherapeutic techniques, namely image-guided intensity-modulated RT (IG-IMRT). METHODS AND MATERIALS Fifty-four patients were analyzed. Minimum radiation dose was 50 Gy (2 Gy/fr). Planning target volume encompassed the entire hemithorax, including the ipsilateral mediastinum if interested by disease, the pericardium and diaphragm, and any drain sites. The study endpoints included loco-regional control (LRC), distant metastases free survival (DMFS), and overall survival (OS), as well as radiation-related toxicity. RESULTS Major patients and treatment characteristics were the following: median age 62 years, epithelioid histology in 51 (94%) cases, locally advanced disease in 41 (90%) cases, and metastatic mediastinal lymph nodes in 27 patients (50%). Only 7 patients (13%) had gross residual disease after surgery. Chemotherapy was administered in 38 patients (70%). Median follow-up was 16 months (range 0-73 months). Median and 2-year OS were 21 months and was 43.8%, respectively. The predominant pattern of failure was distant: 34 patients (62.9%) developed some component of distant failure, and only 5 patients (9.2%) developed an isolated loco-regional recurrence. The estimates of LRC and DMFS at 2 years were 63.4% and 43.4%, respectively. Three fatal pneumonitis were documented. Other major toxicities included: Grade 2 and 3 pneumonitis in 1 and 2 cases, respectively, 1 case of bronchial fistula, pleural empyema, and Grade 3 esophagitis, respectively. CONCLUSIONS Although executed in the era of high-technology radiotherapy (IG-IMRT), EPP should not be routinely performed.
Collapse
Affiliation(s)
- Marco Trovo
- Department of Radiation Oncology, Azienda Sanitaria Universitaria Integrata Udine, P.le Santa Maria della Misericordia 15, 33100, Udine, Italy
| | - Davide Franceschini
- Department of Radiotherapy and Radiosurgery, Humanitas Cancer Center and Research Hospital, Rozzano, Via Manzoni 56, Rozzano, Milan, Italy
| | - Carlo Furlan
- Department of Radiation Oncology, Ospedale San Martino di Belluno, Viale Europa 22, 32100, Belluno, Italy
| | - Francesca Pietrobon
- Department of Radiation Oncology, Ospedale San Martino di Belluno, Viale Europa 22, 32100, Belluno, Italy
| | - Stefano Vagge
- Department of Radiation Oncology, Azienda Ospedaliera Universitaria San Martino di Genova - IST, Istituto Nazionale Ricerca sul Cancro, Largo Rosanna Benzi, 10, 16132, Genoa, Italy
| | - Eleonora Farina
- Radiation Oncology Department, National Cancer Institute, CRO IRCCS, Via Franco Gallini, 2, 33081, Aviano, PN, Italy
| | - Alberto Revelant
- Radiation Oncology Department, National Cancer Institute, CRO IRCCS, Via Franco Gallini, 2, 33081, Aviano, PN, Italy
| | - Luca Visani
- Department of Radiation Oncology, Azienda Ospedaliero Universitaria Careggi, University of Florence, Largo Brambilla, 3, 50134, Florence, Italy
| | - Virginia Maragna
- Department of Radiation Oncology, Azienda Ospedaliero Universitaria Careggi, University of Florence, Largo Brambilla, 3, 50134, Florence, Italy
| | - Giuseppe Parisi
- Department of Radiation Oncology, Azienda Sanitaria Universitaria Integrata Udine, P.le Santa Maria della Misericordia 15, 33100, Udine, Italy.
| | - Vieri Scotti
- Department of Radiation Oncology, Azienda Ospedaliero Universitaria Careggi, University of Florence, Largo Brambilla, 3, 50134, Florence, Italy
| |
Collapse
|
10
|
Lewis GD, Dalwadi SM, Farach A, Brian Butler E, Teh BS. The Role of Adjuvant Radiotherapy in the Treatment of Pleural Mesothelioma. Ann Surg Oncol 2019; 26:1879-1885. [PMID: 30798447 DOI: 10.1245/s10434-019-07235-9] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2018] [Indexed: 11/18/2022]
Abstract
BACKGROUND Pleural mesothelioma is a rare but aggressive form of cancer. Local recurrence represents the majority of treatment failures and overall survival (OS) outcomes remain dismal. Adding locoregional treatment with radiotherapy after surgical resection has been considered but its role remains uncertain. OBJECTIVE The purpose of this study was to evaluate the outcomes of adjuvant radiation therapy (RT) for patients with malignant pleural mesothelioma. METHODS The National Cancer Data Base (NCDB) was queried (2004-2013) for patients with malignant mesothelioma. Patients were divided into three groups: observation, surgery alone, and surgery followed by adjuvant RT. Statistics included Fisher's exact or Chi square tests to analyze categorical proportions between groups, Kaplan-Meier analysis to evaluate OS, and Cox proportional hazards modeling to determine variables associated with OS. Propensity matching was performed to make comparisons between homogenous groups. RESULTS Overall, the surgery plus radiotherapy group had a higher median survival (21.4 months) compared with surgery alone (16.59 months) [p < 0.001]. RT was more likely to be delivered after extrapleural pneumonectomy than with lung-sparing surgical approaches. On multivariable analysis, receipt of surgery plus radiotherapy, chemotherapy administration, and higher socioeconomic status were associated with improved OS (p < 0.0001). After propensity matching, receipt of surgery plus radiotherapy and chemotherapy administration were still associated with improved OS (p < 0.05). CONCLUSIONS In the treatment of malignant pleural mesothelioma, adjuvant radiotherapy after surgical intervention was associated with improved OS. This study is the largest study of adjuvant radiotherapy to date, and our findings highlight the need for additional prospective data.
Collapse
Affiliation(s)
- Gary D Lewis
- Department of Radiation Oncology, The University of Texas Medical Branch at Galveston, Galveston, TX, USA.,Department of Radiation Oncology, Houston Methodist Hospital, Cancer Center and Research Institute, Weil Cornell Medical College, Houston, TX, 77030, USA
| | - Shraddha M Dalwadi
- Department of Radiation Oncology, Baylor College of Medicine, Houston, TX, USA
| | - Andrew Farach
- Department of Radiation Oncology, Houston Methodist Hospital, Cancer Center and Research Institute, Weil Cornell Medical College, Houston, TX, 77030, USA
| | - E Brian Butler
- Department of Radiation Oncology, Houston Methodist Hospital, Cancer Center and Research Institute, Weil Cornell Medical College, Houston, TX, 77030, USA
| | - Bin S Teh
- Department of Radiation Oncology, Houston Methodist Hospital, Cancer Center and Research Institute, Weil Cornell Medical College, Houston, TX, 77030, USA.
| |
Collapse
|
11
|
Blais E, Vendrely V, Sargos P, Créhange G, Huguet F, Maingon P, Simon JM, Bourdais R, Ozsahin M, Bourhis J, Clément-Colmou K, Belghith B, Proudhom Briois MA, Gilliot O, Dujols JP, Peyras A, Dupin C, Riet FG, Canova CH, Huertas A, Troussier I. [Chemoradiation for oesophageal cancer: A critical review of the literature]. Cancer Radiother 2019; 23:62-72. [PMID: 30639379 DOI: 10.1016/j.canrad.2018.05.003] [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: 04/09/2018] [Revised: 05/14/2018] [Accepted: 05/16/2018] [Indexed: 10/27/2022]
Abstract
Locally advanced oesophageal cancer treatment requires a multidisciplinary approach with the combination of chemotherapy and radiotherapy for preoperative and definitive strategy. Preoperative chemoradiation improves the locoregional control and overall survival after surgery for locally advanced oesophageal cancer. Definitive chemoradiation can also be proposed for non-resectable tumours or medically inoperable patients. Besides, definitive chemoradiation is considered as an alternative option to surgery for locally advanced squamous cell carcinomas. Chemotherapy regimen associated to radiotherapy consists of a combination of platinum derived drugs (cisplatinum or oxaliplatin) and 5-fluorouracil or a weekly scheme combination of carboplatin and paclitaxel according to CROSS protocol in a neoadjuvant strategy. Radiation doses vary from 41.4Gy to 45Gy for a preoperative strategy or 50 to 50.4Gy for a definitive treatment. The high risk of lymphatic spread due to anatomical features could justify the use of an elective nodal irradiation when the estimated risk of microscopic involvement is higher than 15% to 20%. An appropriate delineation of the gross tumour volume requires an exhaustive and up-to-date evaluation of the disease. Intensity-modulated radiation therapy represents a promising approach to spare organs-at-risk. This critical review of the literature underlines the roles of radiotherapy for locally advanced oesophageal cancers and describes doses, volumes of treatment, technical aspects and dose constraints to organs-at-risk.
Collapse
Affiliation(s)
- E Blais
- Service de radiothérapie, hôpital de la Pitié-Salpêtrière, 47-83, boulevard de l'Hôpital, 75013 Paris, France.
| | - V Vendrely
- Service de radiothérapie, CHU de Bordeaux-Haut Lévêque, avenue du Haut-Lévêque, 33600 Pessac, France
| | - P Sargos
- Service de radiothérapie, institut Bergonié, 229, cours de l'Argonne, 33000 Bordeaux, France
| | - G Créhange
- Service de radiothérapie, centre Georges-François-Leclerc, 1, rue du Professeur-Marion, 21000 Dijon, France
| | - F Huguet
- Service de radiothérapie, hôpital Tenon, 4, rue de la Chine, 75020 Paris, France
| | - P Maingon
- Service de radiothérapie, hôpital de la Pitié-Salpêtrière, 47-83, boulevard de l'Hôpital, 75013 Paris, France
| | - J-M Simon
- Service de radiothérapie, hôpital de la Pitié-Salpêtrière, 47-83, boulevard de l'Hôpital, 75013 Paris, France
| | - R Bourdais
- Service de radiothérapie, hôpital de la Pitié-Salpêtrière, 47-83, boulevard de l'Hôpital, 75013 Paris, France
| | - M Ozsahin
- Service de radio-oncologie, CHUV, rue du Bugnon 46, 1011 Lausanne, Suisse
| | - J Bourhis
- Service de radio-oncologie, CHUV, rue du Bugnon 46, 1011 Lausanne, Suisse
| | - K Clément-Colmou
- Service de radiothérapie, institut de cancérologie de l'Ouest (ICO) centre René-Gauducheau, boulevard Professeur-Jacques-Monod, 44800 Saint-Herblain, France
| | - B Belghith
- Service de radiothérapie, hôpital de la Pitié-Salpêtrière, 47-83, boulevard de l'Hôpital, 75013 Paris, France
| | - M-A Proudhom Briois
- Service de radiothérapie, groupe de radiothérapie et d'oncologie des Pyrénées, 49, rue Aristide-Briand, 64000 Pau, France
| | - O Gilliot
- Service de radiothérapie, groupe de radiothérapie et d'oncologie des Pyrénées, 49, rue Aristide-Briand, 64000 Pau, France
| | - J-P Dujols
- Service de radiothérapie, groupe de radiothérapie et d'oncologie des Pyrénées, 49, rue Aristide-Briand, 64000 Pau, France
| | - A Peyras
- Service de radiothérapie, groupe de radiothérapie et d'oncologie des Pyrénées, 49, rue Aristide-Briand, 64000 Pau, France
| | - C Dupin
- Service de radiothérapie, CHU de Bordeaux-Haut Lévêque, avenue du Haut-Lévêque, 33600 Pessac, France
| | - F-G Riet
- Service de radiothérapie, hôpital de la Pitié-Salpêtrière, 47-83, boulevard de l'Hôpital, 75013 Paris, France
| | - C-H Canova
- Service de radiothérapie, hôpital de la Pitié-Salpêtrière, 47-83, boulevard de l'Hôpital, 75013 Paris, France
| | - A Huertas
- Service de radiothérapie, hôpital européen Georges-Pompidou, 20, rue Leblanc, 75015 Paris, France
| | - I Troussier
- Service de radio-oncologie, hôpitaux universitaires de Genève, rue Gabrielle-Perret-Gentil 4, 1205 Genève, Suisse
| |
Collapse
|
12
|
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
|
13
|
Simon M, Shochat T, Peled N, Zer A, Kramer MR, Eldan O, Saute M, Dudnik ER, Allen AM. Intensity-modulated radiotherapy is a safe and effective treatment for localized malignant pleural mesothelioma. Thorac Cancer 2018; 9:1470-1475. [PMID: 30240138 PMCID: PMC6209784 DOI: 10.1111/1759-7714.12860] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2018] [Revised: 08/09/2018] [Accepted: 08/09/2018] [Indexed: 12/29/2022] Open
Abstract
Background Malignant pleural mesothelioma (MPM) is a rare disease and management of localized disease is controversial. Radiotherapy has been shown to be useful after extrapleural pneumonectomy (EPP), as well as with less aggressive surgery. As no reports of the treatment of this disease have ever been published from Israel, we report our experience with MPM and intensity‐modulated radiotherapy (IMRT). Methods The complete medical records of patients treated for MPM at the Rabin Medical Center from 1 August 2007 to 31 March 2016 were reviewed. Twenty‐seven patients were treated with IMRT, either post‐EPP or without EPP. Patients received 54 Gy in 2 Gy fractions using the restricted field IMRT technique. Chemotherapy was administered sequentially in 26% of patients. Patients were followed up from the date of diagnosis to death or treatment failure. Results Seventy‐eight percent of patients had the epithelioid subtype. Nearly all patients were male (85%) and 90% of non‐surgical patients were administered chemotherapy compared to 56% of post‐EPP patients. All patients completed therapy and only 16% had grade 1–2 radiation pneumonitis, with no incidence of grade 3 or higher. The median follow‐up was 22 months and the mean overall survival was 34.9 months. The mean time to progression following radiation therapy was 26.7 months. The mean time to local and distant failure was 19 and 16 months, respectively. Conclusions IMRT for localized pleural mesothelioma is a tolerable and effective therapy both post‐EPP or without surgery. These results suggest that future investigation in this area is required.
Collapse
Affiliation(s)
- Michael Simon
- Department of Radiation Oncology, Davidoff Center, Rabin Medical Center, Petah Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Maimonides Medical Center, New York, USA
| | - Tzippy Shochat
- Biostatics Core, Rabin Medical Center, Petah Tikva, Israel
| | - Nir Peled
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Department of Oncology, Davidoff Center, Rabin Medical Center, Petah Tikva, Israel
| | - Alona Zer
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Department of Oncology, Davidoff Center, Rabin Medical Center, Petah Tikva, Israel
| | - Mordechai R Kramer
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Department of Pulmonology, Rabin Medical Center, Petah Tikva, Petah Tikva, Israel
| | - Orit Eldan
- Department of Radiation Oncology, Davidoff Center, Rabin Medical Center, Petah Tikva, Israel
| | - Milton Saute
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Department of Thoracic Surgery, Rabin Medical Center, Petah Tikva, Israel
| | - Elizabeth R Dudnik
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Department of Oncology, Davidoff Center, Rabin Medical Center, Petah Tikva, Israel
| | - Aaron M Allen
- Department of Radiation Oncology, Davidoff Center, Rabin Medical Center, Petah Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| |
Collapse
|
14
|
Cramer G, Simone CB, Busch TM, Cengel KA. Adjuvant, neoadjuvant, and definitive radiation therapy for malignant pleural mesothelioma. J Thorac Dis 2018; 10:S2565-S2573. [PMID: 30206500 DOI: 10.21037/jtd.2018.07.65] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
While ionizing radiotherapy (RT) can provide durable local control, the relative radiosensitivity of surrounding organs such as the lungs and heart and the distributed nature of the pleura limit the ability to safely deliver RT for patients with malignant pleural mesothelioma (MPM). Recent advances in the technological sophistication of RT planning and delivery devices have resulted in increased spatial control of irradiation dose that has extended the palliative and definitive applications of RT for patients with MPM. This review will outline the logistical, mechanistic and clinical basics of RT and the clinical trials supporting the use of RT in the multidisciplinary care of patients with MPM.
Collapse
Affiliation(s)
- Gwendolyn Cramer
- Department of Radiation Oncology, Hospital of the University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA, USA
| | - Charles B Simone
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Theresa M Busch
- Department of Radiation Oncology, Hospital of the University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA, USA
| | - Keith A Cengel
- Department of Radiation Oncology, Hospital of the University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA, USA
| |
Collapse
|
15
|
Shaaban SG, Verma V, Choi JI, Shabason J, Sharma S, Glass E, Grover S, Badiyan SN, Simone CB. Utilization of Intensity-Modulated Radiation Therapy for Malignant Pleural Mesothelioma in the United States. Clin Lung Cancer 2018; 19:e685-e692. [PMID: 29803576 DOI: 10.1016/j.cllc.2018.04.019] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2018] [Revised: 04/04/2018] [Accepted: 04/26/2018] [Indexed: 12/11/2022]
Abstract
BACKGROUND Although postoperative radiotherapy (RT) for malignant pleural mesothelioma (MPM) has historically been delivered using 3-dimensional conformal RT (3DCRT) techniques, multiple reports show noteworthy safety and efficacy of the more advanced intensity-modulated RT (IMRT). To our knowledge, this is the only known study to evaluate national practice patterns of IMRT utilization for MPM. MATERIALS AND METHODS The National Cancer Data Base was queried for newly-diagnosed MPM patients who underwent definitive surgery (extrapleural pneumonectomy [EPP] or extended pleurectomy/decortication [P/D]) followed by adjuvant RT. Patients with metastatic disease, non-EPP or P/D surgical techniques, and lack of RT receipt (or without specified RT technique) were excluded. Statistics included multivariable logistic regression, Kaplan-Meier overall survival (OS) analysis, and Cox proportional hazards modeling. RESULTS Overall, 286 patients met criteria (181 [63%] IMRT and 105 [37%] 3DCRT). Temporal trends revealed that although 3DCRT was more common at initial time periods, IMRT utilization rose from 2004 to 2007 and stayed as a relatively constant majority thereafter. This was also present when substratifying the cohort according to EPP versus P/D approaches. IMRT was more often delivered at academic centers, along with institutions in the Southern United States, whereas 3DCRT was more frequently utilized in community facilities and in the Northeast (P ≤ .05 for all). RT technique did not affect OS (P > .05 for all comparisons). CONCLUSION In the United States, IMRT is now the most commonly utilized adjuvant RT technique for MPM. Facility and regional differences might associate with IMRT delivery. The findings of this investigation have implications for insurance coverage, clinical referral patterns, and ongoing and future prospective trial design.
Collapse
Affiliation(s)
- Sherif G Shaaban
- Department of Radiation Oncology, University of Texas M.D. Anderson Cancer Center, Houston, TX
| | - Vivek Verma
- Department of Radiation Oncology, University of Nebraska Medical Center, Omaha, NE
| | - J Isabelle Choi
- Department of Radiation Oncology, University of Maryland Medical Center, Baltimore, MD
| | - Jacob Shabason
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, PA
| | - Sonam Sharma
- Department of Radiation Oncology, The Mount Sinai Hospital, New York, NY
| | - Erica Glass
- California Protons Cancer Therapy Center, San Diego, CA
| | - Surbhi Grover
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, PA
| | | | | |
Collapse
|
16
|
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.
Collapse
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
| | | |
Collapse
|
17
|
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: 265] [Impact Index Per Article: 44.2] [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 .
Collapse
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
| |
Collapse
|
18
|
Blais E, Pichon B, Mampuya A, Antoine M, Lagarde P, Kantor G, Breton-Callu C, Lefebvre C, Gerard M, Aamarcha A, Ozsahin M, Bourhis J, Maingon P, Troussier I, Pourel N. Doses aux organes à risque en radiothérapie conformationnelle et en radiothérapie stéréotaxique : les poumons. Cancer Radiother 2017; 21:584-596. [DOI: 10.1016/j.canrad.2017.07.046] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2017] [Revised: 07/21/2017] [Accepted: 07/23/2017] [Indexed: 12/25/2022]
|
19
|
de Perrot M, Wu L, Wu M, Cho BCJ. Radiotherapy for the treatment of malignant pleural mesothelioma. Lancet Oncol 2017; 18:e532-e542. [PMID: 28884702 DOI: 10.1016/s1470-2045(17)30459-x] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2017] [Revised: 06/06/2017] [Accepted: 06/08/2017] [Indexed: 12/21/2022]
Abstract
Malignant pleural mesothelioma is an aggressive disease that continues to be associated with poor outcomes. Although, traditionally this disease is considered to be resistant to radiotherapy, more recent evidence suggests that radiotherapy can produce positive outcomes. Over the past 15 years, the development of new, highly conformal radiotherapy techniques, such as intensity-modulated radiation therapy (IMRT), has enabled investigators to optimise the delivery of high-dose radiotherapy to the whole of the hemithorax. Prospective single-arm trials have shown that the median survival of patients who have completed high-dose hemithoracic radiotherapy after extrapleural pneumonectomy could reach 23·9-39·4 months independent of the chemotherapeutic response, suggesting that IMRT could potentially have an intrinsic benefit to this subset of patients. These observations have led to a change in practice, with the introduction of adjuvant pleural IMRT after pleurectomy-decortication and the development of induction-accelerated hemithoracic IMRT followed by extrapleural pneumonectomy. This Review focuses on recent observations on the role of radiotherapy in the treatment of malignant pleural mesothelioma, with particular emphasis on the results of clinical trials that evaluate the role of high-dose hemithoracic radiotherapy.
Collapse
Affiliation(s)
- Marc de Perrot
- Division of Thoracic Surgery, Princess Margaret Cancer Centre and Toronto General Hospital, University Health Network, University of Toronto, ON, Canada.
| | - Licun Wu
- Latner Thoracic Surgery Laboratories, Princess Margaret Cancer Centre and Toronto General Hospital, University Health Network, University of Toronto, ON, Canada
| | - Matthew Wu
- Latner Thoracic Surgery Laboratories, Princess Margaret Cancer Centre and Toronto General Hospital, University Health Network, University of Toronto, ON, Canada
| | - B C John Cho
- Department of Radiation Oncology, Princess Margaret Cancer Centre and Toronto General Hospital, University Health Network, University of Toronto, ON, Canada
| |
Collapse
|
20
|
Lee H, Zeng J, Bowen SR, Rengan R. Proton Therapy for Malignant Pleural Mesothelioma: A Three Case Series Describing the Clinical and Dosimetric Advantages of Proton-Based Therapy. Cureus 2017; 9:e1705. [PMID: 29159011 PMCID: PMC5690429 DOI: 10.7759/cureus.1705] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Malignant pleural mesothelioma (MPM) is a malignancy of the pleural cavity that typically presents at an advanced stage. Due to its large, circumferential clinical target volume (CTV) and proximity to major structures, including the heart and contralateral lung, delivering hemithoracic intensity-modulated radiotherapy (IMRT) with photon therapy to achieve loco-regional control following macroscopic complete resection is challenging. Intensity-modulated proton therapy (IMPT) has been shown to be a method for achieving higher therapeutic doses while limiting exposure to organs at risk (OARs), but patient outcomes after treatment have yet to be reported. We present three patients who received IMPT to 54 Gy after extrapleural pneumonectomy (EPP), with two patients receiving boosts to 66 and 60 Gy. All three tolerated treatment well and received doses to OARs markedly lower than those seen in comparison volumetric-modulated arc therapy (VMAT) IMRT photon plans. Radiation pneumonitis, a highly morbid and potentially fatal toxicity in patients receiving thoracic radiotherapy, was not observed even with boost treatments. In practice, IMPT appears to match dosimetric predictions as a feasible and safer alternative to photon IMRT-based radiotherapy.
Collapse
Affiliation(s)
- Howard Lee
- School of Medicine, Duke University School of Medicine
| | - Jing Zeng
- Radiation Oncology, University of Washington School of Medicine
| | - Stephen R Bowen
- Radiation Oncology, University of Washington School of Medicine
| | - Ramesh Rengan
- Radiation Oncology, University of Washington School of Medicine
| |
Collapse
|
21
|
Matsuo Y, Shibuya K, Okubo K, Ueki N, Aoyama A, Sonobe M, Nakamura M, Mizowaki T, Date H, Hiraoka M. Long-term outcomes of intensity-modulated radiotherapy following extra-pleural pneumonectomy for malignant pleural mesothelioma. Acta Oncol 2017; 56:957-962. [PMID: 28117611 DOI: 10.1080/0284186x.2017.1279749] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
BACKGROUND The purpose was to evaluate safety and efficacy of intensity-modulated radiotherapy (IMRT) following extra-pleural pneumonectomy (EPP) for malignant pleural mesothelioma (MPM). MATERIAL AND METHODS Patients with MPM of clinical stage I-III, which were macroscopic completely resected with EPP were eligible for this prospective study. The ipsilateral hemithorax was irradiated with a prescribed dose of 50.4 Gy. When the high-risk surgical margins or FDG-avid regions were identified, simultaneous integrated boost (SIB) with 56.0 Gy or 61.6 Gy was applied. RESULTS Twenty-one patients were enrolled. SIB was applied to five patients. The planned IMRT fractions were completed in all, but four patients who suffered from severe fatigue or radiation pneumonitis. With a potential median follow-up of 6.3 years, overall survival was 37.5% at 3 years since the IMRT. The median survival time was 17.5 and 27.0 months since the IMRT and the initial treatment, respectively. Three patients have survived for more than 5 years. Distant metastasis was observed in 15 patients. Local recurrence was also observed in 2 of the 15 patients. Acute toxicities of Grade 3 or worse were observed in 15 patients, including 9 with hematological, 3 with pneumonitis and 6 with fatigue, nausea or vomiting. Five patients developed Grade 3 or worse late toxicities associated with IMRT, consisting of one with persistent Grade 4 thrombocytopenia, one with brain infarction and congestive liver dysfunction, and three with elevation of serum transaminase or biliary enzyme. No Grade 5 toxicity was observed. Patients with N2 showed significantly worse survival than those with N0-1 (18.2% vs. 60.0% at 3 years, p = .014). CONCLUSION IMRT following EPP achieved excellent local control for MPM, that might lead to the long-term survival in selected patients. However, treatment burden including acute and late toxicities should be considered in this treatment approach.
Collapse
Affiliation(s)
- Yukinori Matsuo
- Department of Radiation Oncology and Image-applied Therapy, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Keiko Shibuya
- Department of Radiation Oncology and Image-applied Therapy, Graduate School of Medicine, Kyoto University, Kyoto, Japan
- Department of Radiation Oncology, Graduate School of Medicine, Yamaguchi University, Ube, Japan
| | - Kenichi Okubo
- Department of Thoracic Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
- Department of Thoracic Surgery, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan
| | - Nami Ueki
- Department of Radiation Oncology and Image-applied Therapy, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Akihiro Aoyama
- Department of Thoracic Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Makoto Sonobe
- Department of Thoracic Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Mitsuhiro Nakamura
- Department of Radiation Oncology and Image-applied Therapy, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Takashi Mizowaki
- Department of Radiation Oncology and Image-applied Therapy, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Hiroshi Date
- Department of Thoracic Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Masahiro Hiraoka
- Department of Radiation Oncology and Image-applied Therapy, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| |
Collapse
|
22
|
Marulli G, Faccioli E, Bellini A, Mammana M, Rea F. Induction chemotherapy vs post-operative adjuvant therapy for malignant pleural mesothelioma. Expert Rev Respir Med 2017; 11:649-660. [PMID: 28580813 DOI: 10.1080/17476348.2017.1338951] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
INTRODUCTION Malignant pleural mesothelioma (MPM) is an aggressive neoplasia. Multidisciplinary treatments, including the association of induction and/or adjuvant therapeutic regimens with surgery, have been reported to give encouraging results. Current therapeutic options are not well standardized yet, especially regarding the best association between surgery and medical treatments. The present review aims to assess safety, efficacy and outcomes of different therapies for MPM. Areas covered: This article focuses on the multimodality treatment of mesothelioma. A systematic review was performed by using electronic databases to identify studies that considered induction and adjuvant approaches in MPM therapy in a multidisciplinary setting, including surgery. Endpoints included overall survival, disease free survival, disease recurrence, and complications. Expert commentary: This systematic review offers a comprehensive view of current multidisciplinary therapeutic strategies for MPM, suggesting that multimodality therapy offers acceptable outcomes with better results reported for trimodality approaches. Individualization of care for each patient is fundamental in choosing the most appropriate treatment. The growing complexity of treatment protocols mandates that MPM patients be referred to specialized Centers, in which every component of the interdisciplinary team can provide the necessary expertise and quality of care.
Collapse
Affiliation(s)
- Giuseppe Marulli
- a Thoracic Surgery Unit, Department of Cardiologic, Thoracic and Vascular Sciences , University of Padova , Padova , Italy
| | - Eleonora Faccioli
- a Thoracic Surgery Unit, Department of Cardiologic, Thoracic and Vascular Sciences , University of Padova , Padova , Italy
| | - Alice Bellini
- a Thoracic Surgery Unit, Department of Cardiologic, Thoracic and Vascular Sciences , University of Padova , Padova , Italy
| | - Marco Mammana
- a Thoracic Surgery Unit, Department of Cardiologic, Thoracic and Vascular Sciences , University of Padova , Padova , Italy
| | - Federico Rea
- a Thoracic Surgery Unit, Department of Cardiologic, Thoracic and Vascular Sciences , University of Padova , Padova , Italy
| |
Collapse
|
23
|
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.
Collapse
Affiliation(s)
- Kenneth E Rosenzweig
- Department of Radiation Oncology, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
| |
Collapse
|
24
|
Wu L, de Perrot M. Radio-immunotherapy and chemo-immunotherapy as a novel treatment paradigm in malignant pleural mesothelioma. Transl Lung Cancer Res 2017; 6:325-334. [PMID: 28713677 DOI: 10.21037/tlcr.2017.06.03] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Malignant pleural mesothelioma (MPM) is an aggressive neoplasm with poor outcome. Novel radical radiation techniques using intensity modulated radiation therapy (IMRT) have become an important component of therapy in mesothelioma. Immunotherapy also provides new therapeutic options. However, how best to integrate immunotherapy with standard therapy such as radiation, chemotherapy and surgery remains unknown. A change of paradigm from adjuvant normofractionation to induction accelerated hypofractionated hemithoracic radiation could provide a platform to combine immunotherapy due to the potential benefit of short course high dose radiation on the immune system. Immunotherapy can also be combined with chemotherapy. Although chemotherapy is generally considered immunosuppressive, some chemotherapeutic agents do induce cell death that can be immunogenic and stimulate a specific immune response against the tumor. Immunotherapy could also be used in between cycles of chemotherapy to limit tumor cell repopulation and optimize the results of both treatments. The integration of immunotherapy into a multimodality approach is opening new avenue of treatment for mesothelioma.
Collapse
Affiliation(s)
- Licun Wu
- Toronto Mesothelioma Research Program, Toronto General Hospital and Princess Margaret Cancer Centre, University Health Network, University of Toronto, Toronto, Canada
| | - Marc de Perrot
- Toronto Mesothelioma Research Program, Toronto General Hospital and Princess Margaret Cancer Centre, University Health Network, University of Toronto, Toronto, Canada
| |
Collapse
|
25
|
Jhavar S, Pruszynski J, Gowan A, Boyle T, Deb N, Patel M. Intensity modulated radiation therapy after extra-pleural pneumonectomy for malignant pleural mesothelioma is feasible without fatal pulmonary toxicity and provides good survival. Asia Pac J Clin Oncol 2017; 14:e88-e94. [PMID: 28371288 DOI: 10.1111/ajco.12680] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2016] [Accepted: 02/02/2017] [Indexed: 11/30/2022]
Abstract
AIM To analyze patterns of failure, toxicity, relapse-free survival (RFS), and overall survival (OS) in malignant pleural mesothelioma (MPM) patients treated with intensity-modulated radiation therapy following extrapleural pneumonectomy (EPP). METHODS We reviewed 18 charts of patients with MPM from 2005 to 2014 who underwent EPP followed by hemithoracic intensity-modulated radiation therapy. Intensity-modulated radiation therapy dose delivery adhered to published lung dose constraints. Kaplan-Meier curves were used to assess the RFS and OS. Median survival times are reported for both RFS and OS. RESULTS Median age was 65 years (range: 40-76 years). Chemotherapy was administered in four neo-adjuvant and seven adjuvant patients. Pathological American Joint Committee on Cancer stages II, III, IV, surgical margin, lympho-vascular space, pericardium, and chest wall involvement were seen in 3, 12, 3, 9, 7, 12 and 3 patients, respectively. The majority of the patients received 45 Gy in 25 fractions. The mean lung dose was 7.14 Gy (range: 5 Gy-9.3 Gy). The mean V20 was 2.23%. At a median follow-up of 3 years, eight patients were alive (44%); 10 experienced relapse (56%). Median RFS and OS were 24.4 months (95% CI: >16.3 months) and 38.2 months (95% CI: 17.4-78.1 months), respectively. Acute toxicities were fatigue, dermatitis, nausea, esophagitis/dysphagia, cough, and dyspnea on exertion. No grade III, IV, or fatal pulmonary toxicities were observed. CONCLUSION Intensity-modulated radiation therapy following EPP for MPM resulted in RFS and OS comparable to the published literature without significant toxicity.
Collapse
Affiliation(s)
- Sameer Jhavar
- Department of Radiation Oncology, Baylor Scott and White Health, Temple, Texas, USA
| | | | - Alan Gowan
- Hematology and Oncology, Baylor Scott and White Health, Temple, Texas, USA
| | - Teresa Boyle
- Radiation Oncology, Austin Cancer Centers, Texas, USA
| | - Niloyjyoti Deb
- Department of Radiation Oncology, Baylor Scott and White Health, Temple, Texas, USA
| | - Mehul Patel
- Department of Radiation Oncology, Baylor Scott and White Health, Temple, Texas, USA
| |
Collapse
|
26
|
Shaikh F, Zauderer MG, von Reibnitz D, Wu AJ, Yorke ED, Foster A, Shi W, Zhang Z, Adusumilli PS, Rosenzweig KE, Krug LM, Rusch VW, Rimner A. Improved Outcomes with Modern Lung-Sparing Trimodality Therapy in Patients with Malignant Pleural Mesothelioma. J Thorac Oncol 2017; 12:993-1000. [PMID: 28341225 DOI: 10.1016/j.jtho.2017.02.026] [Citation(s) in RCA: 43] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2016] [Revised: 02/03/2017] [Accepted: 02/21/2017] [Indexed: 12/19/2022]
Abstract
INTRODUCTION Higher target conformity and better sparing of organs at risk with modern radiotherapy (RT) may result in higher tumor control and less toxicity. In this study, we compare our institutional multimodality therapy experience of adjuvant chemotherapy and hemithoracic intensity-modulated pleural RT (IMPRINT) with previously used adjuvant conventional RT (CONV) in patients with malignant pleural mesothelioma (MPM) treated with lung-sparing pleurectomy/decortication (P/D). METHODS We analyzed 209 patients who underwent P/D and adjuvant RT (131 who received CONV and 78 who received IMPRINT) for MPM between 1974 and 2015. The primary end point was overall survival (OS). The Kaplan-Meier method and Cox proportional hazards model were used to calculate OS; competing risks analysis was performed for local failure-free survival and progression-free survival. Univariate analysis and multivariate analysis were performed with relevant clinical and treatment factors. RESULTS The median age was 64 years, and 80% of the patients were male. Patients receiving IMPRINT had significantly higher rates of the epithelial histological type, advanced pathological stage, and chemotherapy treatment. OS was significantly higher after IMPRINT (median 20.2 versus 12.3 months, p = 0.001). Higher Karnofsky performance score, epithelioid histological type, macroscopically complete resection, and use of chemotherapy/IMPRINT were found to be significant factors for longer OS in multivariate analysis. No significant predictive factors were identified for local failure or progression. Grade 2 or higher esophagitis developed in fewer patients after IMPRINT than after CONV (23% versus 47%). CONCLUSIONS Trimodality therapy including adjuvant hemithoracic IMPRINT, chemotherapy, and P/D is associated with promising OS rates and decreased toxicity in patients with MPM. Dose constraints should be applied vigilantly to minimize serious adverse events.
Collapse
Affiliation(s)
- Fauzia Shaikh
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Marjorie G Zauderer
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York; Department of Medicine, Weill Cornell Medical College, New York, New York
| | - Donata von Reibnitz
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Abraham J Wu
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Ellen D Yorke
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Amanda Foster
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Weiji Shi
- Department of Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Zhigang Zhang
- Department of Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Prasad S Adusumilli
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Kenneth E Rosenzweig
- Department of Radiation Oncology, Mount Sinai Medical Center, New York, New York
| | - Lee M Krug
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York; Department of Medicine, Weill Cornell Medical College, New York, New York
| | - Valerie W Rusch
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Andreas Rimner
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York.
| |
Collapse
|
27
|
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.
Collapse
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
| |
Collapse
|
28
|
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]
|
29
|
Simone CB, Busch TM, Cengel KA. Radiotherapy and Photodynamic Therapy for Malignant Pleural Mesothelioma. ASBESTOS AND MESOTHELIOMA 2017. [DOI: 10.1007/978-3-319-53560-9_14] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
|
30
|
Rimner A, Zauderer MG, Gomez DR, Adusumilli PS, Parhar PK, Wu AJ, Woo KM, Shen R, Ginsberg MS, Yorke ED, Rice DC, Tsao AS, Rosenzweig KE, Rusch VW, Krug LM. Phase II Study of Hemithoracic Intensity-Modulated Pleural Radiation Therapy (IMPRINT) As Part of Lung-Sparing Multimodality Therapy in Patients With Malignant Pleural Mesothelioma. J Clin Oncol 2016; 34:2761-8. [PMID: 27325859 DOI: 10.1200/jco.2016.67.2675] [Citation(s) in RCA: 125] [Impact Index Per Article: 15.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
PURPOSE We conducted a two-center phase II study to determine the safety of hemithoracic intensity-modulated pleural radiation therapy (IMPRINT) after chemotherapy and pleurectomy-decortication (P/D) as part of a multimodality lung-sparing treatment. PATIENTS AND METHODS Patients received up to four cycles of pemetrexed plus platinum. If feasible, P/D was performed. Hemithoracic IMPRINT was administered to a planned dose of 50.4 Gy in 28 fractions. The primary end point was the incidence of grade 3 or greater radiation pneumonitis (RP). RESULTS A total of 45 patients were enrolled; 18 were not evaluable (because of disease progression before radiation therapy [RT], n = 9; refusal of surgery or RT, n = 5; extrapleural pneumonectomy at time of surgery, n = 2; or chemotherapy complications, n = 2). A total of 26 patients received pemetrexed plus cisplatin, 18 received pemetrexed plus carboplatin, and four received a combination. Thirteen patients (28.9%) had a partial response, 15 patients (33.3%) experienced disease progression, one patient died during chemotherapy, and all others had stable disease. Eight patients underwent P/D or an extended P/D, and 13 underwent a partial P/D. A total of 27 patients started IMPRINT (median dose, 46.8 Gy; range, 28.8 to 50.4 Gy) and were evaluable for the primary end point (median follow-up, 21.6 months). Six patients experienced grade 2 RP, and two patients experienced grade 3 RP; all recovered after corticosteroid initiation. No grade 4 or 5 radiation-related toxicities were observed. The median progression-free survival and overall survival (OS) were 12.4 and 23.7 months, respectively; the 2-year OS was 59% in patients with resectable tumors and was 25% in patients with unresectable tumors. CONCLUSIONS Hemithoracic IMPRINT for malignant pleural mesothelioma (MPM) is safe and has an acceptable rate of RP. Its incorporation with chemotherapy and P/D forms a new lung-sparing treatment paradigm for patients with locally advanced MPM.
Collapse
Affiliation(s)
- Andreas Rimner
- Andreas Rimner, Marjorie G. Zauderer, Prasad S. Adusumilli, Preeti K. Parhar, Abraham J. Wu, Kaitlin M. Woo, Ronglai Shen, Michelle S. Ginsberg, Ellen D. Yorke, Kenneth E. Rosenzweig, Valerie W. Rusch, and Lee M. Krug, Memorial Sloan Kettering Cancer Center, Weill Cornell Medical Center, New York, NY; and Daniel R. Gomez, David C. Rice, and Anne S. Tsao, MD Anderson Cancer Center, Houston, TX
| | - Marjorie G Zauderer
- Andreas Rimner, Marjorie G. Zauderer, Prasad S. Adusumilli, Preeti K. Parhar, Abraham J. Wu, Kaitlin M. Woo, Ronglai Shen, Michelle S. Ginsberg, Ellen D. Yorke, Kenneth E. Rosenzweig, Valerie W. Rusch, and Lee M. Krug, Memorial Sloan Kettering Cancer Center, Weill Cornell Medical Center, New York, NY; and Daniel R. Gomez, David C. Rice, and Anne S. Tsao, MD Anderson Cancer Center, Houston, TX
| | - Daniel R Gomez
- Andreas Rimner, Marjorie G. Zauderer, Prasad S. Adusumilli, Preeti K. Parhar, Abraham J. Wu, Kaitlin M. Woo, Ronglai Shen, Michelle S. Ginsberg, Ellen D. Yorke, Kenneth E. Rosenzweig, Valerie W. Rusch, and Lee M. Krug, Memorial Sloan Kettering Cancer Center, Weill Cornell Medical Center, New York, NY; and Daniel R. Gomez, David C. Rice, and Anne S. Tsao, MD Anderson Cancer Center, Houston, TX
| | - Prasad S Adusumilli
- Andreas Rimner, Marjorie G. Zauderer, Prasad S. Adusumilli, Preeti K. Parhar, Abraham J. Wu, Kaitlin M. Woo, Ronglai Shen, Michelle S. Ginsberg, Ellen D. Yorke, Kenneth E. Rosenzweig, Valerie W. Rusch, and Lee M. Krug, Memorial Sloan Kettering Cancer Center, Weill Cornell Medical Center, New York, NY; and Daniel R. Gomez, David C. Rice, and Anne S. Tsao, MD Anderson Cancer Center, Houston, TX
| | - Preeti K Parhar
- Andreas Rimner, Marjorie G. Zauderer, Prasad S. Adusumilli, Preeti K. Parhar, Abraham J. Wu, Kaitlin M. Woo, Ronglai Shen, Michelle S. Ginsberg, Ellen D. Yorke, Kenneth E. Rosenzweig, Valerie W. Rusch, and Lee M. Krug, Memorial Sloan Kettering Cancer Center, Weill Cornell Medical Center, New York, NY; and Daniel R. Gomez, David C. Rice, and Anne S. Tsao, MD Anderson Cancer Center, Houston, TX
| | - Abraham J Wu
- Andreas Rimner, Marjorie G. Zauderer, Prasad S. Adusumilli, Preeti K. Parhar, Abraham J. Wu, Kaitlin M. Woo, Ronglai Shen, Michelle S. Ginsberg, Ellen D. Yorke, Kenneth E. Rosenzweig, Valerie W. Rusch, and Lee M. Krug, Memorial Sloan Kettering Cancer Center, Weill Cornell Medical Center, New York, NY; and Daniel R. Gomez, David C. Rice, and Anne S. Tsao, MD Anderson Cancer Center, Houston, TX
| | - Kaitlin M Woo
- Andreas Rimner, Marjorie G. Zauderer, Prasad S. Adusumilli, Preeti K. Parhar, Abraham J. Wu, Kaitlin M. Woo, Ronglai Shen, Michelle S. Ginsberg, Ellen D. Yorke, Kenneth E. Rosenzweig, Valerie W. Rusch, and Lee M. Krug, Memorial Sloan Kettering Cancer Center, Weill Cornell Medical Center, New York, NY; and Daniel R. Gomez, David C. Rice, and Anne S. Tsao, MD Anderson Cancer Center, Houston, TX
| | - Ronglai Shen
- Andreas Rimner, Marjorie G. Zauderer, Prasad S. Adusumilli, Preeti K. Parhar, Abraham J. Wu, Kaitlin M. Woo, Ronglai Shen, Michelle S. Ginsberg, Ellen D. Yorke, Kenneth E. Rosenzweig, Valerie W. Rusch, and Lee M. Krug, Memorial Sloan Kettering Cancer Center, Weill Cornell Medical Center, New York, NY; and Daniel R. Gomez, David C. Rice, and Anne S. Tsao, MD Anderson Cancer Center, Houston, TX
| | - Michelle S Ginsberg
- Andreas Rimner, Marjorie G. Zauderer, Prasad S. Adusumilli, Preeti K. Parhar, Abraham J. Wu, Kaitlin M. Woo, Ronglai Shen, Michelle S. Ginsberg, Ellen D. Yorke, Kenneth E. Rosenzweig, Valerie W. Rusch, and Lee M. Krug, Memorial Sloan Kettering Cancer Center, Weill Cornell Medical Center, New York, NY; and Daniel R. Gomez, David C. Rice, and Anne S. Tsao, MD Anderson Cancer Center, Houston, TX
| | - Ellen D Yorke
- Andreas Rimner, Marjorie G. Zauderer, Prasad S. Adusumilli, Preeti K. Parhar, Abraham J. Wu, Kaitlin M. Woo, Ronglai Shen, Michelle S. Ginsberg, Ellen D. Yorke, Kenneth E. Rosenzweig, Valerie W. Rusch, and Lee M. Krug, Memorial Sloan Kettering Cancer Center, Weill Cornell Medical Center, New York, NY; and Daniel R. Gomez, David C. Rice, and Anne S. Tsao, MD Anderson Cancer Center, Houston, TX
| | - David C Rice
- Andreas Rimner, Marjorie G. Zauderer, Prasad S. Adusumilli, Preeti K. Parhar, Abraham J. Wu, Kaitlin M. Woo, Ronglai Shen, Michelle S. Ginsberg, Ellen D. Yorke, Kenneth E. Rosenzweig, Valerie W. Rusch, and Lee M. Krug, Memorial Sloan Kettering Cancer Center, Weill Cornell Medical Center, New York, NY; and Daniel R. Gomez, David C. Rice, and Anne S. Tsao, MD Anderson Cancer Center, Houston, TX
| | - Anne S Tsao
- Andreas Rimner, Marjorie G. Zauderer, Prasad S. Adusumilli, Preeti K. Parhar, Abraham J. Wu, Kaitlin M. Woo, Ronglai Shen, Michelle S. Ginsberg, Ellen D. Yorke, Kenneth E. Rosenzweig, Valerie W. Rusch, and Lee M. Krug, Memorial Sloan Kettering Cancer Center, Weill Cornell Medical Center, New York, NY; and Daniel R. Gomez, David C. Rice, and Anne S. Tsao, MD Anderson Cancer Center, Houston, TX
| | - Kenneth E Rosenzweig
- Andreas Rimner, Marjorie G. Zauderer, Prasad S. Adusumilli, Preeti K. Parhar, Abraham J. Wu, Kaitlin M. Woo, Ronglai Shen, Michelle S. Ginsberg, Ellen D. Yorke, Kenneth E. Rosenzweig, Valerie W. Rusch, and Lee M. Krug, Memorial Sloan Kettering Cancer Center, Weill Cornell Medical Center, New York, NY; and Daniel R. Gomez, David C. Rice, and Anne S. Tsao, MD Anderson Cancer Center, Houston, TX
| | - Valerie W Rusch
- Andreas Rimner, Marjorie G. Zauderer, Prasad S. Adusumilli, Preeti K. Parhar, Abraham J. Wu, Kaitlin M. Woo, Ronglai Shen, Michelle S. Ginsberg, Ellen D. Yorke, Kenneth E. Rosenzweig, Valerie W. Rusch, and Lee M. Krug, Memorial Sloan Kettering Cancer Center, Weill Cornell Medical Center, New York, NY; and Daniel R. Gomez, David C. Rice, and Anne S. Tsao, MD Anderson Cancer Center, Houston, TX
| | - Lee M Krug
- Andreas Rimner, Marjorie G. Zauderer, Prasad S. Adusumilli, Preeti K. Parhar, Abraham J. Wu, Kaitlin M. Woo, Ronglai Shen, Michelle S. Ginsberg, Ellen D. Yorke, Kenneth E. Rosenzweig, Valerie W. Rusch, and Lee M. Krug, Memorial Sloan Kettering Cancer Center, Weill Cornell Medical Center, New York, NY; and Daniel R. Gomez, David C. Rice, and Anne S. Tsao, MD Anderson Cancer Center, Houston, TX
| |
Collapse
|
31
|
Maggio A, Cutaia C, Di Dia A, Bresciani S, Miranti A, Poli M, Del Mastro E, Garibaldi E, Gabriele P, Stasi M. Tomotherapy PET-guided dose escalation: A dosimetric feasibility study for patients with malignant pleural mesothelioma. Strahlenther Onkol 2016; 192:102-8. [PMID: 26453534 DOI: 10.1007/s00066-015-0901-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2015] [Accepted: 09/15/2015] [Indexed: 01/15/2023]
Abstract
AIM The aim of this study was to investigate whether a safe escalation of the dose to the pleural cavity and PET/CT-positive areas in patients with unresectable malignant pleural mesothelioma (MPM) is possible using helical tomotherapy (HT). MATERIAL AND METHODS We selected 12 patients with MPM. Three planning strategies were investigated. In the first strategy (standard treatment), treated comprised a prescribed median dose to the planning target volume (PTV) boost (PTV1) of 64.5 Gy (range: 56 Gy/28 fractions to 66 Gy/30 fractions) and 51 Gy (range: 50.4 Gy/28 fractions to 54 Gy/30 fractions) to the pleura PTV (PTV2). Thereafter, for each patient, two dose escalation plans were generated prescribing 62.5 and 70 Gy (2.5 and 2.8 Gy/fraction, respectively) to the PTV1 and 56 Gy (2.24 Gy/fraction) to the PTV2, in 25 fractions. Dose-volume histogram (DVH) constraints and normal tissue complication probability (NTCP) calculations were used to evaluate the differences between the plans. RESULTS For all plans, the 95 % PTVs received at least 95 % of the prescribed dose. For all patients, it was possible to perform the dose escalation in accordance with the Quantitative Analysis of Normal Tissue Effects in the Clinic (QUANTEC) constraints for organs at risk (OARs). The average contralateral lung dose was < 8 Gy. NTCP values for OARs did not increase significantly compared with the standard treatment (p > 0.05), except for the ipsilateral lung. For all plans, the lung volume ratio was strongly correlated with the V20, V30, and V40 DVHs of the lung (p < 0.0003) and with the lung mean dose (p < 0.0001). CONCLUSION The results of this study suggest that by using HT it is possible to safely escalate the dose delivery to at least 62.5 Gy in PET-positive areas while treating the pleural cavity to 56 Gy in 25 fractions without significantly increasing the dose to the surrounding normal organs.
Collapse
Affiliation(s)
- Angelo Maggio
- Medical Physics, Candiolo Cancer Institute - FPO, IRCCS, Turin, Italy.
| | - Claudia Cutaia
- Medical Physics, Candiolo Cancer Institute - FPO, IRCCS, Turin, Italy
| | - Amalia Di Dia
- Medical Physics, Candiolo Cancer Institute - FPO, IRCCS, Turin, Italy
| | - Sara Bresciani
- Medical Physics, Candiolo Cancer Institute - FPO, IRCCS, Turin, Italy
| | - Anna Miranti
- Medical Physics, Candiolo Cancer Institute - FPO, IRCCS, Turin, Italy
| | - Matteo Poli
- Medical Physics, Candiolo Cancer Institute - FPO, IRCCS, Turin, Italy
| | - Elena Del Mastro
- Radiotherapy Department, Candiolo Cancer Institute - FPO, IRCCS, Turin, Italy
| | | | - Pietro Gabriele
- Radiotherapy Department, Candiolo Cancer Institute - FPO, IRCCS, Turin, Italy
| | - Michele Stasi
- Medical Physics, Candiolo Cancer Institute - FPO, IRCCS, Turin, Italy
| |
Collapse
|
32
|
Thieke C, Nicolay NH, Sterzing F, Hoffmann H, Roeder F, Safi S, Debus J, Huber PE. Long-term results in malignant pleural mesothelioma treated with neoadjuvant chemotherapy, extrapleural pneumonectomy and intensity-modulated radiotherapy. Radiat Oncol 2015; 10:267. [PMID: 26715491 PMCID: PMC4696301 DOI: 10.1186/s13014-015-0575-5] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2015] [Accepted: 12/18/2015] [Indexed: 12/14/2022] Open
Abstract
Introduction We investigated the clinical outcome and the toxicity of trimodal therapy of malignant pleural mesothelioma (MPM) treated with neoadjuvant chemotherapy, extrapleural pneumonectomy (EPP) and adjuvant intensity-modulated radiotherapy (IMRT). Methods Chemotherapy regimens included Cisplatin/Pemetrexed, Carboplatin/Pemetrexed and Cisplatin/Gemcitabine, followed by EPP. 62 patients completed the adjuvant radiotherapy. IMRT was carried out in two techniques, either step&shoot or helical tomotherapy. Median target dose was 48 Gy to 54 Gy. Toxicity was scored with the Common Terminology Criteria (CTC) for Adverse Events. We used Kaplan-Meier method to estimate actuarial rate of locoregional control (LRC), distant control (DC) and overall survival (OS), measured from the date of surgery. Rates were compared using the logrank test. For multivariate analysis the Cox proportional hazard model was used. Results The median OS, LRC and DC times were 20.4, 31.4 and 21.4 months. The 1-, 2-, 3-year OS rates were 63, 42, 28 %, the LRC rates were 81, 60, 40 %, and the DC rates were 62, 48, 41 %. We observed no CTC grade 4 or grade 5 toxicity. Step&shoot and helical tomotherapy were equivalent both in dosimetric characteristics and clinical outcome. Biphasic tumor histology was associated with worse clinical outcome compared to epitheloid histology. Conclusions Mature clinical results of trimodal treatment for MPM were presented. They indicate that hemithoracic radiotherapy after EPP can be safely administered by either step&shoot IMRT and tomotherapy. However, the optimal prospective patient selection for this aggressive trimodal therapy approach remains unclear. This study can serve as a benchmark for current and future therapy concepts for MPM. Electronic supplementary material The online version of this article (doi:10.1186/s13014-015-0575-5) contains supplementary material, which is available to authorized users.
Collapse
Affiliation(s)
- Christian Thieke
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany. .,CCU Radiation Oncology, German Cancer Research Center, Heidelberg, Germany. .,Present address: Department of Radiation Oncology, University of Munich (LMU), Marchioninistr. 15, 81377, Munich, Germany.
| | - Nils H Nicolay
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany.,CCU Radiation Oncology, German Cancer Research Center, Heidelberg, Germany.,CCU Molecular Radiation Oncology, German Cancer Research Center, Heidelberg, Germany
| | - Florian Sterzing
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany.,CCU Radiation Oncology, German Cancer Research Center, Heidelberg, Germany
| | - Hans Hoffmann
- Department of Thoracic Surgery, Thoraxklinik, Heidelberg University Hospital, Heidelberg, Germany
| | - Falk Roeder
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany.,CCU Radiation Oncology, German Cancer Research Center, Heidelberg, Germany.,CCU Molecular Radiation Oncology, German Cancer Research Center, Heidelberg, Germany.,Present address: Department of Radiation Oncology, University of Munich (LMU), Marchioninistr. 15, 81377, Munich, Germany
| | - Seyer Safi
- Department of Thoracic Surgery, Thoraxklinik, Heidelberg University Hospital, Heidelberg, Germany
| | - Juergen Debus
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany.,CCU Radiation Oncology, German Cancer Research Center, Heidelberg, Germany
| | - Peter E Huber
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany. .,CCU Radiation Oncology, German Cancer Research Center, Heidelberg, Germany. .,CCU Molecular Radiation Oncology, German Cancer Research Center, Heidelberg, Germany.
| |
Collapse
|
33
|
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.
Collapse
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
| |
Collapse
|
34
|
Wolf AS, Flores RM. Multimodality therapy for malignant pleural mesothelioma: surgery plus chemoradiotherapy? Lung Cancer Manag 2015. [DOI: 10.2217/lmt.15.16] [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, well known for its association with asbestos exposure, is an aggressive cancer of the pleura with poor prognosis if left untreated. There is no defined standard of care, but with curative surgery-based multimodality therapy, long-term survival has been documented. In addition to radiation and/or chemotherapy, multimodality therapy includes one of two operations (extrapleural pneumonectomy or radical pleurectomy/decortication) performed with the goal of resecting all gross disease. Ongoing trials are evaluating various treatment strategies involving radical resection, chemotherapy, radiation, intracavitary chemotherapy, photodynamic therapy and immunologic/biologic agents. Improvement in early diagnosis, targeted treatment and adjuvant therapy to control micrometastatic disease are needed to improve outcomes for patients with this challenging disease.
Collapse
Affiliation(s)
- Andrea S Wolf
- Department of Thoracic Surgery, Mount Sinai Health System, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, Box 1023, NY 10029, USA
| | - Raja M Flores
- Department of Thoracic Surgery, Mount Sinai Health System, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, Box 1023, NY 10029, USA
| |
Collapse
|
35
|
Kishan AU, Cameron RB, Wang PC, Alexander S, Qi SX, Low DA, Kupelian PA, Steinberg ML, Lee JM, Selch MT, Lee P. Tomotherapy improves local control and changes failure patterns in locally advanced malignant pleural mesothelioma. Pract Radiat Oncol 2015; 5:366-73. [PMID: 26432677 DOI: 10.1016/j.prro.2015.07.010] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2015] [Revised: 07/17/2015] [Accepted: 07/30/2015] [Indexed: 12/31/2022]
Abstract
PURPOSE The purpose of the study was to determine whether intensity modulated radiation therapy delivered via helical tomotherapy improves local control (LC) after pleurectomy/decortication (P/D) for malignant pleural mesothelioma compared with 3-dimensional conformal radiation therapy (3D-CRT). METHODS AND MATERIALS Forty-five consecutive patients were treated with adjuvant radiation to 45 Gy in 1.8 Gy fractions after P/D between 2006 and 2014; 23 received 3D-CRT, and 22 received tomotherapy. Kaplan-Meier analysis was used to calculate overall survival, time to in-field or local failure (LF), and time to out-of-field failure. The Student t test and Fisher exact test were used to detect between-group differences. RESULTS Median follow-up time was 19.4 months and 12.7 months for the 3D-CRT and tomotherapy groups, respectively. Eighty-two percent of patients had T3/T4 disease, and 64% had positive nodes; 17.4% and 41% of patients in the 3D-CRT and tomotherapy groups had nonepithelioid histology, respectively. Mean planning target volume dose, percentage of planning target volume receiving 100% of the prescription dose, and lung doses were significantly greater with tomotherapy (P < .05), but toxicity rates (including radiation pneumonitis rates) were equivalent. LC was significantly improved with tomotherapy on Kaplan-Meier analysis with outcomes censored at 2 years (P < .05); uncensored, this became a trend (P = .06). Median time to LF was 19 months with tomotherapy and 10.9 months in 3D-CRT (the latter interval being less than the median follow-up in the tomotherapy group). On univariate analysis, treatment modality was the only significant predictor of LC (P < .05). Isolated LF was significantly more frequent with 3D-CRT (P < .05). Conversely, isolated out-of-field failure was significantly more frequent with tomotherapy (P < .05). Overall survival and out-of-field control were not significantly different. CONCLUSION Tomotherapy after P/D for malignant pleural mesothelioma is associated with improved target coverage that translates into improved LC compared with 3D-CRT. This is related to a change in failure patterns, with isolated LF being more common in the 3D-CRT group and isolated out-of-field failures predominating in the tomotherapy group.
Collapse
Affiliation(s)
- Amar U Kishan
- Department of Radiation Oncology, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California
| | - Robert B Cameron
- Division of Thoracic Surgery, Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Pin-Chieh Wang
- Department of Radiation Oncology, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California
| | - Sherri Alexander
- Department of Radiation Oncology, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California
| | - Sharon X Qi
- Department of Radiation Oncology, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California
| | - Daniel A Low
- Department of Radiation Oncology, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California
| | - Patrick A Kupelian
- Department of Radiation Oncology, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California
| | - Michael L Steinberg
- Department of Radiation Oncology, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California
| | - Jay M Lee
- Division of Thoracic Surgery, Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Michael T Selch
- Department of Radiation Oncology, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California
| | - Percy Lee
- Department of Radiation Oncology, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California.
| |
Collapse
|
36
|
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.
Collapse
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
| |
Collapse
|
37
|
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.
Collapse
|
38
|
Fay M, Poole CM, Pratt G. Recent advances in radiotherapy for thoracic tumours. J Thorac Dis 2014; 5 Suppl 5:S551-5. [PMID: 24163747 DOI: 10.3978/j.issn.2072-1439.2013.08.46] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2013] [Accepted: 08/19/2013] [Indexed: 01/01/2023]
Abstract
Radiation Oncology technology has continued to advance at a rapid rate and is bringing significant benefits to patients. This review outlines some of the advances in technology and radiotherapy treatment of thoracic cancers including brachytherapy, stereotactic radiotherapy, tomotherapy and intensity modulated radiotherapy. The importance of functional imaging with PET and management of movement are highlighted. Most of the discussion relates to non-small cell lung cancer but management of mesothelioma and small cell lung cancer are also covered. This technology has substantial benefits to patients in terms of decreasing toxicity both in the short and longer term.
Collapse
Affiliation(s)
- Michael Fay
- Division of Oncology, Royal Brisbane and Women's Hospital, Queensland Health, Brisbane, Australia; ; School of Medicine, University of Queensland, Brisbane, Australia; ; Visiting Scientist, Preclinical Molecular Imaging, Eberhard Karls Universität Tübingen, Germany
| | | | | |
Collapse
|
39
|
Corcoran JP, Hallifax R, Rahman NM. Advances in the management of pleural disease. Expert Rev Respir Med 2013; 7:499-513. [PMID: 24138694 DOI: 10.1586/17476348.2013.838016] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Pleural disease affects over 3000 people per million population annually. Consequently, it represents a significant proportion of the respiratory physician's workload and can present to clinicians of all backgrounds in primary and secondary care. Pleural effusions have been reported in association with over 50 different conditions; some related to specific pulmonary pathologies, but many being manifestations of multisystem disease. The burden that conditions such as pleural infection; malignant pleural disease; and pneumothorax impose on patients and health care systems is enormous and growing. As such, a clear understanding of these key conditions is crucial to any physician regardless of the specialty. This article addresses a number of areas relating to pleural disease, providing an overview of the diagnostic and therapeutic advances that have been made in our understanding of pleural pathology in recent years. The directions that future research in this important area of respiratory medicine might take will also be discussed.
Collapse
Affiliation(s)
- John P Corcoran
- Oxford Centre for Respiratory Medicine, Oxford University Hospitals, Oxford, OX3 7LE, UK and
| | | | | |
Collapse
|
40
|
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]
|
41
|
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
| | | |
Collapse
|
42
|
Cao C, Tian D, Manganas C, Matthews P, Yan TD. Systematic review of trimodality therapy for patients with malignant pleural mesothelioma. Ann Cardiothorac Surg 2013; 1:428-37. [PMID: 23977533 DOI: 10.3978/j.issn.2225-319x.2012.11.07] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2012] [Accepted: 11/15/2012] [Indexed: 12/11/2022]
Abstract
BACKGROUND Malignant pleural mesothelioma (MPM) is an aggressive form of cancer arising from the pleural mesothelium. Trimodality therapy (TMT) involving extrapleural pneumonectomy with neoadjuvant or adjuvant chemotherapy and adjuvant radiotherapy is a recognized treatment option with a curative intent. Despite encouraging results from institutional studies, TMT in the treatment of MPM remains controversial. The present systematic review aims to assess the safety and efficacy of TMT in the current literature. METHODS A systematic review was performed using five electronic databases from 1 January 1985 to 1 October 2012. Studies were selected independently by two reviewers according to predefined selection criteria. The primary endpoint was overall survival. Secondary endpoints included disease-free survival, disease recurrence, perioperative morbidity and length of stay. RESULTS Sixteen studies were included for quantitative assessment, including one randomized controlled trial and five prospective series. Median overall survival ranged from 12.8-46.9 months. Disease-free survival ranged from 10-16.3 months. Perioperative mortality ranged from 0-12.5%. Overall perioperative morbidity ranged from 50-82.6% and the average length of stay was 9-14 days. CONCLUSIONS Outcomes of patients who underwent TMT in the current literature appeared to be inconsistent. Four prospective series involving a standardised treatment regimen with neoadjuvant chemotherapy indicated encouraging results based on intention-to-treat analysis. However, a small study assessing the feasibility of conducting a randomized controlled trial for TMT versus conservative treatment reported poor short- and long-term outcomes for patients who underwent pneumonectomy. Overall, results of the present systematic review suggest TMT may offer acceptable perioperative outcomes and long-term survival in selected patients treated in specialized centers.
Collapse
Affiliation(s)
- Christopher Cao
- The Systematic Review Unit, Collaborative Research (CORE) Group, Sydney, Australia; ; Department of Cardiothoracic Surgery, St George Hospital, Sydney, Australia; ; The Baird Institute for Applied Heart and Lung Surgical Research, Sydney, Australia
| | | | | | | | | |
Collapse
|
43
|
Amichetti M, Lorentini S, Tonoli S, Magrini SM. Role of new radiation techniques in the treatment of pleural mesothelioma. Thorac Cancer 2013; 4:219-228. [PMID: 28920252 DOI: 10.1111/1759-7714.12008] [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: 10/18/2012] [Accepted: 10/29/2012] [Indexed: 11/30/2022] Open
Abstract
Malignant pleural mesothelioma (MPM) is an aggressive neoplasm arising from the surface serosal cells of the pleural cavity. Surgery remains the main therapeutic standard in the treatment of MPM with the goal of complete gross cytoreduction of the tumor. Because MPM is a diffuse disease affecting the entire mesothelial lining of the hemithorax, surgery alone can rarely achieve adequate tumor-free resection margins. The surgical choices are pleurectomy/decortication (P/D) or extrapleural pneumonectomy (EPP). Radiotherapy (RT) is usually applied postoperatively with the aim to improve local control. However, the efficacy of RT is limited by the large volume of the target to be irradiated (tumor and pleural cavity) and the radiosensitivity of the nearby organs (heart, liver, lung, spinal cord, and esophagus). These factors have historically limited the effective radiation doses that can be given to the patient. There is no role for radical RT alone, but the role of RT as part of multimodality therapy is discussed. After EPP adjuvant RT to the entire hemithorax can reduce the recurrence rate and is well tolerated if strict limits to the dose to contralateral lung are applied: the V20 and V5 (the percent volume of the lung receiving more than 20Gy and 5Gy of radiation) correlate with increased lung toxicity. The use of modern sophisticated techniques allows good target coverage, more conformal high dose delivery, and clinically relevant normal tissue sparing.
Collapse
Affiliation(s)
- Maurizio Amichetti
- ATreP - Provincial Agency for Proton Therapy and Proton Therapy Unit, S. Chiara Hospital, Trento, Italy
| | - Stefano Lorentini
- ATreP - Provincial Agency for Proton Therapy and Proton Therapy Unit, S. Chiara Hospital, Trento, Italy
| | - Sandro Tonoli
- Department of Radiation Oncology, Spedali Civili di Brescia, Brescia, Italy
| | - Stefano Maria Magrini
- Department of Radiation Oncology, Spedali Civili di Brescia, Brescia, Italy.,Faculty of Medicine, University of Brescia, Brescia, Italy
| |
Collapse
|
44
|
Neumann V, Löseke S, Nowak D, Herth FJF, Tannapfel A. Malignant pleural mesothelioma: incidence, etiology, diagnosis, treatment, and occupational health. DEUTSCHES ARZTEBLATT INTERNATIONAL 2013; 110:319-26. [PMID: 23720698 PMCID: PMC3659962 DOI: 10.3238/arztebl.2013.0319] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/19/2012] [Accepted: 02/21/2013] [Indexed: 12/29/2022]
Abstract
BACKGROUND The incidence of malignant mesothelioma in Germany is about 20 cases per million persons per year. Its association with asbestos exposure, usually occupational, has been unequivocally demonstrated. Even though the industrial use of asbestos was forbidden many years ago, new cases of mesothelioma continue to appear because of the long latency of the disease (median, 50 years). Its diagnosis and treatment still present a major challenge for ambulatory and in-hospital care and will do so for years to come. METHODS This article is based on a selective review of the literature, along with data from the German Mesothelioma Register. RESULTS 1397 people died of mesothelioma in Germany in 2010. A plateau in the incidence of the disease is predicted between 2015 and 2030. Most mesotheliomas arise from the pleura. The histological subtype and the Karnofsky score are the main prognostic factors. Only limited data are now available to guide treatment with a combination of the available methods (chemotherapy, surgery, radiotherapy). The prognosis is still poor, with a median survival time of only 12 months. Symptom control and the preservation of the patient's quality of life are the main aspects of care for patients with mesothelioma. CONCLUSION The incidence of mesothelioma is not expected to drop in the next few years. The available treatments are chemotherapy, surgery, and radiotherapy. Specialized treatment centers now increasingly provide multimodal therapy for treatment of mesothelioma.
Collapse
Affiliation(s)
- Volker Neumann
- German Mesothelioma Register at the Institute of Pathology, Ruhr-University Bochum, Bergmannsheil University Hospital, Germany.
| | | | | | | | | |
Collapse
|