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Malignant Pleural Mesothelioma: Preliminary Toxicity Results of Adjuvant Radiotherapy Hypofractionation in a Prospective Trial (MESO-RT). Cancers (Basel) 2023; 15:cancers15041057. [PMID: 36831400 PMCID: PMC9954648 DOI: 10.3390/cancers15041057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2023] [Revised: 02/01/2023] [Accepted: 02/03/2023] [Indexed: 02/11/2023] Open
Abstract
Malignant Pleural Mesothelioma (MPM) is a rare malignancy with an overall poor prognosis. The standard therapeutic strategy in early-stage disease is trimodality therapy. In this publication, we report the preliminary toxicity results of the first 20 patients treated with accelerated hypofractionated radiotherapy. Between July 2017 to June 2019, 20 MPM patients were enrolled and treated with accelerated hypofractionated radiotherapy using helical tomotherapy and intensity-modulated arc therapy. The prescription dose was 30 Gy in five daily fractions, while an inhomogeneous dose escalation to 40 Gy was prescribed based solely upon the presence of gross residual tumor. Only one case of G3 toxicity was reported, which was a bilateral pneumonitis that occurred two years after treatment probably due to superinfection. Median Time to Progression reached 18.2 months while one- and three-year Overall Survival rates were 85% (95% CI:60.4-94.9) and 49.5% (95% CI:26.5-68.9), respectively. Treatment of the intact lung with pleural intensity-modulated arc irradiation is a novel treatment strategy that appears to be safe, feasible, and without a high grade of lung toxicity. Survival rates and Time to Progression are encouraging.
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De Bondt C, Psallidas I, Van Schil PEY, van Meerbeeck JP. Combined modality treatment in mesothelioma: a systemic literature review with treatment recommendations. Transl Lung Cancer Res 2018; 7:562-573. [PMID: 30450295 DOI: 10.21037/tlcr.2018.10.02] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
In spite of recent progress, malignant pleural mesothelioma (MPM) remains synonymous with poor prognosis. A selected minority (<10%) of patients is eligible for a radical treatment with a combination of systemic chemotherapy (CT) and/or surgery and/or radiotherapy (RT), in an effort to maintain locoregional tumor control after achieving a macroscopically complete resection (MCR). However, as of yet there is no standard of care for this so-called multimodality treatment. As its potential gain is still limited (approximately one year added to overall survival), we must balance its efficacy with its cumulative toxicity. Several combined modality treatment trials are currently ongoing using novel techniques in surgery, RT and/or CT in an attempt to reduce the morbidity and mortality associated with older multimodality treatment protocols. Guidelines are following suit and are now including or mentioning this treatment option. In this systematic review, we analyze the available data in order to address the following questions: Is combined modality better than single modality? What is the optimal regimen within each modality? What is the optimal sequence of combined modality?
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Affiliation(s)
- Charlotte De Bondt
- Department Pulmonology and Thoracic Oncology, Antwerp University and Antwerp University Hospital, Antwerp, Belgium
| | - Ioannis Psallidas
- Oxford Centre for Respiratory Medicine, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Paul E Y Van Schil
- Department Thoracic and Vascular Surgery, Antwerp University and Antwerp University Hospital, Antwerp, Belgium
| | - Jan P van Meerbeeck
- Department Pulmonology and Thoracic Oncology, Antwerp University and Antwerp University Hospital, Antwerp, Belgium
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Kindler HL, Ismaila N, Armato SG, Bueno R, Hesdorffer M, Jahan T, Jones CM, Miettinen M, Pass H, Rimner A, Rusch V, Sterman D, Thomas A, Hassan R. Treatment of Malignant Pleural Mesothelioma: American Society of Clinical Oncology Clinical Practice Guideline. J Clin Oncol 2018; 36:1343-1373. [PMID: 29346042 DOI: 10.1200/jco.2017.76.6394] [Citation(s) in RCA: 262] [Impact Index Per Article: 43.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Purpose To provide evidence-based recommendations to practicing physicians and others on the management of malignant pleural mesothelioma. Methods ASCO convened an Expert Panel of medical oncology, thoracic surgery, radiation oncology, pulmonary, pathology, imaging, and advocacy experts to conduct a literature search, which included systematic reviews, meta-analyses, randomized controlled trials, and prospective and retrospective comparative observational studies published from 1990 through 2017. Outcomes of interest included survival, disease-free or recurrence-free survival, and quality of life. Expert Panel members used available evidence and informal consensus to develop evidence-based guideline recommendations. Results The literature search identified 222 relevant studies to inform the evidence base for this guideline. Recommendations Evidence-based recommendations were developed for diagnosis, staging, chemotherapy, surgical cytoreduction, radiation therapy, and multimodality therapy in patients with malignant pleural mesothelioma. Additional information is available at www.asco.org/thoracic-cancer-guidelines and www.asco.org/guidelineswiki .
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Affiliation(s)
- Hedy L Kindler
- Hedy L. Kindler and Samuel G. Armato III, The University of Chicago, Chicago, IL; Nofisat Ismaila, American Society of Clinical Oncology; Mary Hesdorffer, Mesothelioma Applied Research Foundation, Alexandria, VA; Raphael Bueno, Harvard Medical School, Boston, MA; Thierry Jahan, University of California San Francisco, San Francisco, CA; Clyde Michael Jones, Baptist Cancer Center Physicians Foundation, Memphis, TN; Markku Miettinen, Anish Thomas and Raffit Hassan, Center for Cancer Research, National Cancer Institute, Bethesda, MD; Harvey Pass and Daniel Sterman, New York University Langone Medical Center; and Andreas Rimner and Valerie Rusch, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Nofisat Ismaila
- Hedy L. Kindler and Samuel G. Armato III, The University of Chicago, Chicago, IL; Nofisat Ismaila, American Society of Clinical Oncology; Mary Hesdorffer, Mesothelioma Applied Research Foundation, Alexandria, VA; Raphael Bueno, Harvard Medical School, Boston, MA; Thierry Jahan, University of California San Francisco, San Francisco, CA; Clyde Michael Jones, Baptist Cancer Center Physicians Foundation, Memphis, TN; Markku Miettinen, Anish Thomas and Raffit Hassan, Center for Cancer Research, National Cancer Institute, Bethesda, MD; Harvey Pass and Daniel Sterman, New York University Langone Medical Center; and Andreas Rimner and Valerie Rusch, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Samuel G Armato
- Hedy L. Kindler and Samuel G. Armato III, The University of Chicago, Chicago, IL; Nofisat Ismaila, American Society of Clinical Oncology; Mary Hesdorffer, Mesothelioma Applied Research Foundation, Alexandria, VA; Raphael Bueno, Harvard Medical School, Boston, MA; Thierry Jahan, University of California San Francisco, San Francisco, CA; Clyde Michael Jones, Baptist Cancer Center Physicians Foundation, Memphis, TN; Markku Miettinen, Anish Thomas and Raffit Hassan, Center for Cancer Research, National Cancer Institute, Bethesda, MD; Harvey Pass and Daniel Sterman, New York University Langone Medical Center; and Andreas Rimner and Valerie Rusch, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Raphael Bueno
- Hedy L. Kindler and Samuel G. Armato III, The University of Chicago, Chicago, IL; Nofisat Ismaila, American Society of Clinical Oncology; Mary Hesdorffer, Mesothelioma Applied Research Foundation, Alexandria, VA; Raphael Bueno, Harvard Medical School, Boston, MA; Thierry Jahan, University of California San Francisco, San Francisco, CA; Clyde Michael Jones, Baptist Cancer Center Physicians Foundation, Memphis, TN; Markku Miettinen, Anish Thomas and Raffit Hassan, Center for Cancer Research, National Cancer Institute, Bethesda, MD; Harvey Pass and Daniel Sterman, New York University Langone Medical Center; and Andreas Rimner and Valerie Rusch, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Mary Hesdorffer
- Hedy L. Kindler and Samuel G. Armato III, The University of Chicago, Chicago, IL; Nofisat Ismaila, American Society of Clinical Oncology; Mary Hesdorffer, Mesothelioma Applied Research Foundation, Alexandria, VA; Raphael Bueno, Harvard Medical School, Boston, MA; Thierry Jahan, University of California San Francisco, San Francisco, CA; Clyde Michael Jones, Baptist Cancer Center Physicians Foundation, Memphis, TN; Markku Miettinen, Anish Thomas and Raffit Hassan, Center for Cancer Research, National Cancer Institute, Bethesda, MD; Harvey Pass and Daniel Sterman, New York University Langone Medical Center; and Andreas Rimner and Valerie Rusch, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Thierry Jahan
- Hedy L. Kindler and Samuel G. Armato III, The University of Chicago, Chicago, IL; Nofisat Ismaila, American Society of Clinical Oncology; Mary Hesdorffer, Mesothelioma Applied Research Foundation, Alexandria, VA; Raphael Bueno, Harvard Medical School, Boston, MA; Thierry Jahan, University of California San Francisco, San Francisco, CA; Clyde Michael Jones, Baptist Cancer Center Physicians Foundation, Memphis, TN; Markku Miettinen, Anish Thomas and Raffit Hassan, Center for Cancer Research, National Cancer Institute, Bethesda, MD; Harvey Pass and Daniel Sterman, New York University Langone Medical Center; and Andreas Rimner and Valerie Rusch, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Clyde Michael Jones
- Hedy L. Kindler and Samuel G. Armato III, The University of Chicago, Chicago, IL; Nofisat Ismaila, American Society of Clinical Oncology; Mary Hesdorffer, Mesothelioma Applied Research Foundation, Alexandria, VA; Raphael Bueno, Harvard Medical School, Boston, MA; Thierry Jahan, University of California San Francisco, San Francisco, CA; Clyde Michael Jones, Baptist Cancer Center Physicians Foundation, Memphis, TN; Markku Miettinen, Anish Thomas and Raffit Hassan, Center for Cancer Research, National Cancer Institute, Bethesda, MD; Harvey Pass and Daniel Sterman, New York University Langone Medical Center; and Andreas Rimner and Valerie Rusch, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Markku Miettinen
- Hedy L. Kindler and Samuel G. Armato III, The University of Chicago, Chicago, IL; Nofisat Ismaila, American Society of Clinical Oncology; Mary Hesdorffer, Mesothelioma Applied Research Foundation, Alexandria, VA; Raphael Bueno, Harvard Medical School, Boston, MA; Thierry Jahan, University of California San Francisco, San Francisco, CA; Clyde Michael Jones, Baptist Cancer Center Physicians Foundation, Memphis, TN; Markku Miettinen, Anish Thomas and Raffit Hassan, Center for Cancer Research, National Cancer Institute, Bethesda, MD; Harvey Pass and Daniel Sterman, New York University Langone Medical Center; and Andreas Rimner and Valerie Rusch, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Harvey Pass
- Hedy L. Kindler and Samuel G. Armato III, The University of Chicago, Chicago, IL; Nofisat Ismaila, American Society of Clinical Oncology; Mary Hesdorffer, Mesothelioma Applied Research Foundation, Alexandria, VA; Raphael Bueno, Harvard Medical School, Boston, MA; Thierry Jahan, University of California San Francisco, San Francisco, CA; Clyde Michael Jones, Baptist Cancer Center Physicians Foundation, Memphis, TN; Markku Miettinen, Anish Thomas and Raffit Hassan, Center for Cancer Research, National Cancer Institute, Bethesda, MD; Harvey Pass and Daniel Sterman, New York University Langone Medical Center; and Andreas Rimner and Valerie Rusch, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Andreas Rimner
- Hedy L. Kindler and Samuel G. Armato III, The University of Chicago, Chicago, IL; Nofisat Ismaila, American Society of Clinical Oncology; Mary Hesdorffer, Mesothelioma Applied Research Foundation, Alexandria, VA; Raphael Bueno, Harvard Medical School, Boston, MA; Thierry Jahan, University of California San Francisco, San Francisco, CA; Clyde Michael Jones, Baptist Cancer Center Physicians Foundation, Memphis, TN; Markku Miettinen, Anish Thomas and Raffit Hassan, Center for Cancer Research, National Cancer Institute, Bethesda, MD; Harvey Pass and Daniel Sterman, New York University Langone Medical Center; and Andreas Rimner and Valerie Rusch, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Valerie Rusch
- Hedy L. Kindler and Samuel G. Armato III, The University of Chicago, Chicago, IL; Nofisat Ismaila, American Society of Clinical Oncology; Mary Hesdorffer, Mesothelioma Applied Research Foundation, Alexandria, VA; Raphael Bueno, Harvard Medical School, Boston, MA; Thierry Jahan, University of California San Francisco, San Francisco, CA; Clyde Michael Jones, Baptist Cancer Center Physicians Foundation, Memphis, TN; Markku Miettinen, Anish Thomas and Raffit Hassan, Center for Cancer Research, National Cancer Institute, Bethesda, MD; Harvey Pass and Daniel Sterman, New York University Langone Medical Center; and Andreas Rimner and Valerie Rusch, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Daniel Sterman
- Hedy L. Kindler and Samuel G. Armato III, The University of Chicago, Chicago, IL; Nofisat Ismaila, American Society of Clinical Oncology; Mary Hesdorffer, Mesothelioma Applied Research Foundation, Alexandria, VA; Raphael Bueno, Harvard Medical School, Boston, MA; Thierry Jahan, University of California San Francisco, San Francisco, CA; Clyde Michael Jones, Baptist Cancer Center Physicians Foundation, Memphis, TN; Markku Miettinen, Anish Thomas and Raffit Hassan, Center for Cancer Research, National Cancer Institute, Bethesda, MD; Harvey Pass and Daniel Sterman, New York University Langone Medical Center; and Andreas Rimner and Valerie Rusch, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Anish Thomas
- Hedy L. Kindler and Samuel G. Armato III, The University of Chicago, Chicago, IL; Nofisat Ismaila, American Society of Clinical Oncology; Mary Hesdorffer, Mesothelioma Applied Research Foundation, Alexandria, VA; Raphael Bueno, Harvard Medical School, Boston, MA; Thierry Jahan, University of California San Francisco, San Francisco, CA; Clyde Michael Jones, Baptist Cancer Center Physicians Foundation, Memphis, TN; Markku Miettinen, Anish Thomas and Raffit Hassan, Center for Cancer Research, National Cancer Institute, Bethesda, MD; Harvey Pass and Daniel Sterman, New York University Langone Medical Center; and Andreas Rimner and Valerie Rusch, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Raffit Hassan
- Hedy L. Kindler and Samuel G. Armato III, The University of Chicago, Chicago, IL; Nofisat Ismaila, American Society of Clinical Oncology; Mary Hesdorffer, Mesothelioma Applied Research Foundation, Alexandria, VA; Raphael Bueno, Harvard Medical School, Boston, MA; Thierry Jahan, University of California San Francisco, San Francisco, CA; Clyde Michael Jones, Baptist Cancer Center Physicians Foundation, Memphis, TN; Markku Miettinen, Anish Thomas and Raffit Hassan, Center for Cancer Research, National Cancer Institute, Bethesda, MD; Harvey Pass and Daniel Sterman, New York University Langone Medical Center; and Andreas Rimner and Valerie Rusch, Memorial Sloan Kettering Cancer Center, New York, NY
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Parisi E, Romeo A, Sarnelli A, Ghigi G, Bellia SR, Neri E, Micheletti S, Dipalma B, Arpa D, Furini G, Burgio MA, Genestreti G, Gurioli C, Sanna S, Bovolato P, Rea F, Storme G, Scarpi E, Arienti C, Tesei A, Polico R. High dose irradiation after pleurectomy/decortication or biopsy for pleural mesothelioma treatment. Cancer Radiother 2017; 21:766-773. [PMID: 29132803 DOI: 10.1016/j.canrad.2017.05.007] [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] [Received: 04/10/2017] [Revised: 05/18/2017] [Accepted: 05/19/2017] [Indexed: 12/11/2022]
Abstract
PURPOSE The role played by radiation therapy after pleurectomy/decortication or surgical biopsy in malignant pleural mesothelioma is uncertain. We treated patients with accelerated hypofractionated radiotherapy using helical tomotherapy and intensity-modulated arc therapy in an attempt to keep lung toxicity to a minimum. The present study reports the feasibility and toxicity of this approach. MATERIAL AND METHODS Between 2008 and 2012, 36 patients with malignant pleural mesothelioma underwent accelerated hypofractionated radiotherapy to the hemithorax after pleurectomy/decortication (19 patients) or biopsy (17 patients). The prescription dose was 25Gy in five fractions over 5 consecutive days. RESULTS We observed three patients with G3 pneumonitis, five cases of grade 2 dyspnea and six cases of grade 2 cough. The median follow-up was 37 months (range: 3-54 months). The median overall survival for patients who underwent pleurectomy/decortication followed by radiotherapy was 21.6 months [95% confidence interval (95% CI): 15.5-24.1] compared to 19.4 months for patients not submitted to surgery. CONCLUSION Treatment of intact lung with pleural intensity-modulated arc irradiation in malignant pleural mesothelioma patients with malignant pleural mesothelioma proved safe and feasible, with an acceptable rate of pneumonitis. Survival rates were encouraging for both biopsy-only and pleurectomy/decortication groups. We are currently conducting a phase II dose escalation trial in a similar patient setting to prospectively evaluate the impact of radiotherapy on toxicity, disease-free survival and overall survival.
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Affiliation(s)
- E Parisi
- Radiotherapy Unit, Istituto Scientifico Romagnolo per lo Studio e la Cura dei Tumori (IRST) IRCCS, via P. Maroncelli 40, 47014 Meldola, Italy.
| | - A Romeo
- Radiotherapy Unit, Istituto Scientifico Romagnolo per lo Studio e la Cura dei Tumori (IRST) IRCCS, via P. Maroncelli 40, 47014 Meldola, Italy
| | - A Sarnelli
- Medical Physics Unit, Istituto Scientifico Romagnolo per lo Studio e la Cura dei Tumori (IRST) IRCCS, Meldola, Italy
| | - G Ghigi
- Medical Physics Unit, Istituto Scientifico Romagnolo per lo Studio e la Cura dei Tumori (IRST) IRCCS, Meldola, Italy
| | - S R Bellia
- Radiotherapy Unit, Istituto Scientifico Romagnolo per lo Studio e la Cura dei Tumori (IRST) IRCCS, via P. Maroncelli 40, 47014 Meldola, Italy
| | - E Neri
- Radiotherapy Unit, Istituto Scientifico Romagnolo per lo Studio e la Cura dei Tumori (IRST) IRCCS, via P. Maroncelli 40, 47014 Meldola, Italy
| | - S Micheletti
- Radiotherapy Unit, Istituto Scientifico Romagnolo per lo Studio e la Cura dei Tumori (IRST) IRCCS, via P. Maroncelli 40, 47014 Meldola, Italy
| | - B Dipalma
- Radiotherapy Unit, Istituto Scientifico Romagnolo per lo Studio e la Cura dei Tumori (IRST) IRCCS, via P. Maroncelli 40, 47014 Meldola, Italy
| | - D Arpa
- Radiotherapy Unit, Istituto Scientifico Romagnolo per lo Studio e la Cura dei Tumori (IRST) IRCCS, via P. Maroncelli 40, 47014 Meldola, Italy
| | - G Furini
- Medical Physics Unit, Istituto Scientifico Romagnolo per lo Studio e la Cura dei Tumori (IRST) IRCCS, Meldola, Italy
| | - M A Burgio
- Department of Medical Oncology, Istituto Scientifico Romagnolo per lo Studio e la Cura dei Tumori (IRST) IRCCS, Meldola, Italy
| | - G Genestreti
- Department of Medical Oncology, Bellaria Hospital, Bologna, Italy
| | - C Gurioli
- Department of Pneumology, Morgagni-Pierantoni Hospital, Forlì, Italy
| | - S Sanna
- Department of Thoracic Surgery, Morgagni-Pierantoni Hospital, Forlì, Italy
| | - P Bovolato
- Department of Thoracic Surgery, Spedali Civili di Brescia, Brescia, Italy
| | - F Rea
- Department of Thoracic Surgery, Azienda Ospedaliera Padova, University of Padua, Padua, Italy
| | - G Storme
- Department of Radiation Oncology, Oncologic Centre UZ, Brussels, Belgium
| | - E Scarpi
- Unit of Biostatistics and Clinical Trials, Istituto Scientifico Romagnolo per lo Studio e la Cura dei Tumori (IRST) IRCCS, Meldola, Italy
| | - C Arienti
- Biosciences Laboratory, Istituto Scientifico Romagnolo per lo Studio e la Cura dei Tumori (IRST) IRCCS, Meldola, Italy
| | - A Tesei
- Biosciences Laboratory, Istituto Scientifico Romagnolo per lo Studio e la Cura dei Tumori (IRST) IRCCS, Meldola, Italy
| | - R Polico
- Radiotherapy Unit, Istituto Scientifico Romagnolo per lo Studio e la Cura dei Tumori (IRST) IRCCS, via P. Maroncelli 40, 47014 Meldola, Italy
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The role of radical radiotherapy in the management of malignant pleural mesothelioma: A systematic review. Radiother Oncol 2017; 125:1-12. [PMID: 28859932 DOI: 10.1016/j.radonc.2017.08.003] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2017] [Revised: 05/19/2017] [Accepted: 08/05/2017] [Indexed: 11/24/2022]
Abstract
Malignant pleural mesothelioma (MPM) is a devastating disease with limited treatment options and a dismal prognosis. Attempts to employ radical radiotherapy in this disease have been limited by the complex shape of the pleura and the dose restrictions necessitated by the close proximity of radiosensitive structures. Recent shifts towards a 'lung sparing' surgical approach in MPM have further heightened these challenges. The aim of this systematic review is to assess recent advances in radiotherapy planning and delivery, to ascertain how these developments have impacted on the feasibility of delivering photon-based, high-dose radiotherapy with radical intent in MPM. Three electronic databases were searched and a total of 249 articles reviewed. The challenge of generating high quality, practice-defining data for diseases such as MPM was highlighted by the identification of just two randomised studies. Much of the literature consisted of low quality, retrospective data with small cohorts and inconsistent reporting on radiotherapy techniques and dosimetry. Nevertheless, a number of prospective phase II studies were identified to suggest that radical doses of radiotherapy can be delivered safely after a lung sparing procedure in MPM, reporting encouraging survival data and acceptable levels of toxicity.
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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.
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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
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7
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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.
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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.
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Shaikh F, Rimner A. Optimizing hemithoracic pleural intensity-modulated radiation therapy for malignant pleural mesothelioma. Lung Cancer Manag 2015. [DOI: 10.2217/lmt.15.15] [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
The treatment of malignant pleural mesothelioma (MPM) remains challenging. Optimal management for resectable patients involves an aggressive approach, frequently using trimodality therapy. Historically, poor tumor control and profound pulmonary toxicity prevented conventional radiation therapy from being widely used. The advent of intensity-modulated radiation therapy was a major development in the delivery of radiation for MPM in the adjuvant setting, improving target coverage and dose homogeneity while maintaining acceptable toxicity profiles. Nevertheless, there remains a significant risk of severe pulmonary toxicity, ameliorated by careful target delineation, treatment planning and proactive toxicity management. Innovative technology, including arc therapy, simultaneous integrated boosts and proton therapy as well as neodjuvant delivery of radiation followed by pneumonectomy are being actively investigated to improve outcomes in the treatment of MPM.
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Affiliation(s)
- Fauzia Shaikh
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, 1275 York Ave., NY 10065, USA
| | - Andreas Rimner
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, 1275 York Ave., NY 10065, USA
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Kimura T, Doi Y, Nakashima T, Imano N, Katsuta T, Takahashi S, Kenjo M, Ozawa S, Murakami Y, Nagata Y. Clinical experience of volumetric modulated arc therapy for malignant pleural mesothelioma after extrapleural pneumonectomy. JOURNAL OF RADIATION RESEARCH 2015; 56:315-324. [PMID: 25599996 PMCID: PMC4380050 DOI: 10.1093/jrr/rru102] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 06/19/2014] [Revised: 09/30/2014] [Accepted: 10/05/2014] [Indexed: 06/04/2023]
Abstract
The purpose of this study was to evaluate the efficacy and safety of volumetric modulated arc therapy (VMAT) after extrapleural pneumonectomy (EPP) in patients with malignant pleural mesothelioma (MPM). A total of 15 patients who received VMAT after EPP were enrolled. All patients were males, and the median age was 67 years (Stage IB in two, II in six, and III in seven patients). The clinical target volume (CTV) included the entire preoperative ipsilateral hemithorax and involved nodal stations. The CTV was generally expanded by 10-15 mm beyond the planning target volume (PTV). The dose prescription was designed to cover 95% of the PTV with 54 Gy in 30 fractions. The median follow-up period was 11 months. Treatment-related toxicities were evaluated by Common Terminology Criteria for Adverse Events (CTCAE) ver. 4. One-year local control, disease-free survival, and overall survival rates were 55.7% [95% confidence interval (CI): 25.6-85.8%], 29.3% (95% CI: 5.3-53.3%), and 43.1% (95% CI: 17.1-69.0%), respectively. According to the histological analysis, the one-year LC rate was significantly worse in patients with non-epithelial type (biphasic and sarcomatoid types) than in patients with epithelial type [epithelial type: 83.3% (95% CI, 53.5-100%), non-epithelial type: 0% (95% CI, 0%), P = 0.0011]. Grade 3 pneumonitis after VMAT was observed in three patients (20.0%); however, no patients died of pulmonary toxicity. VMAT appears to be relatively safe for patients with MPM after EPP because of the low pulmonary dose.
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Affiliation(s)
- Tomoki Kimura
- Department of Radiation Oncology, Graduate School of Biomedical Sciences, Hiroshima University, 1-2-3, Kasumi, Minami-ku, Hiroshima City, 734-8551, Japan
| | - Yoshiko Doi
- Department of Radiation Oncology, Graduate School of Biomedical Sciences, Hiroshima University, 1-2-3, Kasumi, Minami-ku, Hiroshima City, 734-8551, Japan
| | - Takeo Nakashima
- Division of Radiation Oncology, Hiroshima University Hospital
| | - Nobuki Imano
- Department of Radiation Oncology, Graduate School of Biomedical Sciences, Hiroshima University, 1-2-3, Kasumi, Minami-ku, Hiroshima City, 734-8551, Japan
| | - Tsuyoshi Katsuta
- Department of Radiation Oncology, Graduate School of Biomedical Sciences, Hiroshima University, 1-2-3, Kasumi, Minami-ku, Hiroshima City, 734-8551, Japan
| | | | - Masahiro Kenjo
- Department of Radiation Oncology, Graduate School of Biomedical Sciences, Hiroshima University, 1-2-3, Kasumi, Minami-ku, Hiroshima City, 734-8551, Japan
| | - Shuichi Ozawa
- Department of Radiation Oncology, Graduate School of Biomedical Sciences, Hiroshima University, 1-2-3, Kasumi, Minami-ku, Hiroshima City, 734-8551, Japan
| | - Yuji Murakami
- Department of Radiation Oncology, Graduate School of Biomedical Sciences, Hiroshima University, 1-2-3, Kasumi, Minami-ku, Hiroshima City, 734-8551, Japan
| | - Yasushi Nagata
- Department of Radiation Oncology, Graduate School of Biomedical Sciences, Hiroshima University, 1-2-3, Kasumi, Minami-ku, Hiroshima City, 734-8551, Japan
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Yang ZX, Shen JT, Li YP, Zhao K, Shi CH, Xiao Y, Yu JJ, Guo WD, Li CC, Wang YQ, Li XL. Helical tomotherapy for cancer treatment: a rapid health technology assessment. J Evid Based Med 2014; 7:192-218. [PMID: 25156336 DOI: 10.1111/jebm.12109] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2013] [Accepted: 06/09/2014] [Indexed: 02/05/2023]
Abstract
OBJECTIVES Helical tomotherapy (HT) can be applied to treat complex malignant cancer with high-precise radiotherapy, and it can reduce the damage to normal tissues and improve treatment effects. But the procurement of HT must be approved by relevant departments of administration affairs. This study, appointed by the National Health and Family Planning Commission of China and undertook by the National Health Development Research Center and the Chinese Evidence-Based Medicine Centre, was aimed to rapidly assess the effectiveness, safety, costs, and applicability of HT, so as to provide currently available best evidence for decision-makers of health policies. METHODS We electronically searched databases including PubMed, EMbase, The Cochrane Library, CNKI, WanFang Data, VIP, CBM, and other professional websites. Two reviewer independently screened literature according to the inclusion and exclusion criteria, extracted data, assessed quality, and then performed descriptive analysis. RESULTS (i) We finally included 150 studies, encompassing 5 HTAs, 18 CCTs, and 127 observational studies. (ii) The included HTAs were published during 2006-2009, providing fairly less evidence of low quality and the results of 145 primary studies showed that: HT had been used mainly in the treatments of 14 kinds of cancer, with low total toxicity and high survival rates. Although the quality of the included studies was poor, there was much evidence about prostate cancer, head and neck cancer, nasopharynx cancer, cervical cancer, lung cancer and liver cancer, with enough sample and fairly reliable results in HT efficacy and safety. And (iii) a total of 56 clinical trials were registered in Clinicaltrials.gov, most of which were registered by the occident. Among them, 9 were completed but the results had not been published yet. CONCLUSIONS The evidence of this study showed that, HT is safe and effective in clinic. But the abovementioned conclusion needs to be verified by conducting more high-quality studies with long-term follow-up. The costs of HT in procurement, maintenance, and application are high; and the skills, training, and qualification of operators are required. We suggest that the procurement of HT should be reduced; it should be allocated rationally and effectively used after comprehensive assessment in China's cancer epidemiology characteristics, health resource allocation, disease burden, medical service level, etc.; and also high-quality studies with long-term follow-up should be financially supported on the basis of establishing projects, so as to provide local evidence and consistently guide and improve scientific decision-making.
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Affiliation(s)
- Zong Xia Yang
- Chinese Evidence-Based Medicine Centre, West China Hospital, Sichuan University, Chengdu, China
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Helou J, Clément-Colmou K, Sylvestre A, Campion L, Amessis M, Zefkili S, Raphael J, Bonnette P, Le Pimpec Barthes F, Périgaud C, Mahé MA, Giraud P. [Helical tomotherapy in the treatment of malignant pleural mesothelioma: The impact of low doses on pulmonary and oesophageal toxicity]. Cancer Radiother 2013; 17:755-62. [PMID: 24269017 DOI: 10.1016/j.canrad.2013.06.045] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2013] [Revised: 05/17/2013] [Accepted: 06/24/2013] [Indexed: 10/26/2022]
Abstract
PURPOSE To evaluate the adjuvant treatment of malignant pleural mesothelioma by helical tomotherapy and the impact of low doses on esophageal and pulmonary toxicity. PATIENTS AND METHODS Between June 2007 and May 2011, 29 patients diagnosed with malignant pleural mesothelioma received adjuvant radiotherapy by helical tomotherapy. The median age was 63 years (34-72). Histologically, 83 % of patients had epithelioid malignant pleural mesothelioma. Clinically, 45 % of patients were T3 and 55 % N0. Eighty six percent of the patients were treated by extrapleural pneumonectomy and 35 % received neoadjuvant chemotherapy with platinum and pemetrexed. The median dose in the pneumonectomy cavity was 50Gy at 2Gy/fraction. RESULTS The mean follow-up was 2.3 years after diagnosis. Overall survival at 1 and 2 years was 65 and 36 % respectively. The median survival from diagnosis was 18 months. Median lung volumes receiving 2, 5, 10, 13, 15 and 20Gy (V2, V5, V10, V13, V15 and V20) were 100, 98, 52, 36, 19 and 5 %. The median of the mean remaining lung dose was 11Gy. Two patients died of pulmonary complications, three patients had grade 3 lung toxicity, while esophageal grade 3-4 toxicity was observed in three other patients. No significant impact of clinical characteristics and dosimetric parameters were found on pulmonary toxicity, however a V10≥50 %, a V15≥15 % and mean lung dose of 10Gy or more had a tendency to be predictive of pulmonary toxicity (P<0.1). Moreover, in our analysis, the mean lung dose seems to have a significant impact on esophageal toxicity (P=0.03) as well as low doses to the controlateral lung: V5, V10 and V13 (P<0.05). CONCLUSION Helical tomotherapy is a promising technique in the multimodality treatment of malignant pleural mesothelioma. Low doses received by the contralateral lung appear to be the limiting factor. A dosimetric comparison with volumetric modulated arctherapy techniques would be interesting in this setting.
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Affiliation(s)
- J Helou
- Service d'oncologie radiothérapie, hôpital européen Georges-Pompidou, 20, rue Leblanc, 75015 Paris, France.
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Rimner A, Rosenzweig KE. Novel radiation therapy approaches in malignant pleural mesothelioma. Ann Cardiothorac Surg 2013; 1:457-61. [PMID: 23977536 DOI: 10.3978/j.issn.2225-319x.2012.10.07] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2012] [Accepted: 10/26/2012] [Indexed: 11/14/2022]
Affiliation(s)
- Andreas Rimner
- Department of Radiation Oncology, Memorial Sloan-Kettering Cancer Center, New York, NY, USA
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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.
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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
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Techniques of surgery and radiotherapy for multimodal treatment of pleural mesothelioma. J Thorac Oncol 2011; 6:2146. [PMID: 22088997 DOI: 10.1097/jto.0b013e3182377281] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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