1
|
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.
Collapse
|
2
|
Maerz M, Treutwein M, Nabo J, Dobler B. Three-dimensional printers applied for the production of beam blocks in total body irradiation treatment. J Appl Clin Med Phys 2022; 23:e13592. [PMID: 35290701 PMCID: PMC9121048 DOI: 10.1002/acm2.13592] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2021] [Revised: 01/20/2022] [Accepted: 03/01/2022] [Indexed: 12/02/2022] Open
Abstract
Purpose Total body irradiation (TBI) in extended source surface distance (SSD) is a common treatment technique before hematopoietic stem cell transplant. The lungs are organs at risk, which often are treated with a lower dose than the whole body. Methods This can be achieved by the application of blocks. Three‐dimensional (3D) printers are a modern tool to be used in the production process of these blocks. Results We demonstrate the applicability of a specific printer and printing material, describe the process, and evaluate the accuracy of the product. Conclusion The blocks and apertures were found to be applicable in clinical routine.
Collapse
Affiliation(s)
- Manuel Maerz
- Department of Radiotherapy, Regensburg University Medical Center, Regensburg, Germany
| | - Marius Treutwein
- Department of Radiotherapy, Regensburg University Medical Center, Regensburg, Germany
| | - Jan Nabo
- Department for Mathematics and Computer Science, Ostbayerische Technische Hochschule Regensburg, Regensburg, Germany
| | - Barbara Dobler
- Department of Radiotherapy, Regensburg University Medical Center, Regensburg, Germany
| |
Collapse
|
3
|
Arrieta O, Lozano-Ruiz F, Blake-Cerda M, Catalán R, Lara-Mejía L, Salinas MÁ, Maldonado-Magos F, Corona-Cruz JF. Locoregional control and toxicity after pleurectomy/decortication and intensity-modulated pleural radiation therapy in patients with malignant pleural mesothelioma. Thorac Cancer 2020; 11:3448-3455. [PMID: 33030313 PMCID: PMC7705616 DOI: 10.1111/1759-7714.13668] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Revised: 09/03/2020] [Accepted: 09/03/2020] [Indexed: 12/03/2022] Open
Abstract
Background Treatment of malignant pleural mesothelioma (MPM) represents a major challenge for oncologists. Multimodality treatment, which generally involves induction chemotherapy, surgery and radiotherapy have recently shown promising results. The aim of this study was to evaluate the locoregional control and toxicity of intensity modulated radiotherapy (IMRT) after pleurectomy and decortication (P/D) as part of trimodality therapy for patients with locally advanced MPM. Methods We prospectively analyzed data from 20 patients with MPM treated at a single tertiary‐care institution. Initially every patient received induction chemotherapy with platinum‐based chemotherapy. After chemotherapy, patients without progression underwent P/D, and if feasible, hemi‐thoracic IMRT was administered at a planned dose of 50.4–54 Gy in 28–30 fractions and treated with 9–11 noncoplanar fields. Results A total of 15 of the 20 enrolled patients underwent P/D followed by IMRT to the hemi‐thoracic cavity. The median total radiotherapy dose was 48.7 Gy (23.4–54 Gy). Radiation pneumonitis (RP) developed in nine patients (60%), and of these, two patients (13.3%) experienced G3 or G4 RP. The estimated locoregional‐relapse‐free survival at two years was 75.9%, and the main pattern of recurrence was distant (72.7%). For the entire cohort median follow‐up was 22.7 months, median progression‐free survival was 18.9 months and median overall survival 23.6 months. Conclusions Platinum‐based chemotherapy followed by lung‐sparing surgery (P/D) and IMRT is a feasible and safe treatment modality that yields acceptable locoregional control in patients with locally advanced MPM; however, these results should be corroborated in larger studies.
Collapse
Affiliation(s)
- Oscar Arrieta
- Thoracic Oncology Unit, Instituto Nacional de Cancerología (INCan), México City, Mexico
| | - Francisco Lozano-Ruiz
- Radiation Oncology Department, Instituto Nacional de Cancerología (INCan), México City, Mexico
| | - Monika Blake-Cerda
- Radiation Oncology Department, Instituto Nacional de Cancerología (INCan), México City, Mexico
| | - Rodrigo Catalán
- Thoracic Oncology Unit, Instituto Nacional de Cancerología (INCan), México City, Mexico
| | - Luis Lara-Mejía
- Thoracic Oncology Unit, Instituto Nacional de Cancerología (INCan), México City, Mexico
| | - Miguel Ángel Salinas
- Thoracic Oncology Unit, Instituto Nacional de Cancerología (INCan), México City, Mexico
| | | | - José F Corona-Cruz
- Thoracic Surgery Department, Instituto Nacional de Cancerología (INCan), México City, Mexico
| |
Collapse
|
4
|
Nakamura A, Takuwa T, Hashimoto M, Kuroda A, Nakamichi T, Matsumoto S, Kondo N, Kijima T, Yamakado K, Hasegawa S. Clinical Outcomes With Recurrence After Pleurectomy/Decortication for Malignant Pleural Mesothelioma. Ann Thorac Surg 2020; 109:1537-1543. [DOI: 10.1016/j.athoracsur.2019.11.048] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2019] [Revised: 11/13/2019] [Accepted: 11/25/2019] [Indexed: 01/27/2023]
|
5
|
Breen WG, Garces YI, Olivier KR, Park SS, Merrell KW, Nichols FC, Peikert TD, Molina JR, Mansfield AS, Roden AC, Blackmon SH, Wigle DA. Surgery for Mesothelioma After Radiation Therapy (SMART); A Single Institution Experience. Front Oncol 2020; 10:392. [PMID: 32266156 PMCID: PMC7105743 DOI: 10.3389/fonc.2020.00392] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2019] [Accepted: 03/05/2020] [Indexed: 11/13/2022] Open
Abstract
Background: The optimal treatment sequence for localized malignant pleural mesothelioma (MPM) is controversial. We aimed to assess outcomes and toxicities of treating localized MPM with neoadjuvant radiation therapy (RT) followed by extrapleural pneumonectomy (EPP). Methods: Patients were enrolled on an institutional protocol of surgery for mesothelioma after radiation therapy (SMART) between June 2016 and May 2017. Eligible patients were adults with MPM localized to the ipsilateral pleura. Patients underwent staging with PET/CT, pleuroscopy, bronchoscopy/EBUS, mediastinoscopy, and laparoscopy. Five fractions of RT were delivered using intensity modulated radiation therapy (IMRT), with 30 Gy delivered to gross disease and 25 Gy to the entire pleura. EPP was performed 4-10 days following completion of RT. Results: Five patients were treated on protocol. Median age was 62 years (range 36-66). Histology was epithelioid on initial biopsy in all patients, but one was found to have biphasic histology after surgery. Three patients had surgeon-assessed gross total resection, and two had gross residual disease. While all patients were clinically node negative by pretreatment staging, three had positive nodal disease at surgery. Patients were hospitalized for a median 24 days (range 5-69) following surgery. Two patients developed empyema, one of whom developed respiratory failure and subsequently renal failure requiring dialysis, while the other required multiple surgical debridements. Two patients developed atrial fibrillation with rapid ventricular response after surgery, one of whom developed acute respiratory distress requiring intubation and tracheostomy. At last follow-up, one patient died at 1.4 years after local and distant progression, two were alive with local and distant progression, and the remaining two were alive without evidence of disease at 0.1 and 2.7 years. Median time to progression was 9 months. Three patients received salvage chemotherapy. Conclusions: SMART provided promising oncologic outcomes at the cost of significant treatment related morbidity. Due to the significant treatment associated morbidity and favorable treatment alternatives, we have not broadly adopted SMART at our institution.
Collapse
Affiliation(s)
- William G Breen
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN, United States
| | - Yolanda I Garces
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN, United States
| | - Kenneth R Olivier
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN, United States
| | - Sean S Park
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN, United States
| | - Kenneth W Merrell
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN, United States
| | - Francis C Nichols
- Division of Thoracic Surgery, Mayo Clinic, Rochester, MN, United States
| | - Tobias D Peikert
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN, United States
| | - Julian R Molina
- Division of Medical Oncology, Mayo Clinic, Rochester, MN, United States
| | - Aaron S Mansfield
- Division of Medical Oncology, Mayo Clinic, Rochester, MN, United States
| | - Anja C Roden
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, United States
| | - Shanda H Blackmon
- Division of Thoracic Surgery, Mayo Clinic, Rochester, MN, United States
| | - Dennis A Wigle
- Division of Thoracic Surgery, Mayo Clinic, Rochester, MN, United States
| |
Collapse
|
6
|
Gomez DR, Rimner A, Simone CB, Cho BCJ, de Perrot M, Adjei AA, Bueno R, Gill RR, Harpole DH, Hesdorffer M, Hirsch FR, Jackson AA, Pass HI, Rice DC, Rusch VW, Tsao AS, Yorke E, Rosenzweig K. The Use of Radiation Therapy for the Treatment of Malignant Pleural Mesothelioma: Expert Opinion from the National Cancer Institute Thoracic Malignancy Steering Committee, International Association for the Study of Lung Cancer, and Mesothelioma Applied Research Foundation. J Thorac Oncol 2019; 14:1172-1183. [PMID: 31125736 DOI: 10.1016/j.jtho.2019.03.030] [Citation(s) in RCA: 44] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2018] [Revised: 03/28/2019] [Accepted: 03/28/2019] [Indexed: 02/06/2023]
Abstract
INTRODUCTION Detailed guidelines regarding the use of radiation therapy for malignant pleural mesothelioma (MPM) are currently lacking because of the rarity of the disease, the wide spectrum of clinical presentations, and the paucity of high-level data on individual treatment approaches. METHODS In March 2017, a multidisciplinary meeting of mesothelioma experts was cosponsored by the U.S. National Cancer Institute, International Association for the Study of Lung Cancer Research, and Mesothelioma Applied Research Foundation. Among the outcomes of this conference was the foundation of detailed, multidisciplinary consensus guidelines. RESULTS Here we present consensus recommendations on the use of radiation therapy for MPM in three discrete scenarios: (1) hemithoracic radiation therapy to be used before or after extrapleural pneumonectomy; (2) hemithoracic radiation to be used as an adjuvant to lung-sparing procedures (i.e., without pneumonectomy); and (3) palliative radiation therapy for focal symptoms caused by the disease. We discuss appropriate simulation techniques, treatment volumes, dose fractionation regimens, and normal tissue constraints. We also assess the role of particle beam therapy, specifically, proton beam therapy, for MPM. CONCLUSION The recommendations provided in this consensus statement should serve as important guidelines for developing future clinical trials of treatment approaches for MPM.
Collapse
Affiliation(s)
- Daniel R Gomez
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York.
| | - Andreas Rimner
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Charles B Simone
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, Maryland
| | - B C John Cho
- Cancer Clinical Research Unit, Princess Margaret Cancer Centre, Toronto, Ontario, Canada
| | - Marc de Perrot
- Cancer Clinical Research Unit, Princess Margaret Cancer Centre, Toronto, Ontario, Canada
| | - Alex A Adjei
- Department of Oncology, Mayo Clinic, Rochester, Minnesota
| | - Raphael Bueno
- Division of Thoracic Surgery, Brigham and Women's Hospital, Boston, Massachusetts
| | - Ritu R Gill
- Department of Radiology, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - David H Harpole
- Department of Surgery, Duke University School of Medicine, Durham, North Carolina
| | | | - Fred R Hirsch
- Department of Medicine, University of Colorado, Denver, Colorado; Department of Pathology, University of Colorado, Denver, Colorado
| | | | - Harvey I Pass
- Department of Cardiothoracic Surgery, New York University School of Medicine, New York, New York
| | - David C Rice
- Department of Thoracic and Cardiovascular Surgery, The University of Texas M. D. Anderson Cancer Center, Houston, Texas
| | - Valerie W Rusch
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Anne S Tsao
- Department of Thoracic/Head and Neck Medical Oncology, The University of Texas M. D. Anderson Cancer Center, Houston, Texas
| | - Ellen Yorke
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Kenneth Rosenzweig
- Department of Radiation Oncology, Mount Sinai School of Medicine, New York, New York
| |
Collapse
|
7
|
Kato T, Jin CS, Lee D, Ujiie H, Fujino K, Hu HP, Wada H, Wu L, Chen J, Weersink RA, kanno H, Hatanaka Y, Hatanaka KC, Kaga K, Matsui Y, Matsuno Y, De Perrot M, Wilson BC, Zheng G, Yasufuku K. Preclinical investigation of folate receptor-targeted nanoparticles for photodynamic therapy of malignant pleural mesothelioma. Int J Oncol 2018; 53:2034-2046. [PMID: 30226590 PMCID: PMC6192720 DOI: 10.3892/ijo.2018.4555] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2018] [Accepted: 08/01/2018] [Indexed: 11/07/2022] Open
Abstract
Photodynamic therapy (PDT) following lung-sparing extended pleurectomy for malignant pleural mesothelioma (MPM) has been investigated as a potential means to kill residual microscopic cells. High expression levels of folate receptor 1 (FOLR1) have been reported in MPM; therefore, targeting FOLR1 has been considered a novel potential strategy. The present study developed FOLR1‑targeting porphyrin-lipid nanoparticles (folate-porphysomes, FP) for the treatment of PDT. Furthermore, inhibition of activated epidermal growth factor (EGFR)-associated survival pathways enhance PDT efficacy. In the present study, these approaches were combined; FP-based PDT was used together with an EGFR-tyrosine kinase inhibitor (EGFR-TKI). The frequency of FOLR1 and EGFR expression in MPM was analyzed using tissue microarrays. Confocal microscopy and a cell viability assay were performed to confirm the specificity of FOLR1‑targeting cellular uptake and photocytotoxicity in vitro. In vivo fluorescence activation and therapeutic efficacy were subsequently examined. The effects of EGFR-TKI were also assessed in vitro. The in vivo combined antitumor effect of EGFR-TKI and FP-PDT was then evaluated. The results revealed that FOLR1 and EGFR were expressed in 79 and 89% of MPM samples, respectively. In addition, intracellular uptake of FP corresponded well with FOLR1 expression. When MPM cells were incubated with FP and then irradiated at 671 nm, there was significant in vitro cell death, which was inhibited in the presence of free folic acid, thus suggesting the specificity of FPs. FOLR1 targeting resulted in disassembly of the porphysomes and subsequent fluorescence activation in intrathoracic disseminated MPM tumors, as demonstrated by ex vivo tissue imaging. FP-PDT resulted in significant cellular damage and apoptosis in vivo. Furthermore, the combination of pretreatment with EGFR-TKI and FP-PDT induced a marked improvement of treatment responses. In conclusion, FP-based PDT induced selective destruction of MPM cells based on FOLR1 targeting, and pretreatment with EGFR-TKI further enhanced the therapeutic response.
Collapse
Affiliation(s)
- Tatsuya Kato
- Division of Thoracic Surgery, Toronto General Hospital, University Health Network, Toronto, ON M5G 2C4, Canada
- Department of Cardiovascular and Thoracic Surgery, Hokkaido University Graduate School of Medicine, Sapporo, Hokkaido 060-8638, Japan
| | - Cheng s. Jin
- Graduate Department of Pharmaceutical Sciences, Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, ON M5S 3M2
- Institute of Biomaterials and Biomedical Engineering, University of Toronto, Toronto, ON M5S 3G9
- Guided Therapeutics, TECHNA Institute, University Health Network, Toronto, ON M5G 1L5
| | - Daiyoon Lee
- Division of Thoracic Surgery, Toronto General Hospital, University Health Network, Toronto, ON M5G 2C4, Canada
| | - Hideki Ujiie
- Division of Thoracic Surgery, Toronto General Hospital, University Health Network, Toronto, ON M5G 2C4, Canada
| | - Kosuke Fujino
- Division of Thoracic Surgery, Toronto General Hospital, University Health Network, Toronto, ON M5G 2C4, Canada
| | - Hsin-Pei Hu
- Division of Thoracic Surgery, Toronto General Hospital, University Health Network, Toronto, ON M5G 2C4, Canada
| | - Hironobu Wada
- Division of Thoracic Surgery, Toronto General Hospital, University Health Network, Toronto, ON M5G 2C4, Canada
| | - Licun Wu
- Division of Thoracic Surgery, Toronto General Hospital, University Health Network, Toronto, ON M5G 2C4, Canada
| | - Juan Chen
- Department of Medical Biophysics, University of Toronto, Toronto, ON M5G 1L7
| | - Rober a. Weersink
- Guided Therapeutics, TECHNA Institute, University Health Network, Toronto, ON M5G 1L5
- Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, Toronto, ON M5G 2M9, Canada
| | - Hiromi kanno
- Department of Surgical Pathology, Hokkaido University Hospital, Sapporo, Hokkaido 060-8648, Japan
| | - Yutaka Hatanaka
- Department of Surgical Pathology, Hokkaido University Hospital, Sapporo, Hokkaido 060-8648, Japan
| | - Kanako c. Hatanaka
- Department of Surgical Pathology, Hokkaido University Hospital, Sapporo, Hokkaido 060-8648, Japan
| | - Kichizo Kaga
- Department of Cardiovascular and Thoracic Surgery, Hokkaido University Graduate School of Medicine, Sapporo, Hokkaido 060-8638, Japan
| | - Yoshiro Matsui
- Department of Cardiovascular and Thoracic Surgery, Hokkaido University Graduate School of Medicine, Sapporo, Hokkaido 060-8638, Japan
| | - Yoshihiro Matsuno
- Department of Surgical Pathology, Hokkaido University Hospital, Sapporo, Hokkaido 060-8648, Japan
| | - Marc De Perrot
- Division of Thoracic Surgery, Toronto General Hospital, University Health Network, Toronto, ON M5G 2C4, Canada
| | - Brian c. Wilson
- Department of Medical Biophysics, University of Toronto, Toronto, ON M5G 1L7
- Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, Toronto, ON M5G 2M9, Canada
| | - Gang Zheng
- Graduate Department of Pharmaceutical Sciences, Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, ON M5S 3M2
- Institute of Biomaterials and Biomedical Engineering, University of Toronto, Toronto, ON M5S 3G9
- Guided Therapeutics, TECHNA Institute, University Health Network, Toronto, ON M5G 1L5
- Department of Medical Biophysics, University of Toronto, Toronto, ON M5G 1L7
- Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, Toronto, ON M5G 2M9, Canada
- DLVR Therapeutics Inc. and University Health Network, Toronto, ON M5G 0A3, Canada
| | - Kazuhiro Yasufuku
- Division of Thoracic Surgery, Toronto General Hospital, University Health Network, Toronto, ON M5G 2C4, Canada
| |
Collapse
|
8
|
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
|
9
|
Nakamura A, Takuwa T, Hashimoto M, Kondo N, Takaki H, Fujiwara M, Yamakado K, Hasegawa S. Radiofrequency Ablation Effectively Treated Focal Recurrence of Mesothelioma. Ann Thorac Surg 2018; 105:e265-e267. [PMID: 29410265 DOI: 10.1016/j.athoracsur.2017.12.039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2017] [Revised: 11/24/2017] [Accepted: 12/30/2017] [Indexed: 11/30/2022]
Abstract
A 55-year-old man with malignant pleural mesothelioma underwent multimodality treatment comprising induction chemotherapy followed by extrapleural pneumonectomy and radiation therapy. After 2.5 years, focal recurrence occurred, with computed tomography revealing a tumor in the left cardiophrenic angle. Surgery was considered a problem for the patient because of the previous extrapleural pneumonectomy and difficult tumor location. Radiofrequency ablation was therefore performed; the course was uneventful, and there was no recurrence. Radiofrequency ablation should be considered an option to treat recurrence of malignant pleural mesothelioma.
Collapse
Affiliation(s)
- Akifumi Nakamura
- Department of Thoracic Surgery, Hyogo College of Medicine, Nishinomiya, Hyogo, Japan.
| | - Teruhisa Takuwa
- Department of Thoracic Surgery, Hyogo College of Medicine, Nishinomiya, Hyogo, Japan
| | - Masaki Hashimoto
- Department of Thoracic Surgery, Hyogo College of Medicine, Nishinomiya, Hyogo, Japan
| | - Nobuyuki Kondo
- Department of Thoracic Surgery, Hyogo College of Medicine, Nishinomiya, Hyogo, Japan
| | - Haruyuki Takaki
- Department of Radiology, Hyogo College of Medicine, Nishinomiya, Hyogo, Japan
| | - Masayuki Fujiwara
- Department of Radiology, Hyogo College of Medicine, Nishinomiya, Hyogo, Japan
| | - Koichiro Yamakado
- Department of Radiology, Hyogo College of Medicine, Nishinomiya, Hyogo, Japan
| | - Seiki Hasegawa
- Department of Thoracic Surgery, Hyogo College of Medicine, Nishinomiya, Hyogo, Japan
| |
Collapse
|
10
|
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 .
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
|
11
|
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.
Collapse
|
12
|
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
|
13
|
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
|
14
|
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
|
15
|
Kim KC, Vo HP. Localized malignant pleural sarcomatoid mesothelioma misdiagnosed as benign localized fibrous tumor. J Thorac Dis 2016; 8:E379-84. [PMID: 27293862 DOI: 10.21037/jtd.2016.03.92] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
Localized malignant pleural mesothelioma (LMPM) is a rare tumor with good prognosis by surgical resection. We report an atypical case of malignant pleural sarcomatoid mesothelioma (SM) in an asymptomatic 65-year-old woman, who had no history of exposure to asbestos. She presented with a small pleural mass without pleural effusion and was misdiagnosed as a benign localized fibrous tumor (BLFT) on pathologic examination through a surgical tumor specimen. However, seven months later, the patient returned with serious cancerous symptoms. A large recurrent tumor mass was found within the chest wall invading at the old surgical resection site. SM, a subtype of LMPM, was confirmed with histopathogy and immunohistochemisty. In conclusion, malignant pleural mesothelioma (MPM) can present with typical radiologic finding similar to a BLFT, and has a wide histopathologic presentation in biopsy specimen. A thorough pathologic investigation should be attempted even when a pleural mass resembles benign, localized, and small on radiologic studies.
Collapse
Affiliation(s)
- Kwan-Chang Kim
- 1 Department of Thoracic and Caridiovascular Surgery, School of Medicine, Ewha Womans University, Seoul, Korea ; 2 Department of Surgery, Windsor University, School of Medicine, St. Kitts Nevis, USA
| | - Hong-Phuc Vo
- 1 Department of Thoracic and Caridiovascular Surgery, School of Medicine, Ewha Womans University, Seoul, Korea ; 2 Department of Surgery, Windsor University, School of Medicine, St. Kitts Nevis, USA
| |
Collapse
|
16
|
Abstract
One particular approach of multimodality treatment for mesothelioma is induction therapy followed by surgery. Among its several advantages, the most important is downstaging of the tumor into a resectable stage, although morbidity and mortality might be increased. In this article we review the principles and outcome of different modalities for induction treatment of mesothelioma.
Collapse
Affiliation(s)
- Isabelle Opitz
- Division of Thoracic Surgery, University Hospital Zurich, Zurich, Switzerland..
| | - Walter Weder
- Division of Thoracic Surgery, University Hospital Zurich, Zurich, Switzerland
| |
Collapse
|
17
|
Kostron A, Friess M, Crameri O, Inci I, Schneiter D, Hillinger S, Stahel R, Weder W, Opitz I. Relapse pattern and second-line treatment following multimodality treatment for malignant pleural mesothelioma. Eur J Cardiothorac Surg 2015; 49:1516-23. [PMID: 26590183 DOI: 10.1093/ejcts/ezv398] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2015] [Accepted: 10/01/2015] [Indexed: 12/11/2022] Open
Abstract
OBJECTIVES To analyse the relapse pattern and influence of second-line treatment after recurrence of malignant pleural mesothelioma (MPM) in patients who had previously undergone multimodality treatment. METHODS Between September 1999 and December 2013, 136 patients underwent macroscopic complete resection (MCR) by extrapleural pneumonectomy after induction chemotherapy for MPM. We analysed 106 patients who presented with recurrent disease until October 2014. Data were retrieved from our mesothelioma database, with additional information regarding precise localization gathered by reviewing the imaging and medical records. RESULTS The overall recurrence rate was 78% (106/136 patients). The median freedom from recurrence was 9 months after surgery [95% confidence interval (95% CI) 7-10]. Local recurrence only was observed in 33 patients (31%), distant metastases only in 27 patients (26%) and simultaneous distant and local recurrence in 46 patients (43%). Local recurrence was observed significantly less frequently in patients having received adjuvant radiotherapy (19 vs 47%, P = 0.003), but there was no significant impact on overall survival (OS) [radiation: 22 months (95% CI 19-24); no-radiation: 23 months (95% CI 18-27), P = 0.6]. The median OS was 22 months (95% CI 21-24), median post-recurrence survival (PRS) was 7 months (95% CI 5-9) and patients with local recurrence only survived significantly longer (12 months, 95% CI 8-16) compared with patients with distant recurrence only (5 months, 95% CI 2-8) or distant plus local relapse (6 months, 95% CI 3-9; P = 0.04). A total of 78 patients received a second-line therapy after tumour recurrence: chemotherapy (n = 48), local radiotherapy (n = 9), surgery (n = 10) or a combination thereof (n = 11). Patients undergoing second-line treatment survived significantly longer compared with patients not receiving therapy (P < 0.0005). The median PRS after surgery was significantly longer than that of patients receiving chemo-, radio- or chemo-radiotherapy (P = 0.04). CONCLUSIONS Local recurrence of MPM remains the most frequent type of relapse even after multimodality treatment including MCR. In the present cohort, active treatment seems beneficial to the patient since surgical excision of local tumour relapse has good long-term outcome in selected patients. Thus, second-line treatment may prolong PRS; however, these results need to be confirmed in a prospective manner.
Collapse
Affiliation(s)
- Arthur Kostron
- Division of Thoracic Surgery, University Hospital Zurich, Zurich, Switzerland
| | - Martina Friess
- Division of Thoracic Surgery, University Hospital Zurich, Zurich, Switzerland
| | - Ornella Crameri
- Division of Thoracic Surgery, University Hospital Zurich, Zurich, Switzerland
| | - Ilhan Inci
- Division of Thoracic Surgery, University Hospital Zurich, Zurich, Switzerland
| | - Didier Schneiter
- Division of Thoracic Surgery, University Hospital Zurich, Zurich, Switzerland
| | - Sven Hillinger
- Division of Thoracic Surgery, University Hospital Zurich, Zurich, Switzerland
| | - Rolf Stahel
- Department of Oncology, University Hospital Zurich, Zurich, Switzerland
| | - Walter Weder
- Division of Thoracic Surgery, University Hospital Zurich, Zurich, Switzerland
| | - Isabelle Opitz
- Division of Thoracic Surgery, University Hospital Zurich, Zurich, Switzerland
| |
Collapse
|
18
|
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.
Collapse
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
| |
Collapse
|
19
|
Early experience with intensity modulated proton therapy for lung-intact mesothelioma: A case series. Pract Radiat Oncol 2015; 5:e345-53. [PMID: 25572666 DOI: 10.1016/j.prro.2014.11.005] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2014] [Revised: 10/28/2014] [Accepted: 11/17/2014] [Indexed: 02/03/2023]
Abstract
PURPOSE The purpose of this study was to describe our experience implementing intensity modulated proton therapy (IMPT) for lung-intact malignant pleural mesothelioma (MPM), including patient selection, treatment planning, dose verification, and process optimization. METHODS AND MATERIALS Seven patients with epithelioid MPM were reviewed; 6 underwent pleurectomy, whereas 1 had biopsy alone. Four patients received IMPT and 3 received intensity modulated radiation therapy. Treatment plans for the other modality were created for dosimetric comparisons. Quality assurance processes included dose verification and robustness analysis. Image-guided setup was performed with the first isocenter, and couch shifts were applied to reposition to the second isocenter. RESULTS Treatment with IMPT was well tolerated and completed without breaks. IMPT plans were designed with 2 isocenters, 4 beams, and ≤64 energy layers per beam. Dose verification processes were completed in 3 hours. Total daily treatment time was approximately 45 minutes (20 minutes for setup and 25 minutes for delivery). IMPT produced lower mean doses to the contralateral lung, heart, esophagus, liver, and ipsilateral kidney, with increased contralateral lung sparing when mediastinal boost was required for nodal disease. CONCLUSIONS Our initial experience showed that IMPT was feasible for routine care of patients with lung-intact MPM.
Collapse
|
20
|
Bece A, Tin MM, Martin D, Lin R, McLean J, McCaughan B. Hemithoracic radiation therapy after extrapleural pneumonectomy for malignant pleural mesothelioma: Toxicity and outcomes at an Australian institution. J Med Imaging Radiat Oncol 2015; 59:355-62. [PMID: 25753747 DOI: 10.1111/1754-9485.12291] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2014] [Accepted: 01/12/2015] [Indexed: 12/23/2022]
Abstract
INTRODUCTION We aim to report the outcome of patients with malignant pleural mesothelioma who underwent extrapleural pneumonectomy (EPP) and adjuvant hemithoracic radiotherapy with or without chemotherapy at a single Australian institution. METHOD Between July 2004 and March 2013, 53 patients were referred for radiation treatment following EPP, of whom 49 were suitable for adjuvant treatment. Radiation treatment initially involved a 3D conformal, mixed electron/photon technique, delivering 45-50.4 Gy in 25-28 fractions (31 patients) and subsequently a nine-field intensity-modulated radiotherapy technique, delivering 50.4-54 Gy in 28-30 fractions (18 patients). Fifty-five per cent of patients also received pre-operative chemotherapy. We assessed toxicity, disease-specific and overall survival in patients who commenced radiation treatment. RESULTS Forty-one patients (84%) completed treatment as prescribed. Six patients stopped prematurely due to toxicity, and two with disease progression. Most patients discontinuing due to toxicity received over 90% of the prescribed dose. Common acute toxicities included nausea, fatigue, anorexia and dermatitis. Severe early toxicities were rare. Late toxicities were uncommon, with the exception of a persistent elevation in liver enzymes in those with right-sided disease. Neither clinical hepatitis nor radiation pneumonitis was documented. With a median follow up of 18.7 months, median disease-free and overall survival were 21.6 and 30.5 months, respectively, and 2-year overall survival was 57.3%. CONCLUSION Hemithoracic radiotherapy following EPP, although associated with significant early toxicity, is well tolerated. Most patients complete the prescribed treatment, and clinically significant late toxicities are rare.
Collapse
Affiliation(s)
- Andrej Bece
- Radiation Oncology, Chris O'Brien Lifehouse, Camperdown, New South Wales, Australia.,Radiation Oncology, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia
| | - Mo Mo Tin
- Radiation Oncology, Chris O'Brien Lifehouse, Camperdown, New South Wales, Australia.,Radiation Oncology, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia
| | - Darren Martin
- Radiation Oncology, Chris O'Brien Lifehouse, Camperdown, New South Wales, Australia.,Radiation Oncology, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia
| | - Robert Lin
- Radiation Oncology, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia.,Innovative Integrated Premium Healthcare, New South Wales, Australia
| | - Jocelyn McLean
- Cardiothoracic Surgery, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia
| | - Brian McCaughan
- Cardiothoracic Surgery, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia
| |
Collapse
|
21
|
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
|
22
|
Rimner A, Spratt DE, Zauderer MG, Rosenzweig KE, Wu AJ, Foster A, Yorke ED, Adusumilli P, Rusch VW, Krug LM. Failure patterns after hemithoracic pleural intensity modulated radiation therapy for malignant pleural mesothelioma. Int J Radiat Oncol Biol Phys 2014; 90:394-401. [PMID: 25073664 DOI: 10.1016/j.ijrobp.2014.05.032] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2014] [Revised: 05/03/2014] [Accepted: 05/07/2014] [Indexed: 12/23/2022]
Abstract
PURPOSE We previously reported our technique for delivering intensity modulated radiation therapy (IMRT) to the entire pleura while attempting to spare the lung in patients with malignant pleural mesothelioma (MPM). Herein, we report a detailed pattern-of-failure analysis in patients with MPM who were unresectable or underwent pleurectomy/decortication (P/D), uniformly treated with hemithoracic pleural IMRT. METHODS AND MATERIALS Sixty-seven patients with MPM were treated with definitive or adjuvant hemithoracic pleural IMRT between November 2004 and May 2013. Pretreatment imaging, treatment plans, and posttreatment imaging were retrospectively reviewed to determine failure location(s). Failures were categorized as in-field (within the 90% isodose line), marginal (<90% and ≥50% isodose lines), out-of-field (outside the 50% isodose line), or distant. RESULTS The median follow-up was 24 months from diagnosis and the median time to in-field local failure from the end of RT was 10 months. Forty-three in-field local failures (64%) were found with a 1- and 2-year actuarial failure rate of 56% and 74%, respectively. For patients who underwent P/D versus those who received a partial pleurectomy or were deemed unresectable, the median time to in-field local failure was 14 months versus 6 months, respectively, with 1- and 2-year actuarial in-field local failure rates of 43% and 60% versus 66% and 83%, respectively (P=.03). There were 13 marginal failures (19%). Five of the marginal failures (38%) were located within the costomediastinal recess. Marginal failures decreased with increasing institutional experience (P=.04). Twenty-five patients (37%) had out-of-field failures. Distant failures occurred in 32 patients (48%). CONCLUSIONS After hemithoracic pleural IMRT, local failure remains the dominant form of failure pattern. Patients treated with adjuvant hemithoracic pleural IMRT after P/D experience a significantly longer time to local and distant failure than patients treated with definitive pleural IMRT. Increasing experience and improvement in target delineation minimize the incidence of avoidable marginal failures.
Collapse
Affiliation(s)
- Andreas Rimner
- Department of Radiation Oncology, Memorial Sloan-Kettering Cancer Center, New York, New York.
| | - Daniel E Spratt
- Department of Radiation Oncology, Memorial Sloan-Kettering Cancer Center, New York, New York
| | - Marjorie G Zauderer
- Department of Medicine, Thoracic Oncology Service, Memorial Sloan-Kettering Cancer Center; Weill Cornell Medical College, New York, New York
| | - Kenneth E Rosenzweig
- Department of Radiation Oncology, Mount Sinai Medical Center, New York, New York
| | - Abraham J Wu
- Department of Radiation Oncology, Memorial Sloan-Kettering Cancer Center, New York, New York
| | - Amanda Foster
- 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
| | - Prasad Adusumilli
- Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, New York
| | - Valerie W Rusch
- Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, New York
| | - Lee M Krug
- Department of Medicine, Thoracic Oncology Service, Memorial Sloan-Kettering Cancer Center; Weill Cornell Medical College, New York, New York
| |
Collapse
|
23
|
Opitz I. Management of malignant pleural mesothelioma-The European experience. J Thorac Dis 2014; 6 Suppl 2:S238-52. [PMID: 24868442 DOI: 10.3978/j.issn.2072-1439.2014.05.03] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2014] [Accepted: 05/08/2014] [Indexed: 12/29/2022]
Abstract
Management of malignant pleural mesothelioma (MPM) remains a clinical challenge and the incidence of the disease will continue to increase worldwide. Several aspects of mesothelioma treatment are discussed controversially, in particular, regarding extent and best type of surgery, radiotherapy, and the role of neoadjuvant or adjuvant treatment. However, best survival data is reported from groups using multimodality treatment including macroscopic complete resection (MCR) achieved by either extrapleural pneumonectomy (EPP) or (extended) pleurectomy/decortication for patients qualifying from the tumor biology, stage, and patient's performance status and comorbidities. Several aspects have to be considered during surgery but morbidity and mortality have been reduced at experienced centres. The final analysis of extended selection algorithms is pending.
Collapse
Affiliation(s)
- Isabelle Opitz
- Division of Thoracic Surgery, University Hospital Zurich, Zurich, Switzerland
| |
Collapse
|
24
|
van Zandwijk N, Clarke C, Henderson D, Musk AW, Fong K, Nowak A, Loneragan R, McCaughan B, Boyer M, Feigen M, Currow D, Schofield P, Nick Pavlakis BI, McLean J, Marshall H, Leong S, Keena V, Penman A. Guidelines for the diagnosis and treatment of malignant pleural mesothelioma. J Thorac Dis 2013; 5:E254-307. [PMID: 24416529 PMCID: PMC3886874 DOI: 10.3978/j.issn.2072-1439.2013.11.28] [Citation(s) in RCA: 81] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2013] [Accepted: 11/25/2013] [Indexed: 12/24/2022]
|
25
|
Clinical indications and results after chest wall resection for recurrent mesothelioma. J Thorac Cardiovasc Surg 2013; 146:1373-9; discussion 1379-80. [PMID: 24113019 DOI: 10.1016/j.jtcvs.2013.07.012] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2012] [Revised: 05/24/2013] [Accepted: 07/03/2013] [Indexed: 11/21/2022]
Abstract
OBJECTIVE The ipsilateral hemithorax is the most common site of recurrence after surgical resection for malignant pleural mesothelioma. Salvage treatment has generally been ineffective. We reviewed the outcomes after resection of isolated ipsilateral chest recurrence after cytoreductive surgery in patients with malignant pleural mesothelioma. METHODS Patients with malignant pleural mesothelioma who underwent initial surgical resection at our institution from 1988 to 2011 and were subsequently treated for localized recurrence with an additional chest resection were identified and their data retrospectively reviewed. RESULTS A total of 1142 patients underwent either extrapleural pneumonectomy (n = 794) or pleurectomy/decortication (n = 348). Of the patients who returned for follow-up, 47 (4.1%) had chest wall recurrence amenable to resection. The location of recurrence was predominantly incisional (49%) and/or costophrenic (38%). The median time to recurrence after either extrapleural pneumonectomy or pleurectomy/decortication was 16.1 months (range, 2.7-58.2). No 30-day mortality was found for chest wall resection, and the median length of stay in the hospital was 3 days (range, 0-12). The median overall survival duration after chest wall resection correlated positively with the time to recurrence (epithelial: median, 8.9, 17.2, and 35.8 months for a time to recurrence of <12, 12 to <24, and ≥24 months, respectively; biphasic: median, 2.7 and 15.9 months for a time to recurrence of <10 and ≥10 months, respectively). CONCLUSIONS Chest wall resection is a safe and effective therapeutic option in the management of localized chest wall recurrence of malignant pleural mesothelioma. The time to recurrence appears to be predictive of the expected survival benefit in both epithelial and biphasic malignant pleural mesothelioma.
Collapse
|
26
|
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
|
27
|
Gomez DR, Hong DS, Allen PK, Welsh JS, Mehran RJ, Tsao AS, Liao Z, Bilton SD, Komaki R, Rice DC. Patterns of failure, toxicity, and survival after extrapleural pneumonectomy and hemithoracic intensity-modulated radiation therapy for malignant pleural mesothelioma. J Thorac Oncol 2013; 8:238-45. [PMID: 23247629 DOI: 10.1097/jto.0b013e31827740f0] [Citation(s) in RCA: 89] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
INTRODUCTION We investigated safety, efficacy, and recurrence after postoperative hemithoracic intensity-modulated radiation therapy (IMRT) in patients with malignant pleural mesothelioma treated with extrapleural pneumonectomy (EPP), during the past decade at a single institution. METHODS In 2001-2011, 136 consecutive patients with malignant pleural mesothelioma underwent EPP with planned adjuvant IMRT. Eighty-six patients (64%) underwent hemithoracic IMRT; the rest were not eligible because of postoperative complications, disease progression, or poor performance status. We assessed toxicity, survival, and patterns of failure in these 86 patients. Toxicity was scored with the Common Terminology Criteria for Adverse Events version 4.0; survival outcomes were estimated with the Kaplan-Meier method; and locoregional patterns of failure were classified as in-field, marginal, or out-of-field. Risk factors related to survival were identified by univariate and multivariate Cox regression analysis. RESULTS Median overall survival time for all 86 patients receiving IMRT was 14.7 months. Toxicity rates of grade of 3 or more were: skin 17%, lung 12%, heart 2.3%, and gastrointestinal toxicity 16%. Five patients experienced grade 5 pulmonary toxicity. Rates of locoregional recurrence-free survival, distant metastasis-free survival, and overall survival (OS) were 88%, 55%, and 55% at 1 year and 71%, 40%, and 32% at 2 years. On multivariate analysis, pretreatment forced expiratory volume in 1 second, nonepithelioid histology, and nodal status were associated with distant metastasis-free survival and OS. CONCLUSION IMRT after EPP is associated with low rates of locoregional recurrence, though some patients experience life-threatening lung toxicity. Tumor histology and nodal status can be helpful in identifying patients for this aggressive treatment.
Collapse
Affiliation(s)
- Daniel R Gomez
- Department of Radiation Oncology, The University of Texas M.D. Anderson Cancer Center, Houston, Texas 77054, USA.
| | | | | | | | | | | | | | | | | | | |
Collapse
|
28
|
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
|
29
|
Ebara T, Kawamura H, Kaminuma T, Okamoto M, Yoshida D, Okubo Y, Takahashi T, Kobayashi K, Sakaguchi H, Ando Y, Nakano T. Hemithoracic intensity-modulated radiotherapy using helical tomotherapy for patients after extrapleural pneumonectomy for malignant pleural mesothelioma. JOURNAL OF RADIATION RESEARCH 2012; 53:288-294. [PMID: 22374401 DOI: 10.1269/jrr.11130] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
Postoperative hemithoracic irradiation is regarded as an important part of the curative treatment for resectable malignant pleural mesothelioma (MPM). Because the clinical target volume in postoperative MPM is irregular and surrounded by dose-limiting critical structures, intensity-modulated radiation therapy (IMRT) is thought to be suitable. However, postoperative hemithoracic IMRT remains experimental due to a high incidence of fatal pneumonitis. Therefore, a Phase I dose escalation study for hemithoracic IMRT using helical tomotherapy was planned, and the results of the first three patients are herein reported because this technique may provide benefits to such patients. For 3 patients with postoperative MPM, who were treated by extrapleural pneumonectomy (EPP), a radiation dose of 45.0 Gy in 25 fractions was given to cover 95% of the PTV. The lung V5s of the three patients were 14.3%, 10.0%, and 31.3%, respectively. The V5s of the present plans was smaller than that of the recent IMRT planning studies. The lung V20s of these patients were 2.4%, 2.2%, and 4.3%, respectively. Their MLDs were 4.3 Gy, 3.4 Gy, and 5.8 Gy, respectively. The follow-up periods of the patients were 26, 14 and 9 months from initiation of IMRT, respectively. All patients were alive, although local and contralateral recurrences had developed in 1 patient. Only 1 patient had Grade 2 acute esophagitis and nausea. There was no treatment-related pneumonitis. Hemithoracic IMRT using helical tomotherapy may play a crucial role in adjuvant treatment for MPM after EPP.
Collapse
Affiliation(s)
- Takeshi Ebara
- Department of Radiation Oncology, Gunma University Graduate School of Medicine, Maebashi, Gunma 371-8511, Japan.
| | | | | | | | | | | | | | | | | | | | | |
Collapse
|
30
|
Intensity-modulated radiotherapy after extrapleural pneumonectomy in the combined-modality treatment of malignant pleural mesothelioma. J Thorac Oncol 2011; 6:1132-41. [PMID: 21532502 DOI: 10.1097/jto.0b013e3182199819] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
INTRODUCTION Local therapy is becoming increasingly important as a part of the definitive treatment for malignant pleural mesothelioma after extrapleural pneumonectomy (EPP) because of the emergence of trimodality therapy consisted of chemotherapy, EPP, and adjuvant radiotherapy. Herein, we explore the current evidence and indications for adjuvant intensity-modulated radiotherapy (IMRT), as well as how to further improve this technique and adapt new technology in the delivering adjuvant radiotherapy in the setting of trimodality therapy. METHODS A systematic review of relevant studies identified through PubMed, ISI Web of Knowledge (Web of Science), the Cochrane Library, and the National Guideline Clearinghouse search engines was performed. RESULTS Local control remains poor despite the inclusion of conventional adjuvant radiation therapy in trimodality therapy. This can be improved by the delivery of adjuvant IMRT. However, IMRT can be associated with severe pulmonary toxicity if the radiation dose to the remaining lung is not kept to a very low level. This is especially true when patients are receiving chemotherapy. New advances in technology can allow for lower doses to the contralateral lung, decreased treatment delivery time, and improved target dose coverage. CONCLUSION Excellent local control can be achieved through adjuvant IMRT after EPP for malignant pleural mesothelioma. Severe pulmonary toxicity may be avoided by setting stringent dose constraints for the contralateral lung. This can be aided by the advances in technology. Post-treatment surveillance may be reliably conducted by periodical [18F]-fluorodeoxyglucose-positron emission tomography imaging.
Collapse
|
31
|
Bonnette P. [Pleural mesothelioma: where are we with radical surgery and multimodal treatment?]. REVUE DE PNEUMOLOGIE CLINIQUE 2011; 67:184-190. [PMID: 21920276 DOI: 10.1016/j.pneumo.2011.04.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/07/2011] [Accepted: 03/29/2011] [Indexed: 05/31/2023]
Abstract
Multimodal treatment of pleural mesothelioma, which is reserved for specialised centres for epithelial forms without node involvement, must include preliminary laparoscopy, thoracoscopy and mediastinoscopy. Following chemotherapy, in our opinion surgical removal via pleuropneumonectomy should be performed without resection of the diaphragm and the pericardium, because of the risks of seeding and postoperative complications. Our limited experience with 15 patients has confirmed the feasibility of this with no deaths. High-dose radiotherapy of the whole pneumonectomy cavity appears essential, but the optimal technique is debatable. Only five homogeneous series of more than 40 patients incorporating hemithoracic radiotherapy have been published.
Collapse
Affiliation(s)
- P Bonnette
- Service de Chirurgie Thoracique, Hôpital Foch, 40, rue Worth, 92150 Suresnes, France.
| |
Collapse
|
32
|
Abstract
Previously considered to be rare, malignant pleural mesothelioma (MPM) is a highly aggressive tumor with an increasing incidence linked to asbestos exposure, its main etiological factor. MPM is also a very important issue because patients have usually a short survival (median <12 months) despite current treatments. Moreover an optimal treatment for MPM is not defined yet, even if ERS/ESTS experts recently provided clear and up-to-date guidelines on MPM management. These guidelines on chemotherapy and radiotherapy for mesothelioma, as well as new therapeutic developments, are presented in this chapter.
Collapse
|
33
|
Cilla S, Digesù C, Silvano G, Macchia G, Massaccesi M, Deodato F, DA Padula G, Fidanzio A, Piermattei A, Morganti AG. Intensity-Modulated Radiation Therapy with Simultaneous Integrated Boost in Unresected Left-Sided Pleural Mesothelioma: A Case Report. TUMORI JOURNAL 2010; 96:618-22. [DOI: 10.1177/030089161009600417] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
A 77-year-old male patient with unresected malignant pleural mesothelioma, clinical stage T3N0M0 according to the New International Staging System for Diffuse Malignant Pleural Mesothelioma, received intensity-modulated radiotherapy (IMRT) with a simultaneous integrated boost (SIB) after 6 cycles of chemotherapy with cisplatin and pemetrexed. SIB-IMRT delivered 40.5 Gy (1.5 Gy/fraction) to the left pleura and 50 Gy (1.85 Gy/fraction) to the sites of macroscopic disease. Radiotherapy was well tolerated. Two months after the end of radiotherapy the patient showed grade 2 lung toxicity (febrile episodes accompanied by dry cough) that was successfully treated with steroid therapy. Local control lasted for 2 years after SIB-IMRT. Then the tumor recurred marginally to the radiation field and the patient underwent chemotherapy with pemetrexed. Three years from the diagnosis, the patient is alive and in good general condition. He only takes prednisone 5 mg/daily for exertional dyspnea. To the best of our knowledge this is the first reported use of SIB-IMRT in unresected malignant pleural mesothelioma. Considering the dosimetric advantages of SIB-IMRT and the clinical results observed in our patient, additional evaluation of this technique seems justified.
Collapse
Affiliation(s)
- Savino Cilla
- Department of Medical Physics, John Paul II Center for High Technology Research and Education in Biomedical Sciences, Catholic University, Campobasso, Italy
| | - Cinzia Digesù
- Department of Radiotherapy, John Paul II Center for High Technology Research and Education in Biomedical Sciences, Catholic University, Campobasso, Italy
| | | | - Gabriella Macchia
- Department of Radiotherapy, John Paul II Center for High Technology Research and Education in Biomedical Sciences, Catholic University, Campobasso, Italy
| | - Mariangela Massaccesi
- Department of Radiotherapy, John Paul II Center for High Technology Research and Education in Biomedical Sciences, Catholic University, Campobasso, Italy
| | - Francesco Deodato
- Department of Radiotherapy, John Paul II Center for High Technology Research and Education in Biomedical Sciences, Catholic University, Campobasso, Italy
| | - Gilbert DA Padula
- Department of Radiation Oncology, The Lacks Cancer Center, Saint Mary's Health Care, Grand Rapids, MI, USA
| | - Andrea Fidanzio
- Department of Medical Physics, Catholic University, Rome, Italy
| | - Angelo Piermattei
- Department of Medical Physics, John Paul II Center for High Technology Research and Education in Biomedical Sciences, Catholic University, Campobasso, Italy
| | - Alessio G Morganti
- Department of Radiotherapy, John Paul II Center for High Technology Research and Education in Biomedical Sciences, Catholic University, Campobasso, Italy
| |
Collapse
|