title: Outcomes after extrapleural pneumonectomy and intensity-modulated radiation therapy for malignant pleural mesothelioma.
abstract: BACKGROUND
  Malignant pleural mesothelioma is a locally aggressive tumor that is usually fatal. Extrapleural pneumonectomy (EPP) followed by hemithoracic irradiation has shown promise, but local failure remains a significant problem. To improve local control, we have used intensity-modulated radiation therapy (IMRT) as it allows better dose distribution to regions at risk of recurrence as well as reduced radiation to surrounding organs.
  
  
  METHODS
  One hundred consecutive patients underwent EPP. At a median interval of 2.5 months from surgery, 63 patients received IMRT (median dose 45 Gy) with curative intent. Chemotherapy was not routinely administered.
  
  
  RESULTS
  Tumors were right sided in 66 patients (66%) and nonepithelioid in 33 (33%). American Joint Committee on Cancer pathology stage was I in 6 patients (6%), II in 7 (7%), III in 72 (72%), and IV (T4) in 15 (15%). Fifty-four patients (54%) had ipsilateral nodal metastases. Perioperative mortality was 8%. Median overall survival (n = 100) was 10.2 months. For patients who received IMRT (n = 63), median overall and 3-year survival was 14.2 months and 20%. Of these, node-negative patients with epithelioid histology (n = 18) had median and 3-year survival of 28 months and 41%. Distant recurrences occurred in 33 of 61 evaluable patients (54%). Eight patients (13%) had local or regional recurrence, 5 of whom also recurred distally. Only 3 patients (5%) had recurrence within the irradiated field.
  
  
  CONCLUSIONS
  Intensity-modulated radiation therapy after EPP results in excellent local control for malignant pleural mesothelioma; however, distant metastases remain a significant problem and limit survival. This provides a strong rationale for combining aggressive local regimens with systemic therapy.
authors.affiliation: Department of Thoracic and Cardiovascular Surgery, University of Texas, MD Anderson Cancer Center, Houston, Texas 77030, USA. drice@mdanderson.org
authors.forename: David C
authors.initials: DC
authors.lastname: Rice
authors.forename: Craig W
authors.initials: CW
authors.lastname: Stevens
authors.forename: Arlene M
authors.initials: AM
authors.lastname: Correa
authors.forename: Ara A
authors.initials: AA
authors.lastname: Vaporciyan
authors.forename: Anne
authors.initials: A
authors.lastname: Tsao
authors.forename: Kenneth M
authors.initials: KM
authors.lastname: Forster
authors.forename: Garrett L
authors.initials: GL
authors.lastname: Walsh
authors.forename: Stephen G
authors.initials: SG
authors.lastname: Swisher
authors.forename: Wayne L
authors.initials: WL
authors.lastname: Hofstetter
authors.forename: Reza J
authors.initials: RJ
authors.lastname: Mehran
authors.forename: Jack A
authors.initials: JA
authors.lastname: Roth
authors.forename: Zhongxing
authors.initials: Z
authors.lastname: Liao
authors.forename: W Roy
authors.initials: WR
authors.lastname: Smythe
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D003131:Combined Modality Therapy; D005260:Female; D006801:Humans; D008297:Male; D008654:Mesothelioma / Q000000981:diagnostic imaging / Q000401:mortality / Q000628:therapy*; D008875:Middle Aged; D009364:Neoplasm Recurrence, Local; D010997:Pleural Neoplasms / Q000000981:diagnostic imaging / Q000401:mortality / Q000628:therapy*; D011013:Pneumonectomy / Q000379:methods* / Q000401:mortality; D011183:Postoperative Complications / Q000453:epidemiology; D050397:Radiotherapy, Intensity-Modulated; D014057:Tomography, X-Ray Computed