title: Trimodality therapy for malignant pleural mesothelioma.
abstract: BACKGROUND
  Malignant pleural mesothelioma is a fatal disease. The optimal modality and sequence of therapy are controversial. We analyzed the outcomes of a cohort of mesothelioma patients treated with induction chemotherapy, followed by extrapleural pneumonectomy (EPP) and adjuvant radiation.
  
  
  METHODS
  The study comprised a retrospective cohort of 46 patients treated with induction chemotherapy, followed by EPP, during a 10-year period. Of these, 24 completed adjuvant external beam radiotherapy (EBRT), and 14 had intensity-modulated radiotherapy (IMRT).
  
  
  RESULTS
  Mean follow-up was 20.6 months (range, 0.5 to 75 months). Operative mortality after EPP was 4.3% (n = 2). Pathologic stage was p0, 4.3%; pII, 23.9%; pIII, 56.5%; and pIV, 15.2%. Median overall survival was 24 months. On univariate analysis and Cox proportional hazards model, only nodal metastases (hazard ratio, 3.7; 95% confidence interval, 1.6 to 8.7; p = 0.002) was a significant predictor of survival. First site of recurrence was local in 12, the contralateral chest in 5, abdominal in 8, and distant in 5. The incidence of local recurrence was 14.3% with IMRT vs 41.7% with EBRT (p = 0.03). The time to local recurrence with the use of IMRT was 12 months vs 7 for EBRT (p = 0.19).
  
  
  CONCLUSIONS
  Induction chemotherapy, followed by EPP and adjuvant radiotherapy for selected patients with mesothelioma, is safe, with acceptable operative mortality. Adjuvant IMRT may be more effective in terms of local control than EBRT.
authors.affiliation: Swedish Cancer Institute, Seattle, Washington, USA.
authors.forename: Gordon
authors.initials: G
authors.lastname: Buduhan
authors.forename: Shekhar
authors.initials: S
authors.lastname: Menon
authors.forename: Ralph
authors.initials: R
authors.lastname: Aye
authors.forename: Brian
authors.initials: B
authors.lastname: Louie
authors.forename: Vivek
authors.initials: V
authors.lastname: Mehta
authors.forename: Eric
authors.initials: E
authors.lastname: Vallières
mesh_terms: D000328:Adult; D000368:Aged; D000971:Antineoplastic Combined Chemotherapy Protocols / Q000627:therapeutic use*; D015331:Cohort Studies; D003131:Combined Modality Therapy; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D008207:Lymphatic Metastasis / Q000473:pathology; D008297:Male; D008654:Mesothelioma / Q000188:drug therapy* / Q000401:mortality / Q000532:radiotherapy / Q000601:surgery*; D008875:Middle Aged; D020360:Neoadjuvant Therapy; D010997:Pleural Neoplasms / Q000188:drug therapy* / Q000401:mortality / Q000532:radiotherapy / Q000601:surgery*; D011013:Pneumonectomy; D016016:Proportional Hazards Models; D018714:Radiotherapy, Adjuvant; D050397:Radiotherapy, Intensity-Modulated; D012189:Retrospective Studies; D015996:Survival Rate; D014861:Washington