title: Intensity-modulated radiotherapy after extrapleural pneumonectomy in the combined-modality treatment of malignant pleural mesothelioma.
abstract: BACKGROUND
  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.
  
  
  CONCLUSIONS
  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.
authors.affiliation: Department of Radiation Oncology, The University of Arizona, Tucson, Arizona 85724, USA. achiaz2010@gmail.com
authors.forename: Alexander
authors.initials: A
authors.lastname: Chi
authors.forename: Zhongxing
authors.initials: Z
authors.lastname: Liao
authors.forename: Nam P
authors.initials: NP
authors.lastname: Nguyen
authors.forename: Carol
authors.initials: C
authors.lastname: Howe
authors.forename: Daniel
authors.initials: D
authors.lastname: Gomez
authors.forename: Si Young
authors.initials: SY
authors.lastname: Jang
authors.forename: Ritsuko
authors.initials: R
authors.lastname: Komaki
mesh_terms: D003131:Combined Modality Therapy / Q000379:methods; D006801:Humans; D008654:Mesothelioma / Q000532:radiotherapy* / Q000601:surgery*; D010997:Pleural Neoplasms / Q000532:radiotherapy* / Q000601:surgery*; D011013:Pneumonectomy / Q000379:methods*; D050397:Radiotherapy, Intensity-Modulated