title: Pleural intensity-modulated radiotherapy for malignant pleural mesothelioma.
abstract: OBJECTIVE
  In patients with malignant pleural mesothelioma who are unable to undergo pneumonectomy, it is difficult to deliver tumoricidal radiation doses to the pleura without significant toxicity. We have implemented a technique of using intensity-modulated radiotherapy (IMRT) to treat these patients, and we report the feasibility and toxicity of this approach.
  
  
  METHODS
  Between 2005 and 2010, 36 patients with malignant pleural mesothelioma and two intact lungs (i.e., no previous pneumonectomy) were treated with pleural IMRT to the hemithorax (median dose, 46.8 Gy; range, 41.4-50.4) at Memorial Sloan-Kettering Cancer Center.
  
  
  RESULTS
  Of the 36 patients, 56% had right-sided tumors. The histologic type was epithelial in 78%, sarcomatoid in 6%, and mixed in 17%, and 6% had Stage I, 28% had Stage II, 33% had Stage III, and 33% had Stage IV. Thirty-two patients (89%) received induction chemotherapy (mostly cisplatin and pemetrexed); 56% underwent pleurectomy/decortication before IMRT and 44% did not undergo resection. Of the 36 patients evaluable for acute toxicity, 7 (20%) had Grade 3 or worse pneumonitis (including 1 death) and 2 had Grade 3 fatigue. In 30 patients assessable for late toxicity, 5 had continuing Grade 3 pneumonitis. For patients treated with surgery, the 1- and 2-year survival rate was 75% and 53%, and the median survival was 26 months. For patients who did not undergo surgical resection, the 1- and 2-year survival rate was 69% and 28%, and the median survival was 17 months.
  
  
  CONCLUSIONS
  Treating the intact lung with pleural IMRT in patients with malignant pleural mesothelioma is a safe and feasible treatment option with an acceptable rate of pneumonitis. Additionally, the survival rates were encouraging in our retrospective series, particularly for the patients who underwent pleurectomy/decortication. We have initiated a Phase II trial of induction chemotherapy with pemetrexed and cisplatin with or without pleurectomy/decortication, followed by pleural IMRT to prospectively evaluate the toxicity and survival.
authors.affiliation: Department of Radiation Oncology, Mount Sinai Medical Center, New York, NY 10029, USA. ken.rosenzweig@mountsinai.org
authors.forename: Kenneth E
authors.initials: KE
authors.lastname: Rosenzweig
authors.forename: Marjorie G
authors.initials: MG
authors.lastname: Zauderer
authors.forename: Benjamin
authors.initials: B
authors.lastname: Laser
authors.forename: Lee M
authors.initials: LM
authors.lastname: Krug
authors.forename: Ellen
authors.initials: E
authors.lastname: Yorke
authors.forename: Camelia S
authors.initials: CS
authors.lastname: Sima
authors.forename: Andreas
authors.initials: A
authors.lastname: Rimner
authors.forename: Raja
authors.initials: R
authors.lastname: Flores
authors.forename: Valerie
authors.initials: V
authors.lastname: Rusch
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000970:Antineoplastic Agents / Q000627:therapeutic use; D002945:Cisplatin / Q000627:therapeutic use; D005240:Feasibility Studies; D005260:Female; D005971:Glutamates / Q000627:therapeutic use; D006147:Guanine / Q000031:analogs & derivatives / Q000627:therapeutic use; D006801:Humans; D060828:Induction Chemotherapy / Q000379:methods; D008297:Male; D008654:Mesothelioma / Q000188:drug therapy / Q000401:mortality / Q000473:pathology / Q000532:radiotherapy*; D008875:Middle Aged; D009367:Neoplasm Staging; D000068437:Pemetrexed; D010997:Pleural Neoplasms / Q000188:drug therapy / Q000401:mortality / Q000473:pathology / Q000532:radiotherapy*; D017564:Radiation Pneumonitis / Q000209:etiology; D050397:Radiotherapy, Intensity-Modulated / Q000009:adverse effects / Q000379:methods*; D015996:Survival Rate
chemical_list: D000970:Antineoplastic Agents; D005971:Glutamates; D000068437:Pemetrexed; D006147:Guanine; D002945:Cisplatin